HTN, CKD, Lipids Flashcards
Define, HT including the diagnostic criteria
Know the symptoms and complications of, hypertension (HT)
Diagnosis:
systolic blood pressure above or equal 140 mmHg, or diastolic above or equal to 90 mmHg.
The diagnosis is then confirmed with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).
Hypertension is classified according to severity:
Stage 1 — clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.
Stage 2 — clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
Stage 3 or severe hypertension — clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
Accelerated (or malignant) hypertension is a severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve).
If very raised patients may experience:
headaches
visual disturbance
seizures
Complications - end organ damage
hypertensive retinopathy
renal disease
left ventricular hypertrophy or ischaemic heart disease
Familial hypercholesterolaemia
This should be suspected if:
• Total cholesterol concentration is greater than 7.5 mmol/L and/or
• There is a personal or family history of premature CHD (an event before 60 years in an index person or first- degree relative [parents, siblings, children]).
In people with familial hypercholesterolaemia, you may see tendon xanthomas or premature arcus senilis.
These patients are at high risk of CVD and should receive high-intensity lipid lowering treatment. As these are inherited conditions, there is also a need for genetic counselling. Generally, specialist involvement is needed.
Define hyperlipidaemia and recognise the significance of a raised QRISK score.
Symptoms, management
CKD diagnosis + investigations
Chronic kidney disease = abnormalities in kidney function or structure present for more than 3 months with associated health implications.
Should be diagnosed in people with either of the following for a minimum of 3 months:
GFR less than 60 mL/min/1.73 m2 on two occasions 90 days apart
Markers of kidney damage:
urinary albumin:creatinine ratio (ACR) greater than 3 mg/mmol - Early morning urine sample
urine sediment abnormalities
electrolyte and other abnormalities due to tubular disorders
abnormalities detected by histology
structural abnormalities detected by imaging - eg renal tract ultrasound, shows urinary tract stones or obstruction or polycystic kidney disease.
history of kidney transplantation.
Suspect and arrange investigations in people with:
Risk factors for CKD.
An incidental finding of:
Raised serum creatinine / serum eGFR of less than 60 mL/min/1.73 m2.
Proteinuria (a urinary albumin:creatinine ratio [ACR] of 3 mg/mmol or more).
Persistent haematuria (two out of three urine dipstick tests show 1+ or more of blood), after exclusion of a urinary tract infection (UTI).
Urine sediment abnormalities, such as red blood cells (may indicate glomerular disease); white blood cells (may indicate pyelonephritis or interstitial nephritis); or granular casts and renal tubular epithelial cells.
Possible clinical features of CKD. Be aware that the disease is often asymptomatic in the early stages.
Investigations:
eGFR
Serum creatinine
Early morning urine sample for ACR
Urine dipstick for haematuria
A renal tract ultrasound, if indicated, such as suspected urinary tract stones or obstruction or a family history of polycystic kidney disease.
BMI, BP, Hba1c, lipids for CVS risk factors
Know the symptoms and complications of Chronic Kidney Disease (CKD)
Most likely asymptomatic
Signs and symptoms:
Lethargy, itch, breathlessness, cramps (often worse at night)
Sleep disturbance, bone pain, poor appetite
Weight loss, nausea and vomiting
Urine output, such as polyuria (tubular concentrating ability is impaired), nocturia (due to impaired solute diuresis or oedema), or oliguria (urine output less than 0.5 ml/kg/hour).
Medication history, eg potentially nephrotoxic drugs, FH, CVS risk factors.
Examine for signs of progressive CKD, such as:
Cachexia and signs of malnutrition.
Cognitive impairment (language, orientation, and attention affected).
Dehydration or hypovolaemia (risk of AKI).
Dyspnoea (may be due to fluid overload, anaemia, or comorbid ischaemic heart disease).
Frothy urine (may indicate proteinuria).
Hypertension (may be primary or secondary to CKD itself).
Pallor (due to renal anaemia).
Presence of a flank mass (suggesting possible renal cysts or malignancy).
Palpable distended bladder (suggests obstructive uropathy).
Peripheral oedema (may be due to renal sodium retention, hypoalbuminaemia, proteinuria).
Peripheral neuropathy (may present with paraesthesia, sleep disturbance, and restless legs syndrome) or myopathy.
Rashes — ecchymosis and purpura (caused by haematological consequences of CKD), or signs of other systemic causes (for example, lupus).
Uraemic odour (ammonia-like smell of the breath).
Complications:
AKI, hypertension, CVD, renal anaemia, renal mineral and bone disorder, end-stage renal disease (ESRD), and increased all-cause mortality.
CKD RF
hypertension, diabetes mellitus, CVD, AKI, nephrotoxic drugs, and obstructive uropathy.
CKD monitoring + referral
monitoring for disease progression should include:
Measuring eGFR and urine ACR
full blood count to exclude renal anaemia
serum calcium, phosphate, vitamin D, and parathyroid hormone tests to exclude renal metabolic and bone disorders
HBA1C
BP, BMI
Medication review to see if improving BP etc
Referral to a nephrology specialist should be arranged if there is:
A five-year risk of needing renal replacement therapy of greater than 5%.
Accelerated progression of CKD.
persistent haematuria, after exclusion of UTI
Uncontrolled hypertension.
A suspected complication of CKD.
Management CKD
Management in primary care:
Managing risk factors and comorbidities.
Offer ACEi or ARB.
Offering atorvastatin and an antiplatelet.
Considering offering a sodium-glucose cotransporter-2 (SGLT-2) inhibitor.
Providing sources of support.
Ensuring the person is offered immunizations for influenza and pneumococcal disease.
Advise on healthy lifestyle measures, such as:
Stopping smoking, alcohol in moderation, healthy body weight, regular exercise, a healthy diet.
Specialist dietary advice about potassium, phosphate, calorie, and salt intake may be arranged.
Advise to avoid NSAIDs and stop dietary supplements (such as creatine).
Advise on the increased risk of acute kidney injury (AKI) if there is severe, intercurrent illness
BP less than 140/90
Classification of CKD
ACR category
A1: normal to mildly increased -Less than 3 mg/mmol
A2: moderately increased - 3–30 mg/mmol
A3: severely increased - Over 30 mg/mmol
eGFR category
G1: normal or high - 90 ml/min/1.73 m2 or over
G2: mild reduction related to normal range for a young adult - 60-89 ml/min/1.73 m2
G3a: mild to moderate reduction - 45-59 ml/min/1.73 m2
G3b: moderate to severe reduction - 30-44 ml/min/1.73 m2
G4: severe reduction - 15-29 ml/min/1.73 m2
G5: kidney failure - Under 15 ml/min/1.73 m2
G1 + A1 = Low risk - (Not CKD in the absence of markers of kidney damage). G1 + A2 = Moderate risk. G1+ A3 = high
G2 + A1 = low risk, + A2 = moderate risk, + A3 = high
G3a + A1 = mod, +A2 = HIGH, +A3 = V HIGH
G3b + A1= high, A2 = V HIGH, + A3 = V HIGH
G4 + A1,2,3 = V HIGH
G5 + A1, A2, A3 = V HIGH
Note: a significant increase in serum creatinine, for example by more than 20%, may indicate significant renal impairment in the presence of normal eGFR readings.
How should I prevent acute kidney injury?
If a person has risk factors for developing acute kidney injury (AKI):
Arrange regular monitoring of serum creatinine.
Arrange regular monitoring of renal function
Arrange close monitoring of renal function if a person has an acute illness, especially if there is diarrhoea, vomiting and/or signs of dehydration.
Explain the risk of developing AKI is increased with:
Acute illness and inability to maintain fluid intake (such as diarrhoea and vomiting), and/or
Specific medications that may need to be temporarily stopped during intercurrent illness due to risk of hypovolaemia and/or nephrotoxicity.
This is particularly important in people with:
CKD with an (eGFR) less than 60 mL/min/1.73 m2.
Neurological or cognitive impairment or disability
Review the need for specific medications that may worsen renal function.
HTN management - targets, tests, when to refer
While waiting for confirmation of a diagnosis of hypertension, the person should be offered:
Investigations for target organ damage and for secondary causes of hypertension - hba1c, lipids, serum creatinine, LFTs, eGFR
Assessment of cardiovascular risk.
Referral for same-day specialist assessment should be arranged for people with:
A clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema or life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
Suspected phaeochromocytoma, for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis.
For all other people with hypertension, management includes:
Offering lifestyle advice
Ambulatory or home BP monitoring for a week - 2x - morning + night. Considering the need for antihypertensive drug treatment.
Considering the need for statin treatment, following CVS risk assessment.
Monitoring response to lifestyle changes and drug treatment.
Reviewing the person annually.
Target clinic blood pressures are:
Age under 80 years — clinic blood pressure below 140/90 mmHg; ABPM/HBPM below 135/85 mmHg.
Age 80 years and older — clinic blood pressure below 150/90 mmHg; ABPM/HBPM below 145/85 mmHg.
Postural hypertension — blood pressure target should be based on standing blood pressure.
Risk calculator
Using the patient’s Urine, Sex, Age and eGFR, the kidney failure risk equation provides the 2 and 5 year probability of treated kidney failure for a potential patient with CKD stage 3a to 5.
High cholesterol Statins side effects, interactions
Can cause CVS and kidney problems
Counsel liver problems
Muscle aches for rhabdomyolysis
Interactions - grapefruit juice
Alternatives - ezetimibe, bempedoic acid,
Lipid management
In people with a QRISK of 10% or more (including people with type 2 diabetes), people with type 1 diabetes, CKD, or familial hypercholesterolemia, and people aged 85 and older:
If lifestyle change alone is ineffective or inappropriate, Atorvastatin 20 mg daily should be offered
Before statin treatment is started:
Assess for secondary causes of dyslipidaemia - excess alcohol intake, uncontrolled diabetes, liver disease, nephrotic syndrome. hypothyroidism
Clinical assessments and tests:
Smoking status, Alcohol consumption, BP, BMI.
Measure a non-fasting full lipid profile (if it has not already been done)
LFTs - If ALT or AST is greater than 3 times the upper limit of normal, do not start statin treatment. Repeat in 4 weeks.
Renal function (including eGFR)- Specific doses are recommended depending on the stage of CKD.
TFTs
Stop 3 months before conceiving and start again only after done breastfeeding.
If statins are contraindicated, ezetimibe may be considered.
If the person declines lipid-lowering treatment: Record their choice in their medical notes and advise that their CVD risk should be reassessed at a later date.
Lipid follow up
2-3 Months After Starting Statin Therapy
Non-Fasting Full Lipid Profile: Repeat to assess response to treatment. The goal is a 40% reduction in non-HDL cholesterol from baseline.
Liver Transaminase (ALT/AST): Re-check to ensure there are no adverse effects on liver function. If ALT or AST rises to more than three times the upper limit of normal, consider stopping the statin temporarily and investigating further.
Annual Follow-Up
Non-Fasting Full Lipid Profile: To monitor cholesterol levels and ensure targets are being maintained.
Liver Transaminase (ALT/AST): Annual liver function testing if levels were stable at the 2-3 month follow-up.
Annual medication review
