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Refreshers > Renal > Flashcards

Renal Flashcards

1
Q

what do the kidneys aim to maintain in body?

A

remove wastes and extra fluid also acid produced by cells of body and maintain healthy balance of water, salts, and minerals e.g. sodium, calcium, phosphorus and potassium in blood.

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2
Q

list some different things that can be used for the diagnosis/ detection of AKI/ CKD

A

signs
symptoms
risk factors
urine output
serum creatinine

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3
Q

What algorithm is endorsed by nhs england and used in labs to identify potential cases of AKI based on creatinine levels

A

AKI

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4
Q

how is an AKI warning stage test result result communicated once identified

A

to GP clinical systems

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5
Q

what is the benefit of communicating aki warning stage test results to gp clinical systems

A

allows primary care team to take action based on clinical judgement

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6
Q

list some of the different measures for renal function that may be used selectively for different patient groups depending on appropriateness

A

creatinine
24 hr urine collection
51 chromium edta test
cystatin c
egfr

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7
Q

list some different patient groups where gfr may appear BETTER than it actually is

A

elderly
low protein diet
amputees
muscle wasting disorders

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8
Q

list some populations in which gfr may appear WORSE than it actually is

A

high muscle mass
high protein diet
muscle breakdown

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9
Q

name of the equation that is used to calculate creatinine clearance

A

cockcroft gault

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10
Q

whilst creatinine clearance is not good for diagnosis what is it good for

A

bedside calculation and drug dosing

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11
Q

Modification of Diet in Renal Disease (MDRD eGFR) becomes more useful in <60ml/min function or stage 3/4 of CKD, why is is not useful at lower level

A

overestimates renal function

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12
Q

give some patient populations where mdrd egfr is useful for bedside calc and drug dosing but not diagnosis

A

obesity
muscle mass
fluid overload

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13
Q

give a brief description of CKD

A

abnormalities of kidney structure or function present for greater than 3 months with implications for health

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14
Q

why is ckd more prevalent in elderly populations

A

ageing process causes loss of nephrons and natural decline of renal function

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15
Q

UK kidney association has classified ckd as individuals with an egfr of below x on at least 2 occasions y days apart with or without markers of kidney damage

A

X = 60
Y = 90

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16
Q

list some different markers of kidney damage

A

albuminuria
haematuria
electrolyte abnormalities
renal histological abnormalities
structural abnormalities
kidney transplant Hx

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17
Q

examples of structural abnormalities detected by imaging

A

e.g. polycystic kidneys, reflux nephropathy

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18
Q

There are several causes of CKD, give examples 7

A
  • intrinsic kidney disease conditions
  • kidney infections
  • polycystic kidney disease
  • glomerulonephritis
  • meds impacting kidneys
  • obstructive kidney disease conditions
    multi-system diseases involving kidneys
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19
Q

give examples of intrinsic kidney disease conditions that may cause CKD

A

ashypertension
T1,T2DM
hypercholesterolaemia

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20
Q

polycystic kidney disease is inherited t/f?

A

true… cysts develop in kidney

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21
Q

give examples of meds impacting kidneys –> CKD

A

lithium
ciclosporin
calcineurin inhibitors (such as tacrolimus)
aminoglycosides
mesalazine

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22
Q

ckd is classified according to what 3 things

A

cause
gfr
albuminuria

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23
Q

name a tool that is used to predict the risk of kidney failure

A

kfre kidney failure risk equation

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24
Q

the kfre tool determines a persons risk of developing kidney failure within x years

A

2-5

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25
Q

why is it important to have a tool that accurately predicts a patients risk of developing kidney failure

A

helps dr and patient plan best pathway of care and highlight which patients need to be referred to hospital because their disease is more severe

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26
Q

true or false, aki is a term used to a cover a spectrum of injury to the kidneys

A

true

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27
Q

aki is characterised by a decline in renal function over hrs or days that can result in failure to

A

maintain fluid, electrolyte and acid base homeostasis

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28
Q

in the early stages aki can be symptomless, what might some people experience in the early stages however

A

produce less urine than usual

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29
Q

what symptoms can develop rapidly in someone with aki

A

nausea, vomiting, diarrhoea
reduced urine output
changes to urine colour
new or worsening confusion, fatigue, drowsiness

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30
Q

in the context of aki what are nausea, vomiting and diarrhoea all evidence of

A

dehydration

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31
Q

list some different risk factors for aki/ renal hypoperfusion

A

hypotension
hypovolaemia
drugs
sepsis
haemodynamic disturbances
ischaemic aki
intense sodium and water retention

32
Q

what effect does haemodynamic disturbance have on the kidneys

A

endothelial and epithelial injury and immune activation

33
Q

during ischaemic aki what does the kidney lose

A

autoregulatory capacity

34
Q

elderly patients and those that are taking medication deemed nephrotoxic or those that cause dehydration are at a greater or lesser risk of developing aki

A

greater

35
Q

true or false, nsaids and cox II inhibitors do not need to be avoided in patients at high risk of AKI

A

false

36
Q

what effect do nsaids have on the kidney that would be problematic in aki

A

altered haemodynamics leading to underperfusion and reduced glomerular filtration

37
Q

what action should be taken towards opioid analgesics in the presence of aki

A

avoid long acting preparations
reduced dose and frequency
use opiates with minimal renal excretion

38
Q

list some opiate options that have minimal renal excretion

A

fentanyl
oxycodone
hydromorphone
tramadol

39
Q

what change in side effect profile would you expect if using opioid analgesics like morphine, pethidine and codeine in the presence of aki

A

accumulation of active metabolites, increased cns side effects and respiratory depression

40
Q

what changes in side effects would you expect in patients taking pregabalin or gabapentin in the presence of aki

A

accumulation leading to increased cns side effects

41
Q

what action should be taken towards use of pregabalin or gabapentin the case of aki

A

reduce dose

42
Q

in aki what effect might antihypertensives including alpha beta and ca channel blockers have

A

hypotension may exacerbate renal hypoperfusion

43
Q

what change is side effect profile occurs when using beta blockers in states of reduced renal function

A

risk of bradycardia

44
Q

what action is required towards antihypertensive drugs in the presence of aki

A

consider withholding or reduce dose depending on blood pressure

45
Q

what effects can acei/arbs/aliskiren have on the kidneys in aki

A

hypotension and hyperkalaemia

46
Q

in aki withholding acei/arbs and aliskiren can be considered however in some situations continuing them may be helpful, name on situation where this may be the case

A

HF

47
Q

what effect might loop or thiazide diuretics have on the kidneys in aki

A

volume depletion and acute interstitial nephritis (rare)

48
Q

in aki why are loop diuretics such as furosemide and bumetanide preferred

A

thiazides less effect if gfr below 25 ml/min

49
Q

action in presence of AKI for diuretics?

A

withold if volume depleted

50
Q

potassium sparing diuretics such as amiloride, spironolactone and eplerenone can cause volume depletion and hyperkalaemia in aki, what action should be taken if a patient is on these drugs

A

stop

51
Q

statins may cause aki if rhabdomylolysis is present and can generally increase the risk of developing it, what action would be taken if patient develops unexplained or persistent muscle pain

A

stop

52
Q

diigoxin can cause hyperkalaemia and accumulate in AKI -> bradycardia, visual disturbances, mental confusion
action in presence of AKI

A

reduce dose
monitor L+ and drug levels

53
Q

DOACS
INFECTION
DIABETES
OTHER AGENTS
…

A
54
Q

3 categories that aki causes can be divided into

A

pre renal
intrinsic renal
post renal

55
Q

pre renal aki is caused by reduced blood flow to the kidneys, give some causes of this

A

hypovolemia
reduced cardiac output
hypotension
medicines

56
Q

how might loop diuretics cause pre renal aki

A

reduce blood pressure and circulating volume

57
Q

acei and arbs and nsaids may cause pre renal aki by affecting

A

renal blood flow

58
Q

pre renal aki can also be caused by systemic vasodilation, give a condition where this may be the case

A

sepsis

59
Q

which type of aki cause is due to structural damage to the kidney tissues and may be a result of persistent pre and post renal causes

A

Intrinsic renal (or intrarenal)

60
Q

what medicines can also cause intrinsic renal aki

A

antibiotics
x ray contrast media
chemo

61
Q

types of structural damage that result in intrinsic renal aki can be grouped into what different categories depending on the area of the kidneys that are affected

A

vascular
glomerular
tubular
interstitial

62
Q

what is the least common cause of aki that is due to obstruction of the flow of urine out of the kidneys

A

post renal

63
Q

give some different causes for post renal aki

A

renal stones
blocked catheters
enlarged prostate
genitourinary masses

64
Q

Classification of AKI
NICE clinical guideline Acute kidney injuryLinks to an external site.: prevention, detection and management recommends defining acute kidney injury by any of the following criteria:

A

a rise in serum creatinine of 26 micromol/litre or greater within 48 hours a 50 percent or greater rise in serum creatinine known or presumed to have occurred within the past seven days
a fall in urine output to less than 0.5 mL/kg/hour for more than six hours in adults and more than eight hours in children and young people
a 25 percent or greater fall in eGFR in children and young people within the past seven days. AKI can be staged based on severity, and increasing severity of AKI correlates with higher risk of worse outcomes.
Kidney Disease: Improving Global Outcomes (KDIGO) has produced a Clinical practice guideline for acute kidney injury which includes AKI staging information. The information in the following table is taken from this guideline. There are two classification systems used in practice:

65
Q

At risk patients in primary care

A

Diabetes Mellitus
Chronic Kidney Disease – if become acutely unwell, unable to maintain fluid intake, should contact GP to withhold medication ACE/ARB
Dementia –inability to self-care and fluid intake
Heart Failure – often have CKD and on ACE/diuretics
Maintaining optimal fluid intake
Older people
Most at risk
Dementia/frailty/risks of dehydration
Psychiatric Patients
Self-neglect - dehydration
Laxative or diuretic abuse
Recreational drugs
Paediatric Patients with CKD
Patients with Cancer
Awareness in community, management is secondary care
AKI known complication of cancer therapy – drugs/type of cancer/risks of sepsis

66
Q

what is the treatment and management of aki dependent on

A

site
staging
presence of complicating factors

67
Q

what are sick day rules

A

withholding nephrotoxic drugs to prevent the development of aki in patients that start vomiting, diarrhoea, fevers, sweats or shaking

68
Q

aim of treatment is to manage the progression and complications of ckd and patients should be provided with information and education, what should they be encouraged to do non pharmacologically

A

exercise
achieve healthy weight
smoking cessation
dietary advice

69
Q

The mainstay of treatment of CKD is based around the management of the multimorbidities associated with CKD,…

A

Complications of CKD include:
cardiovascular disease (hypertension, peripheral vascular disease and heart failure)
cardiovascular events (stroke and myocardial infarction)
anaemia or chronic disease
renal bone disease
malnutrition
neuropathy (nerve pain)
lipid abnormalities
increased risk of acute kidney injury
end-stage renal disease that requires renal replacement therapy (RRT)
risk of acidosis (to learn about acidosis, access this Lab Tests Online article Acidosis and Alkalosis)
increased risk of infection – those with CKD have been shown to be at increased risk of hospitalisation due to infections such as pneumonia, sepsis, and urinary tract infections.TIs

70
Q

at end stage ckd renal replacement therapies may be more appropriate, give some examples

A

peritoneal dialysis, haemodialysis, kidney transplant

71
Q

the main pharmacological treatments offered to those with ckd are?

A

blood pressure
renal bone disease
renal anaemia
preservation of kidney function
metabolic acidosis

72
Q

why might patients with ckd be offered statin or oral antiplatelet therapy

A

secondary prevention of cvd

73
Q

what is the rationale behind using an sglt2 inhibitor ckd

A

blocks sglt2 in kidneys
reduces pressure and inflammation
stops protein leaking into urine
reduces blood pressure and weight
so reduces damage

74
Q

adding x to the current standard care for ckd has been shown to significantly reduce the risk of

having declining kidney function
end stage kidney disease
dying from causes related to kidney or cv system

A

dapagliflozin

75
Q

name the drug that is recommended as an option for treating end stage 3 and 4 ckd with albuminuria and associated with t2dm in adults

A

finerenone

76
Q

what 2 things have to be measured to determine if finerenone treatment can be initiated and to determine the starting dose

A

serum potassium and egfr

77
Q

CASE STUDIES

A

Refreshers (10 decks)

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