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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
Q

How do you treat anaemia?

A

Erythropoietin = subcutaneous injection
BUT limited by supply of Fe in the body
= need Fe replacement with it

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26
Q

What are the different pharmacological management of CKD?

A

ACEi
Anti platelet
Statin
SGLT-2

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27
Q

When are ACEi used?

A

Protective in CKD
BUT in AKI remove

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28
Q

What are the problem with ACEi?

A

Increase K+ BUT a decreased kidney function also increases it

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29
Q

What is an example of an anti-platelet?

A

Aspirin

30
Q

What must you do with an anti-platelet?

A

Monitor bleeding

31
Q

What are signs for GI bleed?

A

Dark stool + high urea
Coffee ground vomit

32
Q

What is SGLT-2?

A

Na-glucose-ligand transporters
Stops progression
BUT in acute = damaging

33
Q

What are the NICE guidelines for AKI?

A

SrCr increase of > 26 micromol/L in 48hrs

34
Q

Which medications can cause AKI?
DAMN

A

Diuretics
ACEi/ARBs
Metformin
nSAIDs

35
Q

What can also cause AKI?

A

Contrast media (dye)

36
Q

What does serum creatine estimate?

A

Patient’s kidney function

37
Q

What is the equation for serum creatine?

A 
               SrCr

M = 1.23
F = 1.04

38
Q

When do you caution using CrCl measurements?

A

Elderly, body builders, amputees, muscle wasting disorders + vegans

39
Q

Why is CrCl more accurate?

A

Ideal body weight

40
Q

What are the risk factors of AKI?

A

Diabetes
CKD
HF
Elderly = over 65
Liver problems
Medicines
Contrast media (dye)

41
Q

What are the causes of pre-renal conditions?
AKI

A

Lack of perfusion
= pregnancy
= vomiting
= diuretic use
Loss of fluid

42
Q

What are the post renal causes?
AKI

A

Backlog of urine
= pregnancy
= bladder obstruction
= stones

43
Q

What are the intra renal causes?
AKI

A

Pregnancy = preeclampsia
Pregnancy unrelated = glomerular disease

44
Q

How many stages of AKI is there?

A

3

45
Q

What is stage 1 AKI?

A

Rise 1.5-2 fold from baseline creatine or urine output

46
Q

What is stage 2 AKI?

A

Rise of 2-3 fold creatine or urine output

47
Q

What is stage 3 AKI?

A

Rise >3 fold creatine or urine output

48
Q

What is the management of AKI?

A

Underlying cause
Pre-renal = provide IVT resuscitation
Post-renal = remove obstruction
Hold nephrotoxic drugs

49
Q

What is the main complication of AKI?

A

Hyperkalaemia

50
Q

What is the normal range of K+?

A

3.6-5.2
Over 6 = BAD

51
Q

What can hyperkalaemia result in?

A

Fatal cardiac arrhythmias
= ventricular fibrillation

52
Q

How do you treat hyperkalaemia?
Protect the heart

A

IV calcium gluconate

53
Q

What does IV calcium gluconate do?

A

Stabilises myocellular lining of the heart
= prevents arrhythmias

54
Q

How do you treat hyperkalaemia?
Shift K+ into cells

A

IV insulin
Nebulised salbutamol

55
Q

What must IV insulin be given alongside to?

A

Glucose

56
Q

How do you treat hyperkalaemia?
Remove excess K+

A

PO calcium resonium

57
Q

What are the other complications with AKI?

A

Fluid overload
Metabolic acidosis
Uraemia (results in encephalopathy)

58
Q

What is uraemia?

A

Swelling of the brain
= NS disorders

59
Q

What are signs of opioid toxicity?

A

Respiratory depression
Pin prick pupils

60
Q

What are problems with renal drugs?

A

Renally excreted
Risk of accumulation
Increased drug half life
Reduce efficacy

61
Q

What are the prescribing approaches?

A

Increase dosing interval
Decrease dose
Combo of dose reduction + increased interval
Review drug choice

62
Q

Why increase dosing interval?

A

Gives body to excrete the drug

63
Q

Why decrease the dose?

A

Time dependant meds

64
Q

Why do a combo?

A

Increase more time to filter out

65
Q

Why review drug choice?

A

Hepatic metabolism?
Inactive metabolite?

66
Q

What are the conditions that DOACs can be used for renal disease?

A

> 80 years old
<60kg
<133micromol/L

67
Q

What is an example of a DOAC?

A

Apixaban

68
Q

When do you avoid nSAIDs when possible?

A

CKD

69
Q

When do you remove nSAIDs?

A

AKI

70
Q

What do nSAIDs do?

A

Prostaglandin synthesis inhibited
= inhibit vasodilator PGs
= effect renal perfusion

71
Q

What do ACEi do in AKI?

A

Dilate efferent arteriole
= remove blood pressure
= decrease perfusion

72
Q

What do ACEi do in CKD?

A

Remove pressure = good

S2 Case 6 - stroke & anticoagulation (7 decks)

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