Lecture 10 - renal diseases Flashcards by Iraj Pervaiz

What is the primary function of the kidneys?

Regulation of water and electrolytes, acid/Base balance, waste excretion, blood pressure control, and hormone secretion (erythropoietin, vitamin d, renin)

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List the major factors associated with CKD progression according to the 2021 NICE guideline

increasing age
CVD
T2D
HTN
smoking
Proteinuria
previous AKI
untreated urinary outflow obstruction

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Why is proteinuria (protein in the urine) important?

Hallmark of GLOMERULAR disease

Degree of proteinuria is linked to rate of loss of function

Proteinuria is linked with cardiovascular risk

If proteinuria goes up then we know there is progression of kidney disease

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How is renal function commonly measured?

Cockcroft gauld.
limitations are if patient is in catabolic stress
extensive oedema
really poor or good renal function
rapidly changing renal function
pregnant women or children
increased creatine consumption

eGFR
limitations are if patient has a transplant
serious comorbidities eg diabetes
All races
Very poor or good renal function
Rapidly changing renal function
Pregnant women or children
Increased creatine consumption

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what blood test shows proteinuria?

Albumin-creatinine ratio (ACR)

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what is renal disease ?

renal disease can be acute or chronic kidney disease. eGFR, CrCl and CKD-EPI can all be used to estimate the severity.

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What needs monitoring in stage 3A CKD?

Annual eGFR, BP, ACR

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What needs monitoring in stage 3B CKD?

Monitor eGFR, BP, ACR every 6 months

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What are the blood pressure targets for CKD patients with and without diabetes or proteinuria?

Diabetic/proteinuric = < 130/80mmHg
Others = < 140/90mmHg

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What is the main caution of ACE inhibitors in terms of CKD?

Presence of bilateral renal artery stenosis (RAS) - blockage of the arteries to the kidneys

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What is one of the first signs of RAS?

If there is an increase of creatinine by 30%

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what is chronic kidney disease ?

chronic kidney disease is deteriorating progression, irreversible loss of kidney function, that may require renal replacement therapy.

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what should be considered when starting an ace inhibitor in renal of CKD

ACE inhibitors or an ARB slows renal function even in advanced CKD.

There may be an initial fall in eGFR up to 30%. check the bloods initially and after dose changes. there is more likely to be a decline in GFR due to volume depletion eg on high dose diuretic.

The main caution is bilateral renal artery stenosis and hyperkalaemia. Must remember SICK day rules.

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describe SGLT2 inhibitors in renal disease and safety advice

Improve cardiac and renal outcomes
Improves glycemic control

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An eGFR (estimated GFR) of _______ may occur within first 4-6 weeks of commencing a SGLT2 inhibitor

< 30%

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True or false - SGLT2 inhibitors cause hypokalaemia

false - K neutral

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Who should SGLT2 inhibitors be avoided in? Why?

Type 1 diabetics and Type 2 diabetics on insulin
Risk of diabetic ketoacidosis (DKA)

what are they intervention for CKD management

Accurate diagnosis, preventing progression with ACE inhibitors, ARBs, and SGLT2 inhibitors, symptom control, and lifestyle modifications.

What are some biological actions altered in CKD that impact medication management?

Hypovalameia: enhanced antihypertensive effects. start at low dose and increase to max.

Hyperkalaemia: increased side effects with ace inhibitors and potassium salts

uraemia: can cause excess bleeding

enhanced sensitivity to centrally acting eg analgesics especially morphine - start at lower doses.
variation in electrolytes eg digoxin toxicity

what are drugs used to treat hyperkalaemia ?

Patiromer

Calcium Resonium

Salbutamol Nebules

Calcium Gluconate

Insulin/Dextrose

Sodium Bicarbonate 1.26%, 500 mls - over 1 hour

what are drugs that you must take care with

Low therapeutic window drugs

Drugs that are really excreted for example, aminoglycosides and vancomycin

Active metabolites which are really excreted for eg morphine

antibiotics especially cephalasporins and penicillins. lower dose is required as nephrotoxic. ciprofloxacin and macrolides can cause nausea if the dose is too high.

antiviral eg acyclovir need to be drastically reduced otherwise very nephrotoxic and will cause nausea

what are hyperparathyroidism causes

reduced phosphate excretion

reduced calcium absorption

reduced calcitriol production by the kidney

uraemia reduces sensitivity of parathyroid gland to calcium and inhibits the binding of calcitriol to its receptors in the parathyroid gland.

what are CKD mineral and bone disorders?

hyperparathyroidism,

osteomalacia,

dynamic bone disease,

osteoporosis

what are symptoms of raised calcium or phosphate product

itch

conjunctival calcification,

bone pain,

skeletal deformity,

increased risk of fractures

what are treatment option of raised phosphate or low calcium

diet - food rich in protein phosphate binders, vitamin D and cinacelet control of aluminium levels Surgery

give examples of phosphate binders

Calcium carbonate (Calcichew) Calcium acetate (Phosex) Aluminium hydroxide (Alucap) Sevelamer carbonate or hydrochloride Lanthanum carbonate (Fosrenol) Sucroferric oxyhydroxide (Velphoro) Must be taken with (usually before) food - no point in taking it if patients are not having a meal Only effective if regularly taken

What is the mechanism of action of phosphate binders?

Reduce absorption of ingested phosphate by forming insoluble, non-absorbable complexes

What are the treatment options for CKD-related Mineral and Bone Disorder (CKD-MBD)?

Vitamin D analogues: Alfacalcidol , Calcitriol , Paricalcitol Calcimimetics: Cinacalcet (oral), Etelcalcetide (IV).

what are the causes of renal anaemia ?

Uraemia (high urea in blood) Iron deficiency Reduced erythropoiesis (formation of RBCs) Hyperparathyroidism (can damage bone marrow and reduce erythropoiesis)

What measurements can we use to stage an AKI?

Creatinine or urine output Stage 1 - 1.5-2x increase in creatinine Stage 2 - 2-3x increase in creatinine Stage 3- over 3x increase in creatinine

what are symptoms of anaemia ?

Fatigue Breathlessness LVH Impaired cognitive function Loss of libido Decreased cold tolerance

Treatment of anaemia

ESA’s HIF-Inhibitors e.g. Roxadustat IV Iron Oral iron (not at same time as phosphate binders)

Renal Replacement Therapy Modalities

Haemodialysis (HD) / Haemodiafiltration (HDF) Haemofiltration – mainly done in ICU Peritoneal dialysis – CAPD, APD Transplantation Conservative care

What are some common problems associated with HDF (Hemodiafiltration)?

Hypotension Cramps Itch Clotting & blocked lines Nausea & vomiting Exhaustion Anaemia Hair loss Infections Issues with dementia patients - confusion, pulling needles/lines out Restless legs Boredom

True or false - low calcium and high phosphate levels can result in secondary and tertiary hyperparathyroidism

true

Why does renal bone disease occur?

Normal physiological mechanisms regulating blood levels of phosphate, calcium, vitamin D, and parathyroid hormone are disrupted in renal failure

Name some signs and symptoms of an AKI

Reduced urine output or anuria (no urine output) Changes in urine appearance and/or smell Oedema Fatigue Shortness of breath N + V

causes of an AKI

Pre-renal = inadequate perfusion Renal = cellular damage/intrinsic Post-renal = obstruction - may have issues passing urine/issues with the ureter

how to manage an AKI

Check BP to ensure there is adequate perfusion Check urine output Daily U+Es Assess risk factors for AKI Consider if any risk factors are modifiable (e.g. stop nephrotoxic drugs) Identify cause Assess hydration status Review medication

How can we maintain immunosuppression in kidney transplant patients?

Steroids - can withdraw early if there is a low risk of rejection Mycophenolate - more potent (azathioprine 2nd line) Calcinaeurin inhibitors - tacrolimus (ciclosporin 2nd line) Belatacept - if unable to take calcineurin inhibitors We like to use a combination of three anti-rejection drugs

Adjuvant medicines in transplant patients

Valganciclovir for 6 months - cytomegalovirus risk Co-trimoxazole Pneumocystis carnii (PCP) risk Nystatin - oral thrush May also need tuberculosis prophylaxis if the patient is high risk