Diabetes Flashcards
How do you treat diabetes
1.st line: Metformin
2nd line: DPP-4 inhibitor, SGLT2 inhibitor, Glp1 receptor agonist (these reduce death)
What are clinical feature of diabetic nephropaty
Hypertension
proteinuria
derranged kidney function
What is the best way to check for diabetic nephropathy?
look at proteinuria first thing
creatinine goe up higher later
What are you particularly at risk of if you have diabetes with diabetic nephropathy?
much higher risk of cardiovascular events
What are the parts of the kidney that are impacted by diabetic nephropathy
- glomerular:
- Mesangial expansion
- basement membrane thickening
- Glomerulosclerosis
- vascular
- tubulo interestial
How long does it take for someone with diabetes to develop reanal failure
30-40 years
WHat are risk factors that impact whether someone get diabetic nephropathy
age at which you get diabetes
racial factors
age of presentation
loss due to cardiovascular morbidity
What are ways to prevent the onset of diabetic nephropathy in someone with diabetes
- diabebetic control
- blood pressure control
- suppression of RAAS
- stop smoking
What are the antihypertensives that you give to diabetics
ACE inhibitor
If someone get’s a cough with an ACE inhibitor and is diabetic, what is the next drug you would give
ARB
Which of the following are feature of diabetic nephropathy:
A. affects all patient with diabetes over time
B associated with decreased BP
C. progressively increasing proteinuria
D. Unrelated to glycaemic control
E, Associated with a low risk of cardiovascular events
C. progressively increasing proteinuria
Regarding ACE inhibition in patients with diabetes
A. ACE inhibitors cause improvement in the creatinine within days of starting
B. Ace inhibitors cause an increase of the creatinine within days of starting
C. ACE inhibitors increase microalbuminuria
B
What happens if you give somone with renal artery stenosis an ACE inhibitor?
fall in GFR
Regarding ACE inhibitors in patients with diabetes
A. ACE inhibitors are useful in patients with diabetes and resultant renal artery stenosis
- ACE inhibtors increase microalbuminuria
- ACE inhibitors prevent end stage renal failure
- ACE inhibitors cause hypokalaemia
- ACE inhibitors prevent end stage renal failure
if you give some an ACE for their diabetic nephropathy what happens to their kidney function
inititally drops off massively but then it plateau and the fall is much less than without and therefore over many years it is more favourable
What should you do if someone has been given an ACE inhibitor and they have renal artery stenosis
you have to take them off it
AND THEN
call a nephrologist might need to be dialised for a while
BUT they will fully recover
What are the problems/ implications of renal failure
- Electrolyte imbalance: hyponatraemia, hyperkalaemia
- ACIDOSIS
- fluid retention
- retention of waste products: urea, creatinine, urate, phosphate, middle molecules
- LESS secretion of EPO and Vitamin D
WHat are symptoms of renal failure
tiredness - anaemia (lack of EPO)
SOB and oedema
Pruritus - renal bone disease (lack of vit. D)
nocturia, feeling cold, twitching (later on)
poor apetite, nausea, loss of taste, weight loss
What are the lack of kidney functions and how do they manifest
Hyperkalaemia- arrthmias, cardiac arrest
Pulmonary oedema- fluid retention
Nause and vomitting- acidosis
Malnutrition cachexia - loss of apetite and taste
Fits & increasing coma - hypnatraemia
DEATH
What are renal replacement therapies?
Where are they done?
Dialysis
-
haemodialysis:
- HOSPITAL based but can be done at home
-
peritoneal dialisis
- HOME treatment
Transplantation
What are the aims of renal replacement therapy
correct electrolytes
remove waste product
restore fluid balance
improve symptoms
maintain quality of life
When do you refer for renal replacement therapy?
Do you start it then?
eGFR of below 20
No just discuss and organise
and then you may start at 10ml/min (benifits outweigh the risks)
Need to start at 6 or less
What do you need to tell the patient about
Risks of renal failure
types of renal replacement failure and then establish the access
What are the different accesses for renal replacement therapy
fistula
PD catheter
transplant assesment
At what eGFR does someone have to be on dialysis?
At what eGFR woudl it be beneficial?
At what eGFR does someone have to be on dialysis? 10
At what eGFR woudl it be beneficial - 6
What are the risks adn benifits of dyalisis?
Benifit
improve uraemic syndrome (reduce pruritus, nausea and tiredness)
correct fluid balance (less SOB and oedema)
Avoid life threatning complication like acidosis, hyperkalaemia and pulmunary oedema resistant to diuretics
RISKS
infection
hypotension
reduces quality of life (travel, family life)
What does dialysis not treat
anaemia
vitamin D (renal bone diasease)
AND comorbidities
SLE, diabetes and vascular disease
What are the 2 different type of dialysis
haemodialysis: 3 times a week - 4 hours (needs a fistula and catheter)
peritoneal dialysis: Home base: daily and continuous, less haemodynamic stress but need a peritoneal access
GOOD becauses avoid the swings, done at home and less dietary and lfuid restrictions
WHat are the benifits and risks of transpantation
benefits:
- better renal replacement - because also good for anaemia and renal bone disease
- Costs less in long term
- prolongues life
- good for quality of life
RISKS:
- older and sicker patients not eligible
- immunosuppression (increased infection and malignancy)
- surgical complications
- worse off if the transplant fails
how do you predict survival of patients on dialysis?
What do it take into account
body mass index
heart failure
peripheral vascular disease
dysrhythmia
active malignancy
severe behavioural disorder
total dependency
unplanned dialysis
Is dialysis always beneficial?
no study where people over 75 year of age with 2 comorbidities were put on dialysis
SURVIVAL Was the same
What BMI is considered high (obese) in white and asian people
white - 25
asian- 23.9
SOme is obese what would you advise him regarding gym
A. encourage regular exercise
B. ban him from doing any exercise at all and recommend rest adn repeat of his BP
C. advise him to see his GP beofre allowing him to exercise in the gym
D. refer him to casualty for blood pressure control
A. encourage regular exercise
if someone has hypertension what would you look for
Fundoscopy
What happens in the different grades of hypertension?
Grade 1: silver wiring
Grade 2: AV nipping
Grade 3: flame shaped haemorrhage
Grade 4: papilloedema
What could papilloedema indicate
high ICP- possibly brain tumour
hypertension
WHat are feature of long standing hypertension exist
left ventricular hypertrophy (ECG)
feel a heave
hear a bruit
hear an S4
WHat grade is this
grade 3
see flame haemorrhage
What are 6 causes of hypertension
- Conn’s
- Cushing’s
- Phaechromocytoma
- renal artery stenosis
- Acromegaly
- co arctation of the aorta
- essential
What are investigation would you like to do?
if someone presents with hypertension
- FBC
- U&E low K+ high Sodium
- ECG look for LVH
- Urinalysis (renal disease and nephritis)
- Fasting glucose
- Lipids
What percentage of people have secondary hypertension
10%
What are specific investigations to diagnose secondary causes of hypertension
renin aldosterone ration
24 hour urine for catecholamines
24 hour urine cortisol
glucose tolerance test
Someone presents with
renin 0.4 (1.1-4.5)
aldosterone 1600 (100-450)
24 hour urine catecholamine normal
What does he have
Conn
How do you treat conn’s
surgery remove it
patient presents with
renin: 7.4 (1.1-4.5)
aldosterone: 900 (100-450)
24 hour urine catecholamines is normal
What does this patient have
renal artery stenosis
What is the gold standard way of diagnosing renal artery stenosis
Digital subtraction angiogram
what does this patient have?
Renin: 2.4 (1.1 -4-5)
Aldosterone: 300(100-450)
24 hour urine for catecholamines RAISED
phaechromocytoma
how does phaechromocytoma present?
anxiety
palpitation
headache
sweating
What is the treatment for phaechromocytoma?
MEDICAL EMERGENCY
alpha blockade
How do you manage a phaechromocytoma
- alpha blockade (rehydrate if needed)
- beta blockade
- localise the lesion
- surgery (many weeks after alpha blockade)- laprascopic adrenalectomy
What does an MIBG scan show
is a radioactive scan and shows where the tumour is
the bladder always lights up
How do you treat essential hypertension?
