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PHAR 255 > Kidney 2 > Flashcards

Kidney 2 Flashcards

1
Q

What is the leading cause of CKD?

A

Diabetes

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2
Q

What are many CKD guidelines nes based on?

A

Opinion or preference of doctor due to limited evidence from lack of RCTs

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3
Q

What is CKD

A

Progressive loss of kidney function occurring over several months to years

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4
Q

How is CKD characterized?

A

By gradual replacement of normal kidney architecture with fibrosis

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5
Q

What are the two main causes of CKD?

A

Diabetes and hypertension

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6
Q

Definition of CKD by kidney function or kidney structure

A

GFR </= 60mL/min/1.73m2 for 3 months or more, with or without kidney damage OR
Kidney damage for >/= 3 months, with or without decreased GFR, as evidenced by pathological abnormalities, abnormalities in blood or urine, or as seen by renal imaging

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7
Q

What are the markers of kidney damage?

A

Albuminuria (ACR >/= 3mg/mmol)
Urine sediment abnormalities
Abnormalities detected by histology (from biopsy)
Structural abnormalities detected by imaging
History of kidney transplantation

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8
Q

What are the new “rethought” GFR thresholds for CKD?

A

<40yrs = < 75ml/min
40-65yrs = <60ml/min
>65yrs = <45ml/min (because we see a decline with age and it doesn’t always mean its CKD)

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9
Q

What are the stages of CKD with their related GFR?

A

G1 = >/= 90ml/min
G2 = 60-89ml/min
G3a = 45-59ml/min
G3b = 30-44ml/min
G4 = 15-29ml/min
G5 = <15ml/min

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10
Q

What are the stages of CKD by albuminuria category(ACR)?

A

A1 = <3mg/mmol
A2 = 3-30mg/mmol
A3 = >30mg/mmol

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11
Q

To determine the GFR category, what equation would you use to estimate GFR?

A

CKD-EPI

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12
Q

What is the clinical presentation of CKD?

A

Often asymptomatic which is why screening is important
- low energy, fatigue, confusion
- foaming, tea-colored, blood or cloudy urine
- edema
- SOB
- pruritis

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13
Q

What are the goals for overall care in CKD?

A

Delay progression of CKD
CV risk reduction
Treat complications of CKD
Renal replacement therapies (RRT)

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14
Q

What type of CKDs may undergo remission?

A

Autoimmune

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15
Q

What is associated with seeing a faster decline in GFR?

A

Lower GFR and greater albuminuria

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16
Q

Which CKD etiologies of CKD tend to progress more quickly?

A

Diabetic nephropathy
Glomerular diseases
Polycystic kidney disease
Kidney disease in transplant recipients

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17
Q

Which CKD etiologies tend to progress more slowly?

A

Hypertensive kidney disease
Tubulointerstitial diseases

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18
Q

What factors are associated with faster progression of CKD?

A

African-American race
Male
Advanced age
Family history
-
Uncontrolled HTN
Poor BG control
Proteinuria
Smoking
Obesity

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19
Q

What are the interventions to delay progression of CKD?

A

BP control
RAAS blockade - ACEi/ARB or non-steroidal MRAs
BG control in diabetes - SGLT2i and GLP-1 agonists
Smoking cessation
Avoidance of nephrotoxins

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20
Q

What is the difference in decline of GFR between controlled vs. Uncontrolled HTN?

A

Controlled BP <130/80 = GFR declines by 1-2ml/min/year
Uncontrolled BP = GFR declines by 12ml/min/year

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21
Q

What are the BP targets as per the HTN guidelines?

A

<130/80 for diabetic CKD
SBP <110 for adults with polycystic kidney disease
SBP <120 for “high risk” patients
SBP <140 for all other patients

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22
Q

What are the BP targets based on the KDIGO HTN guidelines?

A

SBP <120 for patients with high BP and CKD(not on dialysis), when tolerated
SBP <130/80 for kidney transplant recipients

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23
Q

Which of the following criteria were excluded from the SPRINT trial?
A. eGFR 20-59ml/min
B. Proteinuria <1g/d
C. Framingham risk score >/= 15%
D. Diabetes mellitus
C. Clinical CVD

A

D. Diabetes mellitus

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24
Q

What are the clinical indications for SBP <120?

A

AARF* (high risk patients)
Age > 75
Atherosclerosis (CVD disease)
Renal (CKD)
Framingham risk score >15%

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25
Q

What are the cautions and CI for SBP <120?

A

HF or recent MI
Diabetes mellitus
Previous stroke
eGFR < 20ml/min (includes dialysis and transplant)
*Standing SBP < 110
*Inability to measure SBP accurately
*Known secondary cause of HTN

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26
Q

What was the result of the SPRINT trial?

A

SBP <120 did not slow CKD progression (perhaps worsening, no impact on ESRD)

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27
Q

What is the lifestyle recommendation for BP control from HTN Canada?

A

Salt restriction: reduce sodium intake towards 2000mg (5g of salt) per day
Exercise: 30-60 minutes of moderate intensity 4-7 days/week, in addition to the routine acts of daily living
Weight reduction: in overweight/obese patients
Limited alcohol consumption: 1-2 drinks/day

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28
Q

How many BP drugs are often required for BP control as CKD progresses?

A

3-4

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29
Q

What are the 1st line BP control drugs per KDIGO?

A

ACEi/ARB
Diuretics
Long-acting CCBs

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30
Q

What is the first line treatment in CKD for HTN if a patient has proteinuria?

A

ACEi/ARB
Diabetic - ACR >3mg/mmol
Non-diabetic - ACR >30mg/mmol

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31
Q

What are ACEi/ARB role in therapy for CKD?

A

Reduce BP and glomerular capillary pressure
Reduce proteinuria more than any other antihypertensive
Improvement of kidney outcomes and CV outcomes

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32
Q

CI of ACEi/ARB

A

Bilateral renal artery stenosis
Angioedema
Pregnancy

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33
Q

Precautions with ACEi/ARB

A

Intravascular fluid depletion
eGFR <30ml/min
Hypotension (if BP <110/70)
Hyperkalemia (K+ >5.5mmol/L)

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34
Q

What are the monitoring parameters for ACEi/ARB

A

*2-4 weeks following initiation, or any dose increase
- SCr (dont want an increase >30% from baseline)
- K+ (if high restriction dietary K+, add diuretic)
- BP
- urinary albumin: creatinine ratio (ACR)

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35
Q

Dosing for ACEi/ARB

A

Reduction in albuminuria is dose-dependent
Start at low dose and titrate to maximum tolerated dose(or highest approved dose)

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36
Q

What are the steroidal (non-selective) MRAs used for HTN in CKD?

A

Spironolactone**
Eplerenone

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37
Q

What are the non-steroidal (selective) MRAs used for HTN in CKD?

A

Finerenone - reduction in albuminuria, while having less side effects

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38
Q

When should we use non-steroidal MRAs with proven kidney or CV benefit?

A

T2DM, eGFR >/=25mL/min, Normal K+ levels, and Albuminuria (ACR >/= 3) despite maximum tolerated dose of a RAASi

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39
Q

What are the limitations of finerenone?

A

Biggest risk is hyperkalemia
Not covered by SK drug plan or NIHB
Less evidence in patients who are also taking a SGLT2i
Not to use in combo with a steroidal(Spironolactone) MRA in patients with HF (and not to replace steroidal)

40
Q

Why are diuretics used in CKD?

A

Fluid retention is an important contributor to HTN in CKD so most patients require diuretic therapy

41
Q

What diuretics are used in CKD?

A

Start with a thiazide
Generally avoid potassium-sparing diuretics in stage 3-5 CKD

42
Q

What is of note for diuretic use when GFR<30ml/min?

A

Thiazide diuretic will lose its diuretic effect but maintain BP benefit
- may switch to or combine with loop diuretic for volume control or if BP becomes resistant to therapy
- may prefer combo with metolazone, chlorthalidone, or indapamide (effective diuresis at GFR<30ml/min)

43
Q

What is the most common thiazide?

A

Hydrochlorothiazide

44
Q

What did chlorthalidone improve in the CLICK trial?

A

Significant improvements in BP, and 30-40% reduction in ACR for patients with stage 4 CKD(GFR 15-30ml/min)

45
Q

Which type of CCB would be used in CKD?

A

DHP-CCBs are used most often(amlodipine)

46
Q

When are CCBs preferred over thiazides?

A

In combo with an ACEi/ARB in patients with diabetes

47
Q

Downside of CCBs for CKD

A

May cause fluid retention and edema (problematic in CKD patients)

48
Q

When would we use a non-DHP CCB(diltiazem and verapamil) in CKD?

A

May provide benefit when added to ACEi/ARB for decreasing proteinuria

49
Q

When would we have a compelling indication to use a beta-blocker in CKD?

A

In HF, post MI, angina

50
Q

Which beta-blockers would we use in CKD?

A

Atenolol and bioprolol
- may require dose adjustment once CrCl approaches 30ml/min because they are renally eliminated

51
Q

What are some other drugs used for HTN in CKD?

A

Clondine - adjunctive therapy
Terazosin, prazosin - adjunctive (might consider in patients with prostatic hypertrophy)
Hydralazine - adjunctive (use limited by side effects)

52
Q

Why is proteinuria a concern for CKD?

A

Damages the glomerulus
High risk of progressing to kidney failure

53
Q

What does microalbuminuria predict?

A

Loss of kidney function

54
Q

Classifications of proteinuria

A

> 150mg protein lost in urine per day (albumin or other plasma proteins)
Mild: 150-500mg - category A2
Moderate: >500mg - category A3
Nephrotic range: >3000mg = 3g or albumin excretion >2200mg/24h

55
Q

What is nephrotic syndrome?

A

Associated with hyperlipidemia, hypoalbuminemia, generalized edema, thromboembolic risk, foamy urine

56
Q

What are the kidney diseases associated with proteinuria?

A

Diabetic nephropathy
Hypertensive kidney disease
Primary glomerular diseases
Lupus nephritis
Post-streptococcal glomerulonephritis

57
Q

What is the first line treatment for CKD with proteinuria and why?

A

ACEi/ARB
Reduce glomerular capillary pressure and volume
Possible direct effect on podocytes to decrease proteinuria (protective benefit to kidney)

58
Q

What is an SGLT2i place in therapy for CKD?

A

Cardiovascular risk reduction in adults with ACR>20mg/mmol and eGFR >/=25ml/min, by reducing decline in eGFR

59
Q

What % of patient with T2DM have CKD?

A

40%

60
Q

How often should screening be done in people with diabetes?

A

At least annually in stable patients
Begin 5 years after diagnosis of T1DM and at time of diagnosis for T2DM
- do random urine ACR, SCr, and eGFR

61
Q

How does BG control help in CKD?

A

Prevents and delays progression of diabetic nephropathy

62
Q

What is the first line therapy for BG control in diabetic CKD?

A

Metformin + SGLT2i
Preferred add on would be a GLP-1 agonist

63
Q

What is the concern with Metformin in CKD patients?

A

Accumulation because it is cleared by the kidney, and this could lead to lactic acidosis which has a high mortality rate (~50%)
Recommended to avoid in eGFR <30ml/min and dose is halved for eGFR of 30-44ml/min

64
Q

What are the benefits for Metformin in diabetic CKD?

A

Primarily for CV benefit
Lack evidence for kidney protective effects

65
Q

What are the benefits of SGLT2i for diabetic CKD?

A

CV benefits and reducing the progression of CKD

66
Q

When is an SGLT2i the first line agent?

A

For patients with T2DM, CKD, and eGFR>20ml/min
Recommended regardless of the patients A1C (even if targets are met)
*trial done using lowest dose

67
Q

Which drugs may be effected when starting an SGLT2i?

A

Loop diuretics - may want to reduce dose when starting
Insulin - might need to lower to prevent hypoglycemia

68
Q

What are the benefits of GLP-1 agonists for diabetic CKD?

A

CV benefits and kidney benefits
Appear to reduce albuminuria or an extent
Weight loss
Decrease A1C (SGLT2i does not)

69
Q

When is a GLP-1 agonist(semaglutide) used for diabetic CKD?

A

Use if A1C targets not achieved with Metformin/SGLT2i

70
Q

How can smoking cessation help with CKD progression?

A

Smoking increased progression of CKD so we want to avoid this
- increased BP and heart rate, decreased renal blood flow(construction), vascular injury
Smoking is also a risk factor for CV events

71
Q

What are the nephrotoxic drugs that should be avoided in CKD?

A

NSAIDs, COX-2 inhibitors
Lithium
Aminoglycosides
Amphotericin B
Calcineurin inhibitors
Cisplatin
especially avoid combo of ACEi/ARB, NSAIDs, and diuretic

72
Q

What is sick day management?

A

When patients with CKD become acutely ill and and are unable to maintain adequate fluid intake, it is recommended to hold potentially nephrotoxic or renally excreted drugs

73
Q

Which drugs should be held for sick day management?

A

(SAD MANS)
Sulfonylureas
ACEi
Diuretics, direct renin inhibitors

Metformin
ARBs
NSAIDs
SGLT2i

74
Q

What are the common CV risk factors?

A

DM
Dyslipidemia
HTN
LVH
Smoking
Obesity

75
Q

Is CKD a statin indicated condition?

A

Yes

76
Q

What is the recommendation with statins in CKD?

A

Patient >/=50 with eGFR<60 (NOT ON DIALYSIS) should ne on a low-dose statin or statin/ezetimibe combo irrespective of LDL level
>/= 50 with CKD and eGFR>/=60 should be on a statin

77
Q

What is the benefit of statins in CKD?

A

CV risk reduction and mortality, no benefits to slowing CKD progression

78
Q

What would be the low dose statins used in CKD?

A

Atorvastatin 20mg
Rostuvastatin 10mg
Simvastatin/ezetmibe 20/10mg

79
Q

What are the four first line drugs for CKD?

A

SGLT2i (T2DM ONLY)
Metformin (T2DM ONLY)
ACEi/ARB
Statin

80
Q

What are the RRTs?

A

Dialysis
- hemodialysis
- peritoneal dialysis
Kidney transplant**preferred option

81
Q

What should RRT be initiated?

A

No set GFR
Based on symptoms:
- serositis, acid-based or electrolyte abnormalities
- Inability to control volume status or BP
- Malnutrition refractory to dietary intake
- cognitive impairment
Most patients require RRT at GFR ~10ml/min

82
Q

What is the most common RRT?

A

Hemodialysis

83
Q

What is hemodialysis?

A

Patient blood is passed through an external filter to remove wastes and fluid
- solutes removed by diffusion
- filtered blood returned to patients body

84
Q

Where is hemodialysis done?

A

At home or in dialysis clinic

85
Q

How often is hemodialysis done?

A

3x per week (3-5 hours each visit)

86
Q

What are the types of hemodialysis?

A

Arteriovenous (AV) fistulapreferred
Insertion of a synthetic AV graft
Catheter in neck

87
Q

What is required during hemodialysis?

A

Systemic anticoagulation

88
Q

Complications of hemodialysis

A

Fatigue
Hypotension
Hypertension
Cramps
N/V
*vascular access problems
- infection, clotting, bleeding

89
Q

What should hemodialysis patients be taking?

A

Replavite tablets (renal vitamins) because water soluble vitamins are removed during treatment

90
Q

What needs to be monitored during hemodialysis?

A

Serum folate, vitamin B12 every 6-12 months

91
Q

What should be avoided in hemodialysis patients?

A

Multivitamins containing minerals
Vitamin A or D

92
Q

What is peritoneal dialysis?

A

Relies on patient own peritoneal membrane to act as a filter for fluid and wastes

93
Q

What is instilled in the peritoneal cavity for peritoneal dialysis?

A

2-3L of dialysate

94
Q

How often is peritoneal dialysis done?

A

Continuous ambulatory: 4-5x per day for 30-45 minutes each time
Automated: 8-10 hours while you sleep (using cycler)

95
Q

What is the most common complication of peritoneal dialysis?

A

Peritonitis: inflammation and infection of the peritoneal lining

96
Q

What is CRRT recommended?

A

For hemodynamically unstable patients requiring RRT for an AKI
- patients who cannot tolerate abrupt fluid shifts

PHAR 255 (8 decks)

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