Management of CKD Flashcards
What different aspects do you need to manage in CKD?
1) Specific disease management
2) Water balance, BP and cardiac risk factors
3) Electrolytes
4) Acid-base balance
5) Erythropoiesis
6) Bone management
7) Assessment of uraemic symptoms
8) Planning and initiation of RRT or conservative management
What should management of CKD in primary care include?
1) Providing sources of information, advice and support
2) Assessing for and managing risk factors and co-morbidities
3) Advising on healthy lifestyle measures and avoiding the use of OTC NSAIDs
4) Assessing for hypertension and CVD, and managing appropriately
5) Prescribing a low-cost renin-angiotensin system antagonist, if appropriate
6) Ensuring the person is offered immunisations for influenza, pneumococcal disease
What are lifestyle risk factors for CKD?
1) Diet
2) Physical activity
3) Cigarette smoking
4) Alcohol consumption
What are risk factors for CKD progression to renal fibrosis/ESRD?
1) Proteinuria
2) Abnormal lipid metabolism
3) Sleep apnoea
4) CVD
5) Nephrolithiasis
6) Cancer
What are 3 types of specific disease management for diseases that can lead to CKD?
1) Immunosuppression e.g. lupus nephritis
2) Chemotherapy e.g. myeloma (blood cancer of B cells)
3) Blood sugar control in diabetes
Describe blood pressure and volume management in CKD
1) Assess fluid status - weight, JVP, oedema
2) Correct volume then BP i.e. if overloaded start with diuretic
3) Use ACEI or A2B in almost all cases for BP control
4) Targets - 130/80 - good control improves almost CKD (lupus, polycystic kidney disease)
How do you minimise cardiac risk factors in CKD (proteinuria and CKD are risk factors)?
1) Cholesterol ideally < 4
2) Glycaemic control
3) Stop smoking
4) Weight loss/exercise
How can CVD present differently in CKD?
Sequence of smaller CV events
What drug is good to use in diabetic CKD and why?
Canagliflozin
- SGLT2 inhibitor so wee out glucose
- Reduces progression of CKD
- Reduces fibrosis of kidney
What is erythropoietin?
- Hormone synthesised by interstitial fibroblasts in the kidney in response to hypoxia which goes to the bone marrow and causes transcription of products in RBCs and stops red cell apoptosis and promotes red cell generation
- Increases oxygen carrying capacity
- Stimulated by low oxygen tension
Why do you become anaemic in CKD?
Bc don’t make enough epo in kidneys
How do you managed renal anaemia?
1) Check Hb and ferritin regularly
2) Check folate and B12
3) Make iron stores super normal by giving IV iron - target iron level much higher in renal patients to correct epo deficiency anaemia and Hb without using epo which is more expensive
4) Use epo injections (every 2 weeks-month or 3x a week) once have lots of iron, B12/folate is normal and not bleeding e.g. from bowel cancer
What is the target Hb level in renal patients and why?
100-115
- The normal range of 130-170 is too high and can lead to a stroke/MI in renal patients (but some may benefit from high Hb e.g. patients with unstable heart disease)
How does CKD lead to metabolic bone disease?
1) Kidneys make active vitamin D and get rid of phosphate
2) So if kidneys aren’t working get calcium phosphate imbalance (low active vitamin D and high phosphate)
3) This causes hyperparathyroidism due to activation of PTH gland and high levels of PTH
4) This causes thinning of the bones as PTH tries to release excess calcium from bones
5) The high PTH also tries to get rid of excess phosphate in the kidneys but doesn’t work due to CKD
6) This leads to high calcium and high phosphate in the body
What is the serious complication of CKD-MBD due to high calcium and phosphate that we want to avoid?
Calciphylaxis - deposition of calcium and phosphate, causes bad looking ulcers, v painful, high mortality due to sepsis
