dm and nephropathy Flashcards
dm nephropathy
HTN from dm
Progressively increasing proteinuria
• Progressively deteriorating kidney function
• Classic histological features
why important
- Associated morbidity and mortality
- Health care burden
- Treatment options present
summarise the increased risk of CVS with kidney disease
o Risk double in dm
o Risk worse with CKD
o With both much higher risks
where can histological changes occur
glomerular
vascular
tubointerstitial
summarise the glomerular histological changes
Mesangial expansion
– Basement membrane thickening
– Glomerulosclerosis
epidemiology of nephropathy in dm
• Type 1 DM : 20-40% after 30-40 years probably same in T2 but: Age at development of disease - die first, however survival is increasing now = more nephropathy • Racial Factors • Age at presentation • Loss due to cardiovascular morbidity
clinical features of diabetic retinopathy
progressive proteinuria - screened for this, albumin and creatinine measured from 1st diagnosis - at first signs of proteinuria give ACEi
increased BP
deranged renal function
proteinuria levels
Normal Range <30mg/24hrs • Microalbuminuric Range 30 - 300mg/24hrs • Assymptomatic Range 300 - 3000mg/24hrs • Nephrotic Range >3000mg/24hr
how do you control nephropathy
hyperglycaemia control
bp control
inhibition of RAAS
stop smoking
summarise how BP control helps nephropathy
o As renal func worse with no treatment GFR fall
o As control BP – rate of fall of GFR changes (reduces)
o So tightly control BP minute get microa to reduce the rate of fall
summarise effect of inhibition of RAAS
o Captoprim – 1st ACEi – reduce risk of renal failure
Immediately things get worse then they get better eventually
Should not be used in renal artery stenosis
They prevent end stage renal failure in pts with new microalbuminuria
o ARB – block later in pathway – reduce incidence of renal failure
mechanism of how ACEi help renal function
- ANG2 – squeeze arteriole and maintain GFR
- ACEi – ACE fall – BP fall = reduction in albuminuria, GFR will also fall a bit and creatinine will rise a bit - fine
- If renal artery stensosis because of atheroma – drop in pressure – JGA = more renin= more ACE – squeeze arteriole tight – pressure high but flow poor because afferent blocked. This push out GFR. If give ACEi – pressure fall and so GFR fall a lot possibly to 0. If want to sacrifice kidney this is a way to do it – pressure can damage other kidney. Stop peeing if stenosis – ACE CI = creatinine rocket
- As long as pt doesn’t go into pul oedema – stop ACE – pressure rise – start peeing. So if pee before breathless fine
- Measure creatine before start, if shoot up then stop ACE
does nephropathy effect all pts
no - small number dont get it
implications of renal failure
electrolyte misbalance - hyperkalaemia = arrhythmias, hyponatraemia
acidosis
fluid retention
retention of waste - small molecules (urea, creatinine, urate), phosphate, middle molecules (peptides, B2-microalbumin)
secretory failure - erythropoietin, 1,25 vit D
anaemia exacerbates tiredness
renal bone disease - aches and pains, pruritis
symptoms of renal failure
tiredness, lethargy SOB, oedema pruritis nocturia cold twitching poor appetite nausea loss of/nasty taste weight loss
consequences if no renal replacement treatment
hyperkalaemia = arrhythmias, cardiac arrest pul oedema (most common presentation) nausea, vom malnutrition/cachexia fits increasing coma death
options for renal replacement
– not cure, replace 1 long term condition for another
o Dialysis – peritoneal (home) or haemodialysis (mainly hospital based - can be done at home)
o Transplantation
aims of renal replacement treatment
maintain QOL improve symptoms correct electrolyte and acid-base status remove waste products restore fluid balance
when to start dialysis
o Don’t want to wait until people come in in an emergency = worse outcomes
conversation started with eGFR <20ml/min
education - risks of renal failure, types of RRT
establish access to chosen RRT - fistua for HD, catheter for PD, transplant assessment
o <10 – do benefits outweigh risk
o <6 and no reversible features -high risk sudden death
o Life threatening complications
benefits of dialysis
improve uraemic symptoms -tiredness, nausea, pruritis
correct fluid balance - less SOB and oedema
avoid life threatening events - severe acidosis, severe hyperkalaemia, pul oedema resistant to diuretics
risks of dialysis
dialysis related complications - infection, access related, in HD: hypotension, arrhythmias
effect work, family life and travel - QOL
doesnt help:
getting old
lack of erythropoietin - anaemia
lack of vit D - hyperparathyroidism, renal bone disease
comorbidities - SLE, dm, vascular disease
summarise haemodynamic dialysis (HD)
o Blood from fistula in wrist through dialyser (rods) and bathed by dialysate. Machine makes the dialysate by reverse osmosis water which is mixed with concentrate. Dialysate exposed to blood then goes down drain
o Hospital – 3x wk but only 4hr but 6hr recovery and transport, and hanging around waiting
o Vascular access – catheter into jug vein or arteriovenous fistula
o QOL – doesn’t invade home, limit work and travel so lose independence
summarise peritoneal dialysis
o Fluid into abdo and it drains out – uses peritoneal lining
o Slower and more gentle – done at home
o Manual bags or cycling machine – attached to person at night, useful for people who work
o Home based
o Daily and continuous
o Less haemodynamic stress
o Limited by access to peritoneum and ability to do technique – have technicians come in -less expensive than HD
o Avoids swings of HD
o Less dietary and fluid restrictions
how does renal failure affect the brain
• Neuropathy and fits because of uraemic toxins – damage nerve endings = change in brain activity – cognitive problems main issue. Reversed by dialysis. Problem with vascular dementia
benefits of transplants
o Better renal replacement – GFR goes up to 50
o Improvement in metabolic disorders - anaemia, renal bone disease
o 1st year expensive but long term cheaper
o Better QOL
o Avoids disadvantages of dialysis, easier to maintain independence
disadvantages of transplant
older and sicker not eligible,
immunosuppresion - increased infection and malignancy.
Not a cure – surgical complications, a lot of hospital visits
o Median survival 10-15yrs
often worse off if/when the transplant fails
important outcomes of dialysis for patients/caregivers
ability to travel dialysis adequacy dialysis free time fatigue anaemia BP impact on family/friends washed out after dialysis
important dialysis outcomes for medical professionals
vascular access problems cardiovascular disease death/mortality drop in BP hospitalisation fatigue infection/immunity ability to work
decision to start dialysis - pt perspective
relief of symptoms
achieve quality of life goals - interactions, physical activity, mental activity
extend life with good quality
avoid complications of treatment
decision to start dialysis - dr perspective
sick pt - have to do something
meets criteria
belief it will benefit
spaces in unit need filling - especially private
pt might not do well but lets give dialysis a try, easier than a ling converstaion about prognosis
considerations for the old on dialysis
o Multiple comorbid o Impaired physical and cog function o Malnourished o Depressed o Social isolation o Vision o Hearing o Social support
prognosis of end stage kidney disease
o Survival with end stage kidney disease is worse than with some cancers. Av
what is the scoring system for 6mo prognosis in pts >-75yr
BMI <18.5 = 1 point
CHF stages 3-4 = 2 points
peripheral vascular disease stage 3-4 = 2points
dysrhythmia = 1 pint
active malignancy = 1 point
severe behavioral disorder = 2points
total dependancy for transfers = 3 points
unplanned dialysis = 2points
• More points – less likelihood of being alive after 6mo of having started
importance of looking at people’s prognosis score
• If we don’t dialyse people with high score >75m and >2 comorbidities – people who started and people who had conservative – survival is identical – no advantage for this gp to start
dialysis autonomy
must have accurate and realistic info to make appropriate decision
pts cannot demand inappropriate treatment
not relevant if lack capacity
dialysis beneficience
prolong survival
improve QOL
improve symptom burden
dialysis avoid harm
shouldnt shorten survival - if cardiac problems and then you do HD and drop their BP = fatal arrhythmia, profound hypotension, stroke,
have no improvement/worsem QOL
increase symptom burden
dialysis justice
limited resources in all health care systems
dialysing pts who wouldnt benefit = less available for people who would, money/resources not available for other healthcare needs
considerations for dialysis/conservative care
pt outcomes - QOL, symptoms, physical functioning, hospitalisation
survival
conservative care
o Non-dialysis pathway, shared decision making with predialysis team
o People remain with ok functional status right until the end
active management of anaemia with ESA or IV iron
BP control - slow rate of decline and lower stroke risk
optimise fluid balance - avoid over and under hydration
symptom control, including pain
joint managemnet with palliative care team at end of life phase
supportive care
care that helps patient and family to cope with condition and treatment from prediagnosis, through diagnosis and treatment, to cure, continuing illness or death, into bereavement
helps pt maximise the benefits of treatments and to live as well as effects of the disease
as important as diagnosis and treatment
role of supportive care in advanced CKD management
combined with aggressive treatment from the start
aggressive - dialysis, transplant, access, surgery, AB
supportive - pain control, symptom control, psycho-social support, awareness of pt goals and concerns
what is palliative care
management of all frail older pts with chronic disease is palliative care
enables people with progressive and/or life threatening conditions who are approaching end of life to live according to their wishes and preferences where ever possible
achieving the aims of supportive care
communication with pt and family, symptoms and pain control, realistic prognosis
awareness of pt being near end of life
advance care planning = better end ol life care, pt and family satisfaction and reduces stress, anxiety and depression in surviving relatives
appropriate active interventions - AB, dialysis, ventilation and discussing withdrawal where appropriate, or not starting
early palliative care improves survival
