List I - Core Conditions Flashcards
What are the causes of chronic kidney disease?
- Diabetic neuropathy
- Glomerulonephritis
- Hypertension
- Systemic disease e.g. SLE, vasculitis, amyloid, myeloma
- Renal artery stenosis
- Hereditary e.g. PCKD
- Chronic pyelonephritis
- Nephrotoxic drugs
How might CKD patients present?
- Incidental finding on blood or urine tests in investigation of other condition/routine test
- Hypertension
- Monitoring “at risk” individuals
- Symptoms usually occur later at advanced stage
How is kidney function assessed?
- Serum urea - increased with reduced renal excretion
- Breakdown of amino acids (protein catabolism)
- Disproportionately high serum urea
- Catabolic state, high protein intake, gastrointestinal bleed, glucocorticoids
- Dehydration/cardiac failure
- Disproportionately low serum urea
- Low protein intake, liver failure
- Serum creatinine
What is the problem with creatinine?
- Insensitive marker - can have very impaired kidney function with relatively little creatinine increase
- Related to musculature
How else is kidney function measured?
- eGFR
- Calculated from blood results and demographic data
- Has a degree of error relating to muscle mass - especially extremes
- Racial correction (multiply 1.2 x if Afro Caribbean / Black patient)
What is the classification of eGFR?
- Stage 1 >90 Normal/high
- Stage 2 60-90 Mild decrease
- Stage 3a 45-59 Mild/moderate decrease
- Stage 3b 30-44 Moderate/severe decrease
- Stage 4 15-29 Severe decrease
- Stage <15 Kidney failure
What is an important marker of risk of progression of CKD?
- Proteinuria
* Spot urine sample
How is the cause of CKD investigated?
- Clinical history
- Biochemistry/hameatology
- Urine - dipstick, microscopy (cells, casts)
- Immunology screen (e.g. SLE, vasculitis, myeloma)
- Renal ultrasound - “normal”, obstruction, cystic disease, scarring, renovascular, renal asymmetry, small kidneys
- Renal biopsy/angiography
What is CKD associated with?
- Accelerated cardiovascular disease and mortality
* Significant life-expectancy reduction
What are the normal functions of the kidneys?
- Excretory function
- Homeostasis - fluid balance, BP
- Endocine - bone metabolism, erythropoiesis
What are the metabolic complications of CKD?
- Anaemia - reduced erythropoietin
- Bone mineral disorder - e.g. low serum Ca, high PO4, high PTH
- Lack of vitamin D 1-alpha hydroxylation by kidneys
- Phosphate retention because low GFR
- Metabolic acidosis (low sodium bicarbonate on venous bloods)
- Hyperkalaemia
What are the clinical features of CKD?
- Renal - fluid retention, polyuria, nocturia
- Cardiovascular
- hypertension, pulmonary, oedema
- LVH/dysfunction, vascular disease, dyslipidaemia, vascular calcification
- Gastrointestinal
- Anorexia, nausea, vomiting, malnutrition, peptic ulceration
- Neurological - peripheral neuropathy, restless legs
- Dermatological - pigmentation, pruritis
- Endocrine - erectile dysfunction, oligoammenorrhea, reduced fertility/ability to carry pregnancy
- Musculoskeletal - bone pain, fractures, arthropathy
When should patients be referred to a specialist for renal function?
- eGFR<30
- Progression
- Uncertain cause or suspected systemic disease
- Hereditary
- Significant proteinuria
- Haematuria and proteinuria
- Complications of CKD
What is the management of CKD?
- Treatment of underlying cause of CRF if possible
- Lifestyle
- BP control
- CVS risk reduction
- Diet
- Anaemia - erythropoietin
- Bone disease
- Vitamin D analogues, phosphate control (diet phosphate binders)
- Bicarbonate supplements for acidosis
- Restless legs - sleep hygiene and off licence gabapentin/pregabalin
When should CKD be suspected?
- Incidental finding of:
- Raised serum creatinine and/or serum eGFR of <60mL/min/1.73m2
- Proteinuria (ACR >3mg/mmol)
- Persistent haematuria (2/3 dipstick tests show 1+ or more of blood) after exclusion of UTI
- Urine sediment abnormalities (RBCs, WBCs, granular casts and renal tubular epithelial cells
- Be aware that CKD can be asymptomatic in the early stages
If CKD is suspected, what should be asked about in the history?
- General symptoms - lethargy, itch, breathlessness, cramps, sleep disturbance, bone pain, loss of appetite, vomiting, weight loss, taste disturbance
- Urine output - polyuria, oliguria, nocturia, anuria, obstructive uropathy
- Nephrotoxic drugs
- Risk factors - previous AKI
- Comorbidities or complications
- Polycystic kidney disease
- Associated features of anxiety or depression
What are the examination signs for progression of CKD?
- Uraemic odour (ammonia smell to breath)
- Pallor
- Cachexia and signs of malnutrition
- Cognitive impairment
- Dehydration or hypovolaemia
- Tachypnoea
- Hypertension
- Palpable flank masses with possible hepatomegaly
- Palpable distended bladder (suggests obstructive uropathy)
- Peripheral oedema
- Peripheral neuropathy
- Frothy urine
What are the initial investigations for CKD?
- Arrange blood tests for serum creatinine and eGFR
- Advise the person not to eat red meat for 12 hours before the test
- Arrange early morning urine sample to measure the urine albumin:creatinine ratio(ACR)
- Arrange a urine dipstick to check for haematuria
- Check the persons nutritional status, BMI, BP and serum HbA1c and lipid profile
- Consider arranging a renal tract USS (if indicated)
What is the management of the eGFR result for CKD?
- If eGFR <60mL/min/1.73m2 - repeat the test within 2 weeks
- If eGFR remains <60mL/min/1.73m2 on repeat, repeat the test in 3 months
- NB interpret with caution for extremes of muscle mass, pregnancy, has oedema, malnourished or uses protein supplements, or is Asian or Chinese in origin
What is the management of the ACR result for CKD?
- <3mg/mmol (no proteinuria) no action required
- Between 3 and 70mg/mmol, repeat the test within 3 months
- 70mg/mmol or more, a repeat test is not needed as this indicates significant proteinuria
- NB transient increases in urine ACR may be seen with menstruation, UTI, strenuous exercise and upright posture
What is the management of the urine dipstick to check for haematuria in suspected CKD?
- If 1+ or more of blood on dipstick, arrange a mid-stream (MSU) to exclude a UTI and manage accordingly
- If there is isolated persistent haematuria (2/3 dipstick show 1+ blood or more after exclusion of UTI) with no decrease in eGFR and no proteinuria - see pathway for urological cancer recognition and referral
If the eGFR and the ACR tests are repeated within 3 months, how should the be interpreted?
- Make a diagnosis of CKD if there is persistent reduction in eGFR <60mL/min/1/73m2 and/or proteinuria (ACR >3mg/mmol) lasting for atleast 3 months
- CKD diagnosis can be excluded if eGFR is persistently >60 and/or ACR is persistently <3mg/mmol and there are no other markers of kidney damage
What how is CKD categorised once a diagnosis is made?
- Using eGFR and urinary ACR
- Increased ACR is associated with increased risk of adverse outcomes
- Decreased GFR is associated with increased risk of adverse outcomes
- Combination multiplies the risk of adverse outcomes
How is ACR combined with eGFR to classify CKD?
- ACR 1/2/3
- eGFR G1/G2/G3a/G3b/G4/G5
E.G. G2A2 or G4A3 - A1=<3mg/mmol normal to mild increase
- A2=3-30mg/mmol moderately increased
- A3=>30 Severely increased
See earlier slide or NICE table for details combined with eGFR
Which further measure of renal function which is less influenced by muscle mass, can be used in people with borderline renal function (eGFR values between 45-59 with no evidence of proteinuria) and may be more accurate at determining CKD?
- Cystatin C
How is accelerated progression of CKD defined?
- Persistent decrease in eGFR of 25% or more and a change in CKD category within 12 months; Or
- Persistent decrease in eGFR of 15mL/min/1.73m2 within 12 months
How is CKD monitored after a confirmed diagnosis?
- Monitor renal function by checking serum creatinine and eGFR together with ACR
- Repeat the eGFR 3 times over 3 months to monitor progression/identify accelerated
- If the person is at risk of AKI consider stopping potentially nephrotoxic drugs
- Arrange FBC to exclude renal anaemia for people with CKD 3b, 4, and 5
- Arrange serum calcium, phosphate, vitamin D and PTH for people with CKD stage 4 and 5
When should patients be referred?
- 2 week wait referral - Persistent haematuria and urological cancer suspected
- Referral to a nephrology specialist if:
- eGFR <30mL/min/1.73m2
- Accelerated progression of CKD
- Uncontrolled hypertension
- Polycystic kidney disease
- Renal artery stenosis
How should a person with CKD be managed in primary care?
- Assess for and manage risk factors and co-morbidities including:
- Nephrotoxic drugs
- Disease progression
- Lifestyle risk factors
- Associated anxiety or depression
- Risk of CV disease
- Assess for hypertension, if a person is not diabetic and has:
- ACR <30mg/mmol and associated hypertension, arrange appropriate management
- ACR >30mg/mmol and associated hypertension, prescribe a low cost renin-angiotensin antagonist (lisinopril or losartan) do not prescribe a combination
- ACR <70mg/mmol, aim for a BP target of systolic <140mmHg (target 120-139mmHg) and diastolic <90mmHg
- ACR >70mg/mmol, aim for a BP target of systolic <130mmHg (target 120-129mmHg) and diastolic <80mmHg (same for ACR >3 with DBM)
- Uncontrolled despite 4 antihypertensive drugs, arrange referral
- If a person has ACR of 70mg/mmol or more (irrespective of BP or CV disease - prescribe a lisinopril or losartan to achieve the optimal tolerated dose and arrange referral to a nephrologist
What should the BP target range be for a person with diabetes and CKD?
- Systollic <130mmHg (target range 120-129) and diastolic <80mmHg
What should all people with CKD be prescribed?
- Lipid lowering therapy with a statin
What should all people with CKD be prescribed for the secondary prevention of CVD?
- Antiplatelet treatment - low dose aspirin
Which immunizations should be offered to people with CKD?
- Influenza
* Pneumococcal
What self management advice should be given to people with CKD?
- Provide information - www.kidneycare.org
- Advise on lifestyle measures - stop smoking, drink alcohol in moderation, maintain a healthy body weight, eat a healthy diet and take regular exercise
- For end stage disease specialist dietary advice about potassium, phosphate, calorie and salt intake may be arranged by the specialist
- Advise the person to avoid over thecounter NSAIDs, avoid herbal remedies and protein supplements with caution
- Advise on the increased risk of AKI with intercurrent illness
How would you explain CKD to a patient?
- Chronic kidney disease is a progressive long term condition where the kidneys dont work as well as they used to
- This can result in tiredness, swelling, breathlessness, feeling sick and even blood in the urine
- There are many different possible causes which can include high BP, diabetes, older age, infections, polycystic kidney disease, medications such as NSAIDs
What are the indications for renal replacement therapy?
- Uraemic sypmtoms
- Fluid overload
- eGFR 5-7 if no symptoms
What is the problem with mineral bone disease in CKD?
- 1-alpha hydroxylation normally occurs in the kidneys - CKD leads to low vitamin D
- Kidneys normally excrete phosphate - CKD leads to high phosphate
Result of this is:
- High phosphate level drags calcium from the bones, resulting in osteomalacia
- Low calcium - due to lack of vitamin D, high phosphate
- Secondary hyperparathyroidism - due to low calcium, high phosphate and low vitamin D
What is the management of mineral bone disease in CKD (high phosphate, low vitamin D and low calcium) seconday hyperparathyroidism?
- Aim is to reduce phosphate and parathyroid hormone levels
- Reduced dietary intake of phosphate is the first line management
- Phosphate binders
- Vitamin D - alfacalcidol, calcitriol
- Parathyroidectomy may be needed in some cases
What are phosphate binders?
- Aluminium based binders are less commonly used now
- Calcium based binders
- Problems include hypercalcaemia and vascular calcification
- Sevelamer
- A non-calcium based binder that is now increasingly used
- Binds dietary phosphate and prevents its absorption
- Also appears to have other beneficial effects including reducing uric acid levels and improving the lipid profiles of patients with chronic kidney disease
How is hypertension managed in patients with CKD?
- Majority of patients with CKD will require more than two drugs to treat hypertension
- First line is ACEi - particularly useful in proteinuric renal disease (e.g. diabetic nephropathy) - these drugs tend to reduce filtration pressure - small fall in eGFR and rise in creatinine can be expected
- NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, any rise should prompt further monitoring and exclusion of other causes e.g. NSAID’s
- Furosemide is useful as a anti-hypertensive in patients with CKD, particularly when the GFR falls below 45 ml/min - it has the added benefit of lowering serum potassium - high doses are usually required
- If the patient becomes at risk of dehydration e.g. gastroenteritis then consideration should be given to temporarily stopping the drug
How should hyperlipidaemia be managed in people with CKD?
- Atorvastatin 20mg should be offered to patients with CKD
What is acute kidney injury?
- Characterised by a decline in renal excretory function over hours or days that can result in failure to maintain fluid, electrolyte and acid base homeostasis
How are the causes of AKI categorised?
- Pre-renal (most common) - due to reduced perfusion to the kidneys leading to a decreased GFR, usually reversible with appropriate early treatment
- Intrinsic renal - consequence of structural damage to the kidney for example tubules, glomeruli, interstitium, and intrarenal blood vessels
- Post renal (least common 10%) - due to acute obstruction of the outflow of urine resulting in increased intratubular pressure and decreased GFR
What are the causes of pre-renal AKI?
- Hypovolaemia - dehydration, haemorrhage, gastrointestinal losses, renal losses, burns
- Reduced cardiac output - heart failure, liver failure, sepsis, drugs
- Drugs that reduce blood pressure, circulating volume or renal blood flow - ACEi, ARB’s, NSAIDs, loop diuretics
What are the post renal causes of AKI?
- Obstruction - renal stones, blocked catheter, enlarged prostate, genitourinary tract tumours/masses, neurogenic bladder
What are the risk factors for AKI?
- Age 65 or older
- History of AKI
- CKD eGFR <60
- Symptoms or history of obstruction or conditions leading to urological obstruction
- Chronic conditions such as heart failure, liver disease and diabetes mellitus
- Neurological or cognitive impairment or disability
- Sepsis
- Oliguria (urine output <0.5mL/kg/hr)
- Nephrotic drugs within the last week (especially if hypovolaemic) e.g. NSAIDS, ACEi, ARB’s and diuretics
- Exposure to iodinated contrast agents within the past week
- Cancer and cancer therapy
Immunocompromise (HIV) - Toxins (herbal remedies, poisonous plants and animals)
What are the complications of AKI?
- Hyperkalaemia - usually asymptomatic until severe but can cause muscle weakness, paralysis, cardiac arrhythmias or in extreme cases cardiac arrest
- Other electrolyte imbalances for example hyperphosphataemia, hyponatraemia, hypermagnesaemia, hypocalcaemia
- Metabolic acidosis - altered consciousness, circulatory collapse and hyperventilation
- Volume overload (peripheral and pulmonary oedema - tachpnoea, tachycardia, cyanosis, lung crepitations
- Uraemia - occurs in severe AKI - confusion, lethargy, altered consciousness
- CKD and end stage renal disease
What are the signs and symptoms of AKI?
- Nausea and vomiting, or diarrhoea, evidence of dehydration
- Reduced urine output or changes to urine colour
- Confusion, fatigue and drowsiness
What is the criteria used to diagnose AKI?
Any of the following:
* Rise in serum creatinine of 26 micromol/L or greater within 48 hours
(Be aware in the absence of a baseline creatinine value, a high serum creatinine level may indicate AKI, even if the rise in creatinine over 48 hours is less than 26 micromol/L)
* 50% or greater rise in serum creatinine (more than 1.5 times baseline) known or presumed to have occurred within the past 7 days
* Fall in urine output to less than 0.5 mL/kg/hour for more than 6 hours
How is a person with suspected AKI assessed?
Assess volume status by checking:
- Volume status
- Fluid intake and losses
- Peripheral perfusion (CRT)
- HR/BP (any postural changes)
- JVP
- Moistness of mucous membranes, skin turgor
- Changes in urination pattern
- Peripheral oedema and pulmonary crackles
- Renal function and serum potassium level (to exclude hyperkalaemia)
- For underlying causes
- Diarrhoea and vomiting
- Recent symptoms suggesting an underlying obstructive cause (LUTS)
- Hx CVD
- Underlying inflammatory process - vasculitic rash, arthralgia, epistaxis or haemoptysis
- Drug history
- Possibility of rhabomyolysis - MSK injury, overexertion, crush injury, prolonged immobility
- For renal disease by performing urine dipstick testing for blood, protein, leucocytes, nitrites and glucose
- Stage of AKI
What are the criteria of stage 1 AKI?
- Rise of creatinine of 26 micromol or more within 48 hours OR
- Creatinine rise of 50-99% from baseline within 7 days OR
- Urine output <0.5mL/kg/hr for more than 6 hours
What are the criteria of stage 2 AKI?
- 100-199% creatinine rise from baseline within 7 days OR
* Urine output <0.5 mL/kg/hr for more than 12 hours
What are the criteria of stage 3 AKI?
- 200% or more rise from baseline within 7 days OR
- Creatinine rise to 354 micromol/L or more with acute rise of 26 mircromol/L or more within 48 hours or 50% or more rise within 7 days OR
- Urine output <0.3 mL/kg/hour for 24 hours or anuria for 12 hours
What are the features of AKI on examination?
- Hypovolaemia - assess volume status (CFT, HR, BP, JVP, skin turgor, pulmonary oedema, peripheral oedema, urine output, weight)
- Palpable bladder
- Signs of vaculitis (weight loss, fever, rash, uveitis, haemoptysis, joint swelling)
- Bruits (renal artery stenosis)
What are the investigations for AKI?
- FBC
- U and E’s
- Bicarbonate
- LTF’s
- Calcium
- Phosphate
- Consider blood cultures if sepsis suspected
- Urine dipstick (presence of blood and protein suggests infection or vaculitis)
- Chest x-ray (pulmoanry infiltrates could indicate fluid, infection or haemorrhage)
- Renal tract USS (assess renal anatomy and exclude renal tract obstruction)
What is the management for AKI in hospital?
- STOP AKI
- Sepsis - complete sepsis 6 if suspected
- Toxins - stop/avoid nephrotoxins e.g. Gentamicin, NSAID’s, iodinated contrast
- Optimise blood pressure
- Volume status assessment, IV fluids, consider holding antihypertensive medications, consider vassopressors
- Prevent harm - treat complications (e.g. hyperkalaemia, pulmonary oedema, acidosis, pericarditis), identify cause e.g. obstruction, review all medications and doses, refer if renal replacement therapy indicated (e.g. intractible hyperkalaemia, pH <7.15, intractible pulmonary oedema, uraemic pericarditis or encephalopathy), monitor (daily volume assessment, fluid balance, U and E’s, bicarbonate)
What is urea?
- Catabolism of amino acids / protein
- Increased serum concentration with reduced renal excretion
- Relatively high serum urea
- Catabolic state, high protein intake, gastrointestinal bleed, glucocorticoids
- Dehydration/cardiac failure
Relatively low urea
- Low protein intake, liver failure
What is creatinine?
- Production is related to muscle mass
- Serum concentrations increased with reduced renal excretion
- Relatively high serum creatinine
- Large muscle mass (young, muscular, male)
- Relatively low serum creatinine
- Low muscle mass (elderly, wasting, amputees, female)
What is the problem with creatinine in terms of identify kidney disease?
- It is an insensitive marker
* Levels can remain low until eGFR is more significantly reduced
What are the features of proteinuria in relation to CKD?
- Important marker of progression of CKD
- Traditionally measured by 24 hr urine excretion
- In practice is quantified by spot urine sample (preferably morning) for protein/creatinine ratio (PCR) in urine, or albumin/creatinine ratio (ACR)
What are the renal effects of CKD?
- Fluid retention
- Polyuria
- Nocturia (fluid depletion)
What are the CV effects of CKD?
- Hypertension
- Pulmonary oedema
- LVH/dysfunction
- Vascular disease
- Dyslipidaemia
- Vascular calcification
- Pericarditis
What are the GI effects of CKD?
- Anorexia
- Nausea
- Vomiting
- Malnutrition
- Peptic ulceration
What are the neurological effects of CKD?
- Peripheral neuropathy
- Myoclonic jerks
- Encephalopathy
- Seizures
What are the dermatological effects of CKD?
- Pigmentation
* Pruritis
What are the endocrine effects of CKD?
- Erectile dysfunction
- Oligoammenorrhoea
- Reduced fertility
- Ability to carry pregnancy
What are the MSK effects of CKD?
- Bone pain
- Fractures
- Arthropathy
What are the risk factors for progression of CKD?
- More advanced CKD stage (lower GFR)
- BP control
- Proteinuria or albuminuria
- Race, gender
- Smoking
- Hyperglycaemia, hyperlipidaemia
- Obesity
- CVS disease
- Nephrotoxic drugs
What aims of management of hypertension in CKD?
- Hypertension is very common in CKD
- Major risk factor affecting the rate of progression of chronic renal failure
- High BP contributes to accelerated CVS disease in CKD
- In CKD aim for BP down to <140/90
- If CKD + diabetes or ACR of 70 mg/mmol aim for <130/80
What is the first line anti-hypertensive medication in CKD?
- ACEi/ARB - particularly where albuminuria/proteinuria (except renal artery stenosis)
- Also indicated for ‘normotensive’ proteinuria
- May cause transient decrease in GFR
- Profound drop in renal artery stenosis, dehydration
- Risk of hyperkalaemia
- Monitoring U and E’s baseline and at 1 week required
What is the haematological abnormality seen in CKD?
- Normochromic normocytic anaemia (anaemia of chronic disease) - reduced erythropoietin production
- Bleeding tendency - reduced platelet aggregation
- Reduced immunity - e.g. reduced response to hepatitis B vaccination
What is this pattern of abnormalities showing?
Serum calcium 2.14 mmol/L (2.2-2.6)
Serum phosphate 1.83 mmol/L (0.8-1.4)
Serum PTH 46 mmol/L (0.9-5.4)
- Secondary hyperparathyroidism and hyperphosphataemia due to CKD
What are the two main factors in the pathophysiology of renal bone disease in CKD?
- Reduced production of 1 alpha hydroxylase (leads to low vitamin D leads to osteomalacia or rickets)
- Increased levels of phosphate due to reduced clearance
Leads to reduced serum calcium
- Secondary hyperparathyroidism (high PTH + low Ca)
- Tertiary hyperparathyroidism (high PTH + high Ca)
What is the treatment of bone disease in CKD?
- Low calcium/high PTH
- Active vitamin D analogues e.g. alfacalcidol
- High phosphate
- Dietary restriction
- Phosphate binder medication with meals
- Dialysis
What is the dietary guidance in CKD?
- Varies according to degree of impairment eGFR and individual patient results
- Salt intake restriction
- Phosphate, potassium - restrict as needed
- Calories (avoid/treat obesity and malnutrition)
- Avoid (or treat) malnutrition
Which drugs should be cautious/contraindicated in patients with CKD?
- Impaired excretion - potential serious toxicity (dose reduction or avoid)
- Digoxin, aminoglycosides, acyclovir
- Nephrotoxins / reduce renal function
- NSAIDs
- Metabolic effects
- Hyperkalaemia (ACEi, ARB, amiloride, spironolactone, potassium sparing supplements)
What is the approach to the management of advanced CKD?
- Pre-dialysis counselling/assessment/modality
* Dialysis/transplantation/conservative management
What does dialysis do?
- Replaces excretory role of kidney (much lower clearance) - diffusion solutes between blood and dialysis fluid
- Removes excess water from the patient
- Options of haemodialysis and peritoneal dialysis
What is the process of haemodialysis?
- Diffusion of solutes between patients blood and dialysis fluid in artificial kidney
- Typical patient dialyses for 4 hours 3 times per week
- Access ideally via AV fistula
What is the process of peritoneal dialysis?
- Diffusion of solutes between the patients blood in peritoneal capillaries and dialysis fluid in peritoneal cavity
- CAPD (continuous ambulatory peritoneal dialysis) - typically 4 x 2-3 litres exchanges per day
- APD (automated PD) - several exchanges by machine whilst asleep at night
What is the role of kidney transplantation in CKD?
- Best rehabilitation and patient survival
- Donor sources
- Deceased donor (national list)
- Live donor - related, altruistic
- Lifelong immunosuppression
- Transplant failure may occur after time
- Significant proportion of patients not suitable for transplantation due to other medical conditions
What is the role of medical / palliative treatment in (end stage) CKD?
- Patients may opt to not have life preserving dialysis/transplantation
- Often elderly/multiple comorbidity - benefits of life may be uncertain vs negative impact on quality of life
- Facilitated by advanced discussion and planning (when relatively well)
- Many electively opting for conservative care die of other causes than renal failure
What is microalbuminuria?
- Increased urinary albumin excretion but below level that registers on protein dipstick
- Normally small amount of protein (small molecules) in urine, but very little albumin (large protein) - increase suggests ‘glomerular leakiness’
Why does microalbuminuria in diabetes matter?
- Risk of progression to established diabetic nephropathy (persistent proteinuria then declining function)
- CVS risk and increase in diabetes complications
- Consider treatment options
What is the sequence in progression of albumin excretion rates?
- Normal - 10-30 mg/day
- Microalbuminuria - 30-300 mg/day
- Macroalbuminuria - 300+ mg/day
- Nephrotic syndrome
What is a normal ACR for males and females?
- Males - 2.5 mg/mmol
* Females - 3.5 mg/mmol
What is the hall mark of established nephropathy?
- Persistent dipstick proteinuria
- Associated with other microvascular complications e.g. retinopathy
- Typically progressive CKD
- High CVS risk (DM + CKD)
- CKD management principles apply - especially RAS blockade i.e. ACEi or ARB
What is the approach to the management of diabetes in CKD?
- Stop metformin when eGFR <30 (risk lactic acidosis)
- Drug dose alterations for oral drugs
- Reducing insulin requirements / hypoglycaemia with worsening kidney function
What are the 3 main types of urinary incontinence?
- Stress
- Urge
- Mixed
What are the specific symptoms to ask about for urinary incontinence?
- Frequency
- Nocturia
- Dysuria
- Haematuria
- Urgency
- Urge incontinence
- Stress incontinence
- Difficulty initiating urination
- Incomplete emptying
What is the management advice for stress incontinence?
- Lifestyle changes - reduce/stop caffeine, smoking and fizzy drinks, lose weight
- Physiotherapy - pelvic floor exercises at least 8 contractions 3 times per day for 3 months
- Follow up in 3 months
What is the management advice for urge incontinence?
- Lifestyle changes - reduce/stop caffeine, smoking and fizzy drinks, lose weight
- Physiotherapy - pelvic floor exercises at least 8 contractions 3 times per day for 3 months
- Bladder diary (3 days minimum) bladder drills
- +/- Anticholinergic +/- Vaginal Oestrogens
- Follow up in 3 months
What can be used to distinguish between urge and stress urinary incontinence?
- Urodynamics
- Stress - no rise in Pdet
- Urge - no rise in Pabd
What is the drug used to manage urinary stress incontinence (after failure of pelvic floor exercises)?
- Duloxetine
What are the further management options for urinary urge incontinence?
- Second anticholinergic
- Cystoscopy and botox - percutaneous posterior nerve stimulation
- Percutaneous sacral nerve stimulation
- Augmentation cystoplast or urinary diversion
How do patients report a pelvic organ prolapse?
- Feel like something is coming down - worse on lifting/walking/end of day
- Usually not painful just uncomfortable
- Lower back pain
- Discomfort during intercourse
Which parts of the pelvic organs prolapse?
- Anterior vaginal wall
- Lower 1/3 cystocele
- Upper 2/3 urethrocele
- Posterior vaginal wall
- First 1/3 deficient perineum
- Middle 1/3 rectocele
- Upper 1/3 enterocele
- Cervix and uterus
- Vault (if had a hysterectomy)
How is pelvic prolapse graded?
- 0 = Normal position for each respective site
- 1 = Descent half way to the hymen
- 2 = Descent to the hymen
- 3 = Descent halfway past the hymen
- 4 = Maximum possible descent (Procidentia)
What is the treatment for prolapse?
- Conservative management - weight loss, avoid heavy lifting, pelvic floor exercises
- +/- Pessary - change every 6 months
- Surgery
- Anterior/posterior repair
- Vaginal hysterectomy
What is mesh treatment?
- TVT for incontinence - Tension free vaginal tapes (for stress incontinence) are mesh and have been used for over 20 years - small piece of mesh sits under the urethra
- Mesh for prolapse - previously used for prolapse repair- large amounts of mesh were inserted behind the vaginal walls