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).
