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S2 Case 6 - stroke & anticoagulation > Principles of Prescribing in Renal Disease > Flashcards

Principles of Prescribing in Renal Disease Flashcards

1
Q

What is the role of the kidney?

A

Filter blood
Regulate blood vol + plasma osmolarity
Secrete hormones

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2
Q

What are the 2 types of renal impairment?

A

Chronic kidney disease (CKD)
Acute kidney disease (AKD)

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3
Q

What is CKD?

A

Reduction in kidney function due to structural damage present for more than 3 months

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4
Q

What is AKI?

A

Acute drop in kidney function

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5
Q

What are the CKD causes?

A

Hypertension
Diabetes
AKI
Medicines
Obstructive uropathy
Obesity
Cardiovascular disease

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6
Q

What is the presentation of CKD?

A

Usually asymptomatic
= diagnosed with routine check ups

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7
Q

What are the complications of CKD?

A

Anaemia
Renal bone disease
Cardiovascular disease
Peripheral neuropathy
Dialysis related problems

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8
Q

Why is anaemia a CKD complication?

A

Secrete erthrocreatine
= increase RBC production
BUT anaemia decreases this

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9
Q

Why is renal bone disease a CKD complication?

A

Impaired absorption of Ca2+
= cannot be used in reabsorption of bone growth

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10
Q

Why is cardiovascular disease a CKD complication?

A

Kidneys don’t work
= fluid build up
= more pressure on the heart

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11
Q

Why is peripheral neuropathy a CKD complication?

A

Imbalance of electrolytes?

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12
Q

How do you manage CKD?

A

Monitor renal function
Suspend nephrotoxic medication
Monitor complications = anaemia + RBD

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13
Q

What do you monitor for CKD?

A

eGFR
CrCl
ACR

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14
Q

What can get through if there is damage?

A

Bigger molecules such as proteins

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15
Q

What is the problem with eGFR?

A

Use standardised BSA = 1.73m2
= overestimates smaller patients
= underestimates larger patients

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16
Q

When do you NOT use eGFR?

A

Drug dose titrations
Elderly patients
Extreme of muscle mass

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17
Q

How many stages of CKD is there?

A

5

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18
Q

What is stage 1 of CKD?

A

Kidney damage with normal kidney function

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19
Q

What is stage 2 of CKD?

A

Kidney damage with mild loss of kidney function

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20
Q

What is stage 3a of CKD?

A

Mild to moderate loss of kidney function

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21
Q

What is stage 3b of CKD?

A

Moderate to severe loss of kidney function

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22
Q

What is stage 4 of CKD?

A

Severe loss of kidney function

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23
Q

What is stage 5 of CKD?

A

Kidney failure

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24
Q

What are the steps to management of treatment of CKD?

A

Identify underlying cause
Treat complications

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25
How do you treat anaemia?
Erythropoietin = subcutaneous injection BUT limited by supply of Fe in the body = need Fe replacement with it
26
What are the different pharmacological management of CKD?
ACEi Anti platelet Statin SGLT-2
27
When are ACEi used?
Protective in CKD BUT in AKI remove
28
What are the problem with ACEi?
Increase K+ BUT a decreased kidney function also increases it
29
What is an example of an anti-platelet?
Aspirin
30
What must you do with an anti-platelet?
Monitor bleeding
31
What are signs for GI bleed?
Dark stool + high urea Coffee ground vomit
32
What is SGLT-2?
Na-glucose-ligand transporters Stops progression BUT in acute = damaging
33
What are the NICE guidelines for AKI?
SrCr increase of > 26 micromol/L in 48hrs
34
Which medications can cause AKI? DAMN
Diuretics ACEi/ARBs Metformin nSAIDs
35
What can also cause AKI?
Contrast media (dye)
36
What does serum creatine estimate?
Patient's kidney function
37
What is the equation for serum creatine?
(140-age) X weight (kg) X F -------------------------------------- SrCr M = 1.23 F = 1.04
38
When do you caution using CrCl measurements?
Elderly, body builders, amputees, muscle wasting disorders + vegans
39
Why is CrCl more accurate?
Ideal body weight
40
What are the risk factors of AKI?
Diabetes CKD HF Elderly = over 65 Liver problems Medicines Contrast media (dye)
41
What are the causes of pre-renal conditions? AKI
Lack of perfusion = pregnancy = vomiting = diuretic use Loss of fluid
42
What are the post renal causes? AKI
Backlog of urine = pregnancy = bladder obstruction = stones
43
What are the intra renal causes? AKI
Pregnancy = preeclampsia Pregnancy unrelated = glomerular disease
44
How many stages of AKI is there?
3
45
What is stage 1 AKI?
Rise 1.5-2 fold from baseline creatine or urine output
46
What is stage 2 AKI?
Rise of 2-3 fold creatine or urine output
47
What is stage 3 AKI?
Rise >3 fold creatine or urine output
48
What is the management of AKI?
Underlying cause Pre-renal = provide IVT resuscitation Post-renal = remove obstruction Hold nephrotoxic drugs
49
What is the main complication of AKI?
Hyperkalaemia
50
What is the normal range of K+?
3.6-5.2 Over 6 = BAD
51
What can hyperkalaemia result in?
Fatal cardiac arrhythmias = ventricular fibrillation
52
How do you treat hyperkalaemia? Protect the heart
IV calcium gluconate
53
What does IV calcium gluconate do?
Stabilises myocellular lining of the heart = prevents arrhythmias
54
How do you treat hyperkalaemia? Shift K+ into cells
IV insulin Nebulised salbutamol
55
What must IV insulin be given alongside to?
Glucose
56
How do you treat hyperkalaemia? Remove excess K+
PO calcium resonium
57
What are the other complications with AKI?
Fluid overload Metabolic acidosis Uraemia (results in encephalopathy)
58
What is uraemia?
Swelling of the brain = NS disorders
59
What are signs of opioid toxicity?
Respiratory depression Pin prick pupils
60
What are problems with renal drugs?
Renally excreted Risk of accumulation Increased drug half life Reduce efficacy
61
What are the prescribing approaches?
Increase dosing interval Decrease dose Combo of dose reduction + increased interval Review drug choice
62
Why increase dosing interval?
Gives body to excrete the drug
63
Why decrease the dose?
Time dependant meds
64
Why do a combo?
Increase more time to filter out
65
Why review drug choice?
Hepatic metabolism? Inactive metabolite?
66
What are the conditions that DOACs can be used for renal disease?
>80 years old <60kg <133micromol/L
67
What is an example of a DOAC?
Apixaban
68
When do you avoid nSAIDs when possible?
CKD
69
When do you remove nSAIDs?
AKI
70
What do nSAIDs do?
Prostaglandin synthesis inhibited = inhibit vasodilator PGs = effect renal perfusion
71
What do ACEi do in AKI?
Dilate efferent arteriole = remove blood pressure = decrease perfusion
72
What do ACEi do in CKD?
Remove pressure = good

S2 Case 6 - stroke & anticoagulation (7 decks)

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