L 30 Therapy of CKD

Question 1

What is chronic kidney Disease?

Answer 1

Abnormalities in the structure or function of the kidney
More than 3 months or more suffering with this condition
It is a progressive disease

Question 2

Risk factors for renal disease PROGRESSION?

Answer 2

• proteinuria
• elevated blood pressure
• hyperglycaemia
• hyperlipidaemia
• AKI
• smoking

Question 3

How is Chronic Kidney Disease diagnosed?

Answer 3

Detected by screening
Structural abnormalities (histology, albuminuria,albumin)
Functional abnormalities (GFR less than 60ml)

Question 4

Signs and symptoms of CKD

Answer 4

Subtle and slow onset with no noticeable symptoms until later stages

Question 5

Epidemiology of CKD?

Answer 5

Maori with increased age

Question 6

Goals of CKD treatment

Answer 6

Prevent or slow the progress of CKD
Decrease CKD complications
Decrease CVD risk

Question 7

Lab result for CKD is

Answer 7

Normal GFR is 90 or above L/min
Mild CKD GFR 60-90 ml/min
Moderate CKD is GFR 30-60 ml/min
Severe GFR 15-30 ml/Min

Question 8

During CKD progressions what are the 2 main functions that become impaired?

Answer 8

Excretory function i.e.water,waste etc

Regulatory function i,e. Extracellular fluid volume, electrolyte imbalance, pH etc.

Question 9

Signs and symptoms of CKD in stage 4 and 5?

Answer 9

Severe renal impairment in stage 4 and 5 usually causes pruritus, taste disturbance, nausea vomiting, muscle pain, fatigue, bleeding etc.
And lab investigation report

Question 10

How is renoprotection achieved in CKD?

Answer 10

Treatment of comorbidities
Managing complications
Renoprotection using ACEIs and ARBs to slow down progression

Question 11

What are the drugs of choice in diabetic and non-diabetic CKD?

Answer 11

\+2x example for each
ACEI (e.g enalapril, quinapril)
ARBs (e.g candesartan, losartan)
Risk factors for CKD and CKD progression
Age, hypertension, diabetes, dyslipidemia, glomerulonephritis.

Question 12

What is the non pharmacological treatment option for CKD?

Answer 12

Dietary sodium restriction 
Protein restriction 
Weight reduction 
Regular physical activity 
Moderate alcohol consumption 
Stop smoking or smoking cessation.

Question 13

What drugs are part of the triple whammy?

Answer 13

Which is the worst offender when added?
What is the triple whammy MoA?
ACEI/ARB + Diuretics + NSAID
NSAID = worst offender
- ACEI/ARB = vasodilation = reduced GFR
- Diuretics = reduce ECF volume
- NSAIDs = afferent arteriolar vasoconstriction = reduces BP and GFR = dangerous ontop of the other 2.

Question 14

Consequence of triple whammy

Answer 14

Increased AKI risk of ~30%

Question 15

At risk patients for triple whammy

Answer 15

Volume depleted patients, elderly, patients with heart failure

Question 16

Management of triple whammy combinations

Answer 16

Not adding an NSAID - remind patients about OTCs

If necessary, monitor GFR and fluid status.

Question 17

QUIZ: ARBs reduce proteinuria by which of the following mechanisms?

Answer 17

1. B2 receptor activation leading to decreased renin release.
2. Inhibition of aldosterone binding to mineralocorticoid receptor.
3. Vasodilation of efferent arterioles leading to reduced GFR and reduced proteinuria
   ARBS act by:
4. Vasodilation of efferent arterioles leading to reduced GFR and reduced proteinuria
   Using ACEI and ARBs, what is the target urine albumin reduction in CKD?
   30-50%

Question 18

ACEI and ARBs can cause a…. therefore need to…

Answer 18

ACEI and ARBs can cause an initial 25% GFR reduction after starting the therapy initiation, therefore need to start low and titrate the dose, as well as monitor sCr, BP, and electrolytes to ensure GFR is not too impacted.

Question 19

Important side effects of ACEI and ARBs in CKD

Answer 19

Hyperkalaemia
Acute renal impairment
Dry cough (ACE, common)
Angioedema (rare but serious)

Question 20

As renal function declines, what kicks into gear and increases

Answer 20

RAAS system kicks into gear and renin increases, therefore ATII also increases

Question 21

What does an increase in ATII cause?

Answer 21

Vasoconstriction = increased glomerular pressure = maintains GFR BUT pushes more protein through the pores.

Question 22

What causes ACE?

Answer 22

Cause vasodilation of the different arterioles, as a result, reduces GFR rate.

Question 23

WHat NSAIDS do in kidney disease?

Answer 23

Vasoconstriction in the arteriole thus reduces blood flow to the nephron result reduces GFR

Question 24

What diuretics reduce kidney disease?

Answer 24

Reduces extracellular fluid volume

Question 25

What happens when protein is pushed through the pores? What does this do?

Answer 25

Proteinuria/albuminuria causes nephron loss, increasing kidney disease, and CV mortality

Question 26

What is the MoA or proteinuria?

Answer 26

Proteins are reabsorbed in the renal tubules, activating inflammatory cytokines causing interstitial damage and damaging nephrons.