Extras Flashcards
CKD notes (Dr. Pettit) - CKD
- Ask what the % of kidney function is. They may not know Cr/GFR
- If a diabetic has no proteinuria, likely they have more ischaemic nephrosclerosis or hypertensive.
- As Cr declines, less insulin gets excreted → better control of diabetes and hypo.
- Beware of ADPKD, familial GNs and Alports (less likely if deafness) given the virtual exam. Need to ask if family been screened
- HTN Mx in CKD - ACE/ARB, CCB, diuretics then BB (3rd line usually earlier if other indications).
- Sick day plans: don’t take metformin/SGLT2 - when they get sick***.
- ADPKD - Vaptan - slow uptake. Generally not that keen.
- Advanced CKD - early Bariatric surgery better if for transplant. Reasonable thing to mention in LC (before renal function becomes too bad).
- Phosphate binders - should be taken with food. Calcium carbonate (important agent to bind phosphate), Magnesium (as phosphate binder), Aluminium (no teeth),
- Dentition is extremely important - correlated to increased risk of poor outcome - always think how are they are going to take meds, nutrition…etc.
dialysis/transplant patient - are they still coming up on the exam?
- Often resonium or newer, better tasting “Patiromir” are used to keep patients on Spinorolactone.
- Micera (4 weekly), Aranesp (1-2 weekly)
- Bone health: Vit D (main factor and the most important), cautious Ca, and restrict phosphate with aim to push PTH down.
- Osteoporosis - a lot more challenging (we don’t know whether it truly is! vs. adynamic bone disease…etc). So phosphate restriction incredibly important.
Tuesday Dr Pettit is relatively free.
Dialysis (Dr Pettit) notes
- APD is very easy to use - machine can be programmed remotely by clinician or technicians.
- CAPD (fluid on all the time, and patient changes fluids)
- PD catheters are usually done by surgeons (vascular) - needs 3 weeks rest before can be used.
- Obesity - relative complication.
- AVF is first line, next line is AV graft - thrombosis/infection is problem.
- bag 0.5, 1.5, 2.5, 4.25, 7.5% (purple - Ichadextrine - does not get absorbed as much as glucose. Others do, and if left for too long, can absorb glucose) - one of the problem is glucose enters - suppresses appetite - they eat no protein - malnutrition. So low-protein diet probably isnt’ a good idea. So these patients can be malnourished but at the same time get obese.
- Higher concentration, more volume out.
- The most important for LC is the impact - on family, patient, do they feel crap all the time, getting to and from dialysis, mental health, sexual health.
- Remember that high fluid gain between dialysis and hypotension is strongly linked to mortality.
- Generally don’t offer dialysis unless life-expectancy >2y.
Transplant (Pettit)
- Note age difference of the donor and recipient
- Life-expectancy should be >5 years to be considered.
- MTX = Cellcept or Myfortic
- AZA remember CI allopurinol.
- mTOR - lung disease (interstitial pneumonitis, pulmonary fibrosis - but uncommon)
- Having transplant still means patient has ESRD
Family planning (Dr Pettit)
A chance to shine!
Any women <50 - consider fertility, and bring this issue up.
Always ask if she has children and if she wants more.
Ask about pregnancy-related complications, fetal complications (e.g. higher risk of prematurity, fetal loss risk)
cR <130, Egfr <40 ASSOCIATED WITH PREGNANCY ASSOCIATED RENAL OUTCOME
they may end up in dialysis at the end of pregnancy - need to speak to patient
will mum be around to look after baby - i.e. if go on dialysis, can go on to die.
ACE/ARB - can continue until conception if proteinuric (risk outweighs the benefit)
Switch to pregnancy compatible - nifedipine, prazocin, labetolol.
Aspirin is safe and used.
Statins generally ok.
Low dose steroids is fine
CNI (cat C) - generally safe to continue
MMF (category X!)
iMMUNE therapy generally OK.
If in doubt, say you don’t know but know where to look - Mothersafe, Excellent resources
IVF is a big ticket item! - freeze eggs, ovarian tissue, embryos - is it safe to delay therapy?
Risk of IVF - drugs (to push out the eggs) and ovarian hyperstimulation syndrome
Ask if women all on contraception** - not on medication list. Approach: Are you planning for any more baby. Are you on any contraception (they may say “oh no” - !). Is it an appropriate strategy?
