Hypertension, CKD, and hyperlipidaemia Flashcards
stepwise ladder of hypertension
- CCB or ACEi
- add other
- An ACE inhibitor or ARB (consider an ARB in preference to an ACE inhibitor in people of black African or African-Caribbean family origin), and
A CCB, and
A thiazide-like diuretic.
causes and risk factors for CKD
HTN, DM, CVD, AKI, nephrotoxic drugs, obstructive uropathy
CKD complications
AKI
HTN
CVD
renal anaemia
mineral and bone disorder
ESRD
death
initial investigations CKD
Serum creatinine and eGFR.
Early morning urine sample to measure the ACR.
Urine dipstick test to check for haematuria.
Body mass index (BMI), blood pressure, and serum HbA1c and lipid profile to assess for cardiovascular risk factors.
A renal tract ultrasound if indicated, such as suspected urinary tract stones or obstruction, or a family history of polycystic kidney disease.
CKD monitor
eGFR and urine ACR, a full blood count to exclude renal anaemia, and serum calcium, phosphate, vitamin D, and parathyroid hormone tests to exclude renal metabolic and bone disorder, depending on the severity of CKD.
referral to nephrology specialist guidlines
eGFR of less than 30 mL/min/1.73 m2.
Accelerated progression of CKD.
A urinary ACR of 70 mg/mmol or more, unless known to be associated with diabetes mellitus.
A urinary ACR of 30 mg/mmol or more together with persistent haematuria, after exclusion of a urinary tract infection (UTI).
Uncontrolled hypertension.
A rare or genetic cause of CKD.
Suspected renal artery stenosis.
A suspected complication of CKD.
primary care management CKD
provide info and support
manage risk factors
avoid over use of NSAID
assess for HTN and CVD
prescribe low cost ACEi
influenza and pneumococcal vaccines
clinical features of CKD
lethargy, itch, breathlessness, cramps (often worse at night), sleep disturbance, bone pain, or loss of appetite, vomiting, weight loss, and taste disturbance
Urine output, such as polyuria (tubular concentrating ability is impaired); oliguria; nocturia (due to impaired solute diuresis or oedema); or anuria (due to possible acute kidney injury [AKI], obstructive uropathy causing urinary retention; or end-stage renal disease)
neprotoxic drug use
risk factors
co morbidities or complications
family hx- APKD
anxiety or depression
progressive CKD clinical features
Uraemic odour (ammonia-like smell of the breath, may be present in advanced disease).
Pallor (due to renal anaemia).
Cachexia and signs of malnutrition.
Cognitive impairment (language, orientation, and attention may be particularly affected).
Dehydration or hypovolaemia (risk of AKI). See the CKS topic on Acute kidney injury for more information.
Tachypnoea (may be due to fluid overload, anaemia, or co-morbid ischaemic heart disease). See the CKS topic on Angina for more information.
Hypertension (may be primary or secondary to CKD itself). See the CKS topic on Hypertension for more information.
Palpable bilateral flank masses with possible hepatomegaly (suggests polycystic kidney disease with possible liver cysts).
Palpable distended bladder (suggests obstructive uropathy).
Peripheral oedema (may be due to renal sodium retention, hypoalbuminaemia, or co-morbid heart failure). See the CKS topic on Heart failure - chronic for more information.
Peripheral neuropathy (may present with paraesthesia, sleep disturbance, and restless legs syndrome) or myopathy. See the CKS topic on Restless legs syndrome for more information.
Frothy urine (may indicate proteinuria).
2 week wait
isolated peristent haematuria
primary care management CKD
monitor
tests
lifestyle factors
treat underyling cause
lipid modification
referral
assess for HTN
stop any potentially nephrotoxic drugs
depression/anxiety
nephrotoxic drugs stopped in AKI
NSAIDS
ACEi
ARB
diuretics
summary poster NICE guidlines HTN
see notability
stages of HTN
Stage 1 hypertension — 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 hypertension — 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 HTN
increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve).
same day specialist assessment
A clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension) 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.
management HTN primary care
liferstyle advice
consider anti hypertesnive
consider statin
monitor
review annually
target clinic blood pressure
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.
Frailty or multimorbidity — clinical judgement should be used.
clinic blood pressure measurement and guidance
If blood pressure measured in the clinic is 140/90 mmHg or higher, take a second measurement during the consultation.
If the second measurement is substantially different from the first, take a third measurement.
Record the lower of the last two measurements as the clinic blood pressure.
If the person’s blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension
investigations to test for target organ damage
Test for haematuria.
Arrange measurement of:
Urine albumin:creatinine ratio (to test for the presence of protein in the urine).
HbA1C (to test for diabetes).
Electrolytes, creatinine, and estimated glomerular filtration rate (to test for chronic kidney disease).
Examine the fundi (for the presence of hypertensive retinopathy).
Arrange for a 12-lead electrocardiograph to be performed (to assess cardiac function and detect left ventricular hypertrophy).
first line - ACEi indications
Are aged under 55 years and who are not of black African or African-Caribbean family origin.
Have type 2 diabetes (irrespective of age or family origin. As above, use an ARB in preference to an ACE for people of black African or African-Caribbean family origin.)
If an ACE inhibitor is not tolerated, for example, because of cough, offer an ARB.
Do not combine an ACE inhibitor with an ARB to treat hypertension.
first line - CCB indications
e aged 55 years or over and do not have type 2 diabetes.
Are of black African or African-Caribbean family origin and do not have type 2 diabetes (of any age).
If a CCB is not tolerated, for example, because of oedema, offer a thiazide-like diuretic, such as indapamide.
HF + HTN
first line - thiazide like
stepwise tx of HTN
SEE NOTABILITY!!!
blood pressure targets based on age
Adults aged under 80 years — clinic blood pressure below 140/90 mmHg.
Adults aged 80 years and over — clinic blood pressure below 150/90 mmHg.
suspect familial hypercholesterolaemia/dyslipidaemia
total cholesterol conc >7.5mmol/L and/or personal or family hx of premature CHD (event before 600 in first degree relatives or index person)
clinical features of familial hypercholesterolaemia
tendon xanthomas
premature arcus senilis
secondary hypercholesterolaemia
caused by conditions or drugs
conditions causing hypercholesterolaemia
kidney disease - nephrotic syndrome
DM
PCOS
hypothyroidism
liver disease
pregnancy
anorexia nervosa
medications causing hypercholesterolaemia
birth control pills
diuretics
steroids
antiretrovirals for HIV
beta blockers
androgens
ciclosporin
statins groups
high – 20-80mg
medium - 10mg daily
low intensity
primary prevention screening
QRISK
conditions caused by atherosclerosis
CHD
stroke
TIA
peripheral arterial disease
blood lipid profile CVD
Total cholesterol is an important predictor of CVD events. However, non-high density lipoprotein cholesterol (non-HDL-C) — the difference between total and HDL-C is a powerful risk factor
A raised triglyceride level is a risk factor for CVD and is independent of total cholesterol.
primary prevention, 20mg atorvastatin indications
type 1 DM and aged >40 or established MD FOR >10 yrs or have established nephropathy or other CVD risk factors
85 or older
84 or younger if QRISK is 10% or more
CKD or familial hypercholestolaemia
secondary prevention, 80mg atorvastatin indications
people with existing CVD (for example past or current history of myocardial infarction, angina, stroke, transient ischaemic attack, or peripheral arterial disease
aim of lipid modification
a greater than 40% reduction in non-HDL-C levels.
before starting lipid modification bloods
A non-fasting lipid profile.
Liver function tests (transaminases).
Renal function, including estimated glomerular filtration rate.
HbA1c.
Creatine kinase (if the person has persistent generalized unexplained muscle pain).
Thyroid stimulating hormone, if dyslipidaemia is present.
