Microvascular Flashcards
What percentage of diabetics with kidney fxn impairment do NOT have albuminuria? Ie: not caused by diabetes?
50% approx.
Why is urine albumin alone not sufficient for monitoring for renal disease?
Approx 50% of renal disease in diabetic pts is not caused by diabetes.
Should also test
EGFR and urinalysis.
When should screening for CKD start for type one and type 2 patients?
Type two screen at diagnosis.
Type one start at 5 years past diagnosis. EVEN IN KIDS!!!
What conditions can cause a transient rise in albuminuria? Ie: shouldnt screen at that time.
Recent major exercise. UTI Febrile illness CHF Menstruation Acute severe increase in glucose Acute severe increase in BP
When should eGFR not be used to diagnose CKD
If it is a transient decrease. Should be a persistent reduction.
Dehydration or intracellular fluid contraction can cause transient decline
When should a pt with CKD be promptly referred to a specialist?
Rapidly declining eGFR
development of severe HTN
ACr > 60
EGFR 30 % rise in SCr within starting ACE or ARB
Unable to remain on ACE or ARB due to ADRs or hyperkalemia
What is the screening for CKD and what is needed for diagnosis?
EGFR and ACr YEARLY
Abnormal test should be repeated within 3 months. If 2/3 ACr are abnormal then diagnosis is confirmed. UNLESS. ACr is in overt category. Ie: >20. No confirmation necessary.
Once diagnosed, a urine dipstick and microscopy should be ordered. If no abnormalities other than proteinuria then can presumptively make dx of CKD due to diabetes.
When a pt with diabetes and CKD has reduced oral intake or has vomitting or diarrhea Ie: dehydrating, what meds should be stopped?
S. Sulfonylurea A. ACE D. Diuretics M. Metformin A. ARB N. NSAIDS S. SGLT2
What are the ACr levels for microalbuminuria and overt nephropathy?
2-20 mg/mmol
> 20
What pt info is needed to calculate MDRD eGFR?
Age
Sex
Race
SCr
What factors would favour an alternate diagnosis of non diabetic renal disease?
Extreme proteinuria. (>6g/day} Rapidly falling eGFR Persistent hematuria Low eGFR with little or no proteinuria Other complications of D not present Known duration of D < 5 years Family hx of non D renal disease S/S of systemic disease
When should eGFR and SCr be checked after starting an ACE or ARB?
Within 1-2 weeks of starting and during times of acute illness.
When should you start screening for retinopathy?
Type 2 at diagnosis.
Type 1 five years after diagnosis in all people age 15 and older
How often should screening for retinopathy be done?
Yearly for type 1
Every 1-2 years for type 2
What are the risk factors for diabetic retinopathy?
Pregnancy for type one Longer duration of D High a1c High BP Dyslipidemia *independant risk factor for hard exudates!!! Low hemoglobin Proteinuria
What percentage of diabetics will demonstrate signs of kidney disease in their lifetime?
50%
Diabetic retinopathy is the most common cause of legal blindness in People of working age.
What percentage of adults with diabetes have retinopathy?
40%
What 3 types of medical intervention can reduce the risk of significant visual loss for those with retinopathy?
Laser therapy
Intraocular pharmacological treatment
Surgery.
To prevent the onset and delay progression of retinopathy what two parameters should be tightly controlled?
Glycemia and BP.
What drug can be used to slow progression of retinopathy?
Fenofibrate
Can RAAS intervention reduce progression of retinopathy? Ie: ACE/ARB
Inconclusive.
BP lowering does. But unclear whether RAAS blockade reduces progression independent of its BP lowering effects.
How many times more likely are diabetics to lose a limb compared to the general population?
20 X
Should people with D soak their feet?
NO
Retinopathy is more common in type one or two?
Type one
After starting ace or ARB and you
Check K and creatinine at 1-2 weeks, what do you do if iK
Becomes elevated or creatinine is greater than 30% difference from baseline?
Review therapy and recheck both levels to see if stablized.
**guidelines are not specific as to what this means for SCr!! See other questions for guidance on increased K.
Under what three conditions should you check SCr and K in reference to RAAS therapy? 3
Initiating ACE or ARB
Titration up
Times if acute illness being on ACE or ARB
If K is mildly or moderately increased after starting or titration up a RAAS drug, what do you do?
Counsel on low K diet. If persistent, use non K sparing diuretics. Can consider temporary hold of drug.
If K is severely increased during RAAS therapy what do you do?
Hold drug and give emergency management
Should all
D patients have a baseline K and SCr done prior to starting an ACE OR ARB?
Yes!
In a patient on dialysis a1c is not accurate. What test should you use instead?
Serum glycated albumin
End stage renal failure is more common in type
One or two?
One.
However due to high prevelance of type 2 over half of all diabetic pts on dialysis are type two.
If a D person has significant renal dysfunction but normal urine albumin what does that mean?
Non diabetic CKD
His often should a pt with CKD have random ACr and eGFR done
At least every 6 months!!
A normal
EGFR is what?
Greater or equal to 90
A mildly decreased eGFR is between what numbers?
60-90
How can autonomic neuropathy affect feet?
Anhydrosis (lack of perspiration)
Xerosis (dry skin prone to cracks and fissures)
In CKD the A1C can be falsely
Low
The leading cause of neuropathy is north anerica is
D
Are males or females at higher risk of nephropathy ?
Males
What’s the difference between non-proliferative and pre-proliferative retinopathy?
Non. Is like background retinopathy. Small blood vessels that supply the retina are weakened and occluded and leak fluids. Almost all pts with D have this after 25 years or more
Pre Proliferative is when new and abnormal blood vessels have formed. They are farhile and easily break open causing bleeding and exudates. Cotton wool
Spots. Treatment is laser
Are ACr and eGFR blood or urine screens?
EGFR. Blood
ACr. Urine. Random.
How many ACr samples over what time period do you need to diagnose CKD?
3 samples over a 3 month period. 2 have to be over 2
At what egfr is a diagnosis of CKD met?
At what ACr (single test)
<60
>20
When screening for CKD, if eGFR and ACr come back in CKD range can you diagnose??
No. Must have repeat of ONE eGFR in 3 months time and up to 2 ACr within the 3 months.
EITHER 2 x eGFR
OR ACr x 2/3 can diagnose.
