renal Flashcards by denise lin

eGFR is based on serum Cr, age, gender and ethnicity. What 3 things may affect the result?

Pregnancy
Muscle mass
Eating red meat 12 hours before

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NICE guidelines suggest referring to a nephrologist from primary care if within 1 year, the eGFR falls by…

Sustained decrease in eGFR by >15 or >25%
Or falls below <30

Within 1 year

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Pruritis can occur in chronic kidney disease secondary to…

uraemia

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Referral to nephrology from primary care if the urinary albumin:creatinine ratio (ACR) is what level

> 70mg/mmol
or >30mg/mmol with haematuria

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eGFR is worked out by which 4 variables

Serum Cr
Age
Gender
Ethnicity

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CKD stages + ranges

CKD 1 = >90
CKD 2 = 60-90
CKD 3 = 30-45 (3a = 45-60, 3b = 30-45)
CKD 4 = 15-30
CKD 5 = <15 or ESRF

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In a patient with ACR > 30, and high blood pressure or CKD, what is the first line anti-hypertensive medication

ACE inhibitor

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Patients with hypertension have different treatment guidelines depending on ACR level. What is the cut-off ACR for these guidelines?

ACR <30 - treat as usual HTN guidelines
ACR >30 - start on ACE inhibitor

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ACE inhibitors are useful in chronic kidney disease when ACR >30 - what is their mechanism of action

Reduces proteinuria
Reduces filtration pressure by causing efferent dilation (therefore can increase Cr, decrease eGFR)

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What is an acceptable decrease in eGFR or rise in Cr for ACE inhibitors in HTN for CKD patients (ACR >30)

eGFR of up to 25% decrease
Cr of up to 30% increase

any higher suggests renal artery stenosis

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What loop diuretic is useful as an anti-hypertensive in patients with CKD?

Furosemide

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Furosemide is useful as anti-HTN in CKD patients particularly when eGFR falls to below…

<45
Also lowers K+

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In non-diabetics if ACR >/= 70
what is the antihypertensive that should be started regardless of BP

Start ACE inhibitor/ARBs
AND refer to nephrology

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In Type 2 Diabetics if ACR > 3
what is the anti-hypertensive

Start ACE inhibitors/ARBs
Make sure it is titrated to max dose
And then offer SGLT-2 inhibitor (-gliflozin) if ACR >70 (consider if ACR 3-30)

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Type 1 diabetes, and ACR >3
what anti-hypertensive should be started

ACE inhibitors/ARBs

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For all patients with CKD what statin should be started

atorvastatin 20mg if no cardiovascular Hx

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ACR to PCT to urinary protein excretion (g/24 hours) equivalent values:
ACR 30
ACR 70

ACR 30 = PCR 50 = 0.5g/24hrs urinary protein excretion

ACR 70 = PCR 100 = 1g/24hrs urinary protein excretion

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ACR sample should be what kind of urine sample

First-pass morning
Spot sample

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If the initial ACR is between 3-70, how should this be confirmed

Subsequent early morning sample
If initial ACR >70, repeat sample does not need to be repeated

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NICE guidelines regard a confirmed ACR of what as clinically important proteinuria

ACR >3

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Other than ACE inhibitors, what other medication may be useful for patients who have proteinuric CKD (with or without diabetes)

SGLT-2 inhibitors
e.g. dapagliflozin, empagliflozin

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SGLT2 inhibitors can be used for proteinuric CKD patients. What is their mechanism of action

Block reabsorption of glucose at the proximal tubule
Increase glycosuria
Reduces sodium reabsorption
Reduces intravascular volume, BP, and intraglomerular pressure

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In order to diagnose CKD, you need eGFR below what and over what timeframe

eGFR <60 on at least 2 occasions separated by at least 90 days

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If the initial ACR test is between 3-70, what should be done in terms of repeat samples/referral?

Repeat another ACR early morning sample
If >30 and haemturia - refer
If >70 - refer

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If the initial ACR test result is >70, what should be done in terms of repeat samples/referral?

Repeat sample does not need to be done Refer to nephrology!

When should ACR urine sample be done

Early morning sample

minimal change disease (usually presents as a nephrotic syndrome) is usually idiopathic in most causes. in 10-20% causes can be found including what three things?

1. drugs - NSAIDs, rifampicin 2. Hodgkin's lymphoma, thymoma 3. infectious mononucleosis

Minimal change disease renal biopsy usually shows what

Normal glomeruli on light microscopy Electron microscopy shows fusion of podocytes, effacement of foot processes

Nephrotic syndrome triad

Oedema Proteinuria Hypoalbuminaemia

Nephritic syndrome triad

Hypertension Haematuria Oliguria

Treatment of minimal change disease

Oral corticosteroids - 80% are steroid-responsive Cyclophosmide for steroid-resistant cases

Prognosis of minimal change disease

1/3 have one episode 1/3 have infrequent relapses 1/3 have frequent relapses that stop before adulthood

painless, visible haematuria indicates what cancer

Transitional cell carcinoma of the bladder n.b. renal cell carcinoma typically has mass + abdo pain!

what 2 drugs can cause red/orange urine (where blood is not present)

rifampicin doxorubicin

persistent haematuria is defined as

blood on 2 out of 3 samples at least 2-3 weeks apart

urgent 2 week referral criteria for haematuria (young - goes to renal, older - goes to urology)

>45 years and: - unexplained visible haematuria without UTI; or - visible haematuria that persists/recurs after UTI treatment >60 years and: - unexplained non-visible haematuria and either dysuria/high WCC on bloods NON-URGENT REFERRAL: >60 years with persistent/resistant UTI

what is a useful medication to lower uric acid and phosphate levels

sevelamer

what is the mechanism of action of Sevelamer

Non-calcium based phosphate binder Prevents absorption by binding to dietary phosphate Reduces uric acid

1-alpha hydroxylation usually occurs where and what does it do

In the kidneys produces active vitamin D

chronic kidney disease leads to lower 1-alpha hydroxylation occurring. what does this do to vitamin D and phosphate levels?

Low vitamin D High phosphate

High phosphate levels due to chronic kidney disease has what effect on the bones

osteomalacia

What parathyroid issue results from chronic kidney disease

Secondary hyperparathyroidism Low vitamin D Low calcium High phosphate

management of mineral bone disease (high phosphate, low vit D, low calcium, osteomalacia) in chronic kidney disease patients

1. Low phosphate diet 2. Phosphate binders - calcium based binders; or non-calcium based binders e.g. sevelamer, binds to dietary phosphate and prevents absorption. Reduces phosphate and uric acid) 3. Vitamin D: alfacalcidol, calcitriol 4. Parathyroidectomy

Calcium based phosphate binders have what 2 side effects

Hypercalcaemia Vascular calcification

Referral to nephrologist if:

ACR >70 ACR >30 and haematuria eGFR drop >25% or >15 in 12 months or <30 overall CKD stage 5

in a patient with eGFR <60, the next step is to

send early morning sample urine for ACR and dipstick urine for haematuria

Henoch schonlein purpura is also known as

IgA vasculitis small vessel vasculitis

Palpable purpura Arthralgia/arthritis Abdominal pain Renal involvement Follows URTI Common in children What is the diagnosis?

Henoch schonlein purpura (IgA vasculitis)

Treatment of Henoch schonlein purpura

1. analgesia for arthralgia 2. generally supportive - not much evidence for steroids or immunosuppressants 3. Monitor BP and urinalysis to detect progressive renal involvement

Prognosis of Henoch schonlein purpura

1. Self-limiting, usually resolves especially if no renal involvement 2. 1/3 patients have relapse

Anaemia in CKD4 - what level of Hb do they aim for?

10-12g/dl

Anaemia in CKD predisposes to the development of what...

Left ventricular hypertrophy associated with 3x increased mortality in renal patients

Management of anaemia in CKD patients

1. Target Hb levels 10-12g/dl 2. Optimise iron levels - give oral iron if not on ESAs or dialysis. If not at target Hb levels by 3 months, switch to IV iron. 3. Erythropoeisis stimulating agents (ESAs) e.g. erythropoeitin, darbepoetin

What 2 drugs are associated with proteinuria

Gold Penicillamine

Main cause of nephrotic syndrome

Primary glomerulonephritis (80%) - minimal change - membranous - focal segmental - membranoproliferative

Primary glomerulonephritis is the main (80%) cause of nephrotic syndrome. What 3 systemic diseases can also lead to nephrotic syndrome?

Diabetes SLE Amyloidosis

What are the 3 diuretics indicated for ascites

Spironolactone Amiloride Chortalidone

5 indications for spironolactone use

1. Ascites - cirrhosis ascites can develop secondary hyperaldosteronism 2. Hypertension 3. Heart failure 4. Nephrotic syndrome 5. Conn's syndrome

Two side effects from spironolactone

Hyperkalaemia Gynaecomastia

Patients with CKD, HTN and urinary ACR or >70 should aim for what BP

<130/80

What diuretic can be useful as an anti-hypertensive in CKD patients with eGFR <45?

Furosemide

What inheritance is polycystic kidney disease

autosomal dominants

what is the screening investigation for relatives with polycystic kidney disease

abdominal ultrasound

what is the ultrasound diagnostic criteria for polycystic kidney disease (if patients have positive family history)

- <30 years - two cysts uni or bilateral - 30-59 years - two cysts in both kidneys - <60 years - four cysts in both kidneys

What is the medication treatment of polycystic kidney disease and the 3 criteria to start it

Tolvaptan (vasopressin receptor 2 antagonist) - if CKD 2 or 3 - evidence of rapidly progressing disease - company discount with patient access scheme

What genes/Chr are involved with polycystic kidney disease

Type 1 (85%) = PKD1, Chr 16 Type 2 = PKD2, Chr 4

Triad of renal cell carcinoma

Haematuria Loin pain Abdominal mass

Endocrine effects of renal cell carcinoma - i.e. what hormones does it secrete

Polycthaemia (secretes EPO) Hypercalcaemia (secretes PTH) Rein ACTH

diabetes insipidius is caused by which hormone abnormality

Cranial DI - decreased secretion of anti-diuretic hormone (ADH) Nephrogenic DI - insensitivity to ADH

What 2 medications can cause nephrogenic DI

Lithium Demeclocycline

What two electrolyte disturbances can induce nephrogenic DI

Hypokalaemia Hypercalacaemia

What will diabetes insipidus show on: plasma osmolality urine osmolality

High plasma osm Low urine osm

Management of diabetes insipidus

Nephrogenic - thiazides and low salt/protein diet Central - desmopressin

Patients with CKD on haemodialysis - what is the most likely cause of death

ischaemic heart disease