L 30 Therapy of CKD Flashcards
What is chronic kidney Disease?
Abnormalities in the structure or function of the kidney
More than 3 months or more suffering with this condition
It is a progressive disease
Risk factors for renal disease PROGRESSION?
- proteinuria
- elevated blood pressure
- hyperglycaemia
- hyperlipidaemia
- AKI
- smoking
How is Chronic Kidney Disease diagnosed?
Detected by screening Structural abnormalities (histology, albuminuria,albumin) Functional abnormalities (GFR less than 60ml)
Signs and symptoms of CKD
Subtle and slow onset with no noticeable symptoms until later stages
Epidemiology of CKD?
Maori with increased age
Goals of CKD treatment
Prevent or slow the progress of CKD
Decrease CKD complications
Decrease CVD risk
Lab result for CKD is
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
During CKD progressions what are the 2 main functions that become impaired?
Excretory function i.e.water,waste etc
Regulatory function i,e. Extracellular fluid volume, electrolyte imbalance, pH etc.
Signs and symptoms of CKD in stage 4 and 5?
Severe renal impairment in stage 4 and 5 usually causes pruritus, taste disturbance, nausea vomiting, muscle pain, fatigue, bleeding etc.
And lab investigation report
How is renoprotection achieved in CKD?
Treatment of comorbidities
Managing complications
Renoprotection using ACEIs and ARBs to slow down progression
What are the drugs of choice in diabetic and non-diabetic CKD?
\+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.
What is the non pharmacological treatment option for CKD?
Dietary sodium restriction Protein restriction Weight reduction Regular physical activity Moderate alcohol consumption Stop smoking or smoking cessation.
What drugs are part of the triple whammy?
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.
Consequence of triple whammy
Increased AKI risk of ~30%
At risk patients for triple whammy
Volume depleted patients, elderly, patients with heart failure
Management of triple whammy combinations
Not adding an NSAID - remind patients about OTCs
If necessary, monitor GFR and fluid status.
QUIZ: ARBs reduce proteinuria by which of the following mechanisms?
- B2 receptor activation leading to decreased renin release.
- Inhibition of aldosterone binding to mineralocorticoid receptor.
- Vasodilation of efferent arterioles leading to reduced GFR and reduced proteinuria
ARBS act by: - 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%
ACEI and ARBs can cause a…. therefore need to…
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.
Important side effects of ACEI and ARBs in CKD
Hyperkalaemia
Acute renal impairment
Dry cough (ACE, common)
Angioedema (rare but serious)
As renal function declines, what kicks into gear and increases
RAAS system kicks into gear and renin increases, therefore ATII also increases
What does an increase in ATII cause?
Vasoconstriction = increased glomerular pressure = maintains GFR BUT pushes more protein through the pores.
What causes ACE?
Cause vasodilation of the different arterioles, as a result, reduces GFR rate.
WHat NSAIDS do in kidney disease?
Vasoconstriction in the arteriole thus reduces blood flow to the nephron result reduces GFR
What diuretics reduce kidney disease?
Reduces extracellular fluid volume
What happens when protein is pushed through the pores? What does this do?
Proteinuria/albuminuria causes nephron loss, increasing kidney disease, and CV mortality
What is the MoA or proteinuria?
Proteins are reabsorbed in the renal tubules, activating inflammatory cytokines causing interstitial damage and damaging nephrons.
