Lecture 10 - renal diseases Flashcards
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)
List the major factors associated with CKD progression according to the 2021 NICE guideline
increasing age, cardiovascular disease, proteinuria, previous AKI, hypertension, diabetes, smoking, African/african-caribbean or asian family origin, chronic NSAIDs, untreated urianry outflow tract obstruction
How is renal function commonly measured?
Using methods like Cockcroft & Gault, eGFR (MDRD), and CrCl, each with limitations like variability in body weight, muscle mass, and rapidly changing renal function.
what are the common causes of CKD
diabetes, hypertension cardiovascular disease, AKI, structural renal tract disease, covid 19 infection, long term nephrotoxic medication use such as nails and tacrolimus and cyclosporin
what are they intervention for CKD management
Accurate diagnosis, preventing progression with ACE inhibitors, ARBs, and SGLT2 inhibitors, symptom control, and lifestyle modifications.
describe the common complication associated with CKD
Hypertension, anemia, renal bone disease, metabolic acidosis, edema, and uraemia.
What are the effects of SGLT2 inhibitors on CKD and cardiovascular outcomes?
SGLT2 inhibitors improve cardiac, renal, and glycemic outcomes, as shown in trials like CREDENCE, DAPA-CKD, and EMPA-Kidney Contra-indicated in T1DM, transplant patients and ADPKD patients. Initial fall in GFR up to 30% within first 4-6 weeks – don’t measure CrCl/ K neutral.
What are some biological actions altered in CKD that impact medication management?
Hypovolaemia: Enhances antihypertensive effects; start with a low dose and increase to the maximum as needed.
Hyperkalaemia: Increases side effects with ACE inhibitors and potassium salts.
Uraemia: Can lead to excess bleeding.
Enhanced CNS sensitivity: Caution with centrally acting drugs like opiates; use lower doses of morphine, tramadol, and be cautious with antidepressants due to increased sensitivity.
Electrolyte variations: Risk of toxicity, e.g., digoxin toxicity.
what are drugs used to treat hyperkalaemia ?
Patiromer 16.8 g once daily or Lokelma – 5-10 g x 1-3 daily
Calcium Resonium – 15 g x 3 daily (o), 30 g (PR)
Salbutamol Nebules – 5 mg x 4 daily
Calcium Gluconate 10% - 30 mls over 5-10 mins
Insulin/Dextrose – 8 units actrapid in 100 mls 20% dextrose over 15 - 30 mins
Sodium Bicarbonate 1.26%, 500 mls - over 1 hour
what are drugs that you must take care with
low therapeutic window drugs, renal excreted, active metabolites which are really excreted eg morphine, antibiotics - especially penciicllina dn cephalosporins, ciprofloxacin and macrocodes - cause nausea of the dose is too high
antivirals eg acyclovir need to drastically reduce dose otherwise very neurotic and will become nauseous
remember to increase doses of drugs as renal function improves
what are hyperparathyroidism causes
reduced phosphate excretion, reduced calcium absorption, reduced calcitriol production by the kidney, uraemia reduces sensitivity of parathyroid gland to calcium, inhibitors of binding oc calitriol to receptor in parathyroid gland
what are symptoms of raised calcium or phosphate product
pruritic, conjunctival calcification, bone pain, skeletal deformity, increased risk of fractures
What treatments are available for CKD-related mineral and bone disorders?
Phosphate binders, vitamin D analogues, and calcimimetics are commonly used to manage CKD-MBD.
What are the types of phosphate binders and examples of each?
Calcium Based: Calcichew, Calcium 500, Calcium Acetate (e.g., Phosex, Renacet), Osvaren (Mg).
Iron Based: Velphoro.
Heavy Metal Based: Lanthanum carbonate.
Polymer Based: Sevelamer carbonate & hydrochloride (Renagel, Renvela).
What are the treatment options for CKD-related Mineral and Bone Disorder (CKD-MBD)?
Vitamin D analogues: Alfacalcidol (1α-hydroxycholecalciferol, oral/IV), Calcitriol (1,25-dihydroxycholecalciferol, oral), Paricalcitol (vitamin D analogue, oral/IV).
Calcimimetics: Cinacalcet (oral), Etelcalcetide (IV).
what are the causes of renal anaemia ?
Lack of erythropoietin production
Iron deficiency (TSATS > 20, Ferritin: 200-500)
Increased red blood cell breakdown due to uraemia
Blood loss
Hyperparathyroidism
Aluminium toxicity
Infection or Inflammation
Inadequate dialysis
what are symptoms of anaemia ?
Fatigue
Breathlessness
LVH
Impaired cognitive function
Loss of libido
Decreased cold tolerance
Treatment of anaemia
ESA’s e.g. Epoetin alfa, beta & zeta, Darbepoetin, Mircera – SC/IV
HIF-Inhibitors e.g. Roxadustat – oral option
IV Iron: e.g. iron sucrose, iron dextran, Ferinject, ferric derrisomaltose
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 (“crash”) - 25-60%
Cramps - 5-25%
Itch - 1-5%
Clotting & blocked lines
Nausea & vomiting - 5-15%
Exhaustion
Anaemia
Hair loss
Infections
Issues with dementia patients - confusion, pulling needles/lines out
Restless legs
Boredom
what are risk factors for AKI
Increasing age
Diabetes
CKD
Cardiac failure
Dehydrated
On more than 1 nephrotoxin
Chronic liver disease
People with reduced renal blood flow
