Renal Biochemistry - CKD Flashcards
Define CKD. (1)
Chronic Kidney Disease:
- Reduction in kidney function or structural damage (or both) present for > 3 months with associated health implications.
What is the GFR categories for CKD? (6)
G1 (Normal/high): >=90
G2 (Mildly decreased): 60-89
G3a (Mildly to moderately decreased): 45-59
G3b (Moderate to severely decreased): 30-44
G4 (Severely decreased): 15-29
G5 (Kidney failure): <15
What is the albuminuria criteria for CKD? (3)
A1 (Normal to mildly increased): < 30mg/g / <3mg/mmol
A2 (Moderately increased): 30-300mg/g / 3-30mg/mmol
A3 (Severely increased): >300mg/g / >30mg/mmol
What are the risk factors for CKD? (10)
Diabetes (cause of stage G5)
HPT
Proteinuria / Albuminuria
Obesity
Smoking
Hyperlipidaemia
Age
CVD
NSAID use
AKI
What are the common symptoms of kidney disease? (10)
Puffy eyelids
High BP
Loin pain
Bloody/tea coloured urine
Discomfort/pain when passing urine
Difficulty in passing urine
Passing urine frequently
Passing urine frequently at night (nocturia)
Passing stone/sand with urine
Ankle oedema
What are the symptoms of kidney failure? (7)
Poor appetite, nausea, vomiting
Fatigue
Pale (anaemia)
SOB
Drowsiness
Coma
Convulsions
Explain the prevention of kidney disease. (9)
Adequate water intake to maintain good urine volume.
Good personal hygiene, especially female to prevent UTI.
Balanced diet (avoid excessive salt + meat intake)
For patients with kidney stones, avoid high calcium intake.
Good control of diabetes and BP.
Seek early and adequate tx for kidney stones and UTO (large prostate).
Caution for taking drugs including painkillers and ABx.
Early detection of kidney disease by routine urine exam and blood tests for kidneys.
Early tx of kidney disease.
Explain the management of CKD with persistent proteinuria without diabetes. (2)
Refer for nephrology assessment and offer ARB/ACEi (titrated to highest tolerable dose, if ACR = 70mg/mmol or more.
If ACR = 30-70mg/mmol consider discussing with a nephrologist if eGFR declines or ACR increases (Dapagliflozin/Empagliflozin)
State the general management of CV risk in CKD. (4)
Primary and secondary prevention (statins/HPT)
Diabetes control
Exercise
Smoking
What are the complications of CKD? (3)
Renal anaemia: Folate, B12, iron (IV), epoetin stimulating agents.
CKD mineral and bone disorder: Reduce phosphate, diet, phosphate binders. Cinacalcet, Vitamin D.
Metabolic acidosis: NaHCO3
What are the main differences between AKI and CKD? (3)
Baseline
AKI (creatinine), CKD (GFR)
1st presentation: Symptoms (acute infection, hypovolaemia), Ultrasound.
What CrCl value would indicate dose modifications? (1)
< 30/mL/min
Explain the effect of reduced CrCl in medications. (3)
Accumulation in reduced GFR (normally when > 25% of drug renally eliminated.)
Altered drug distribution (protein binding)
Decreased in drug metabolism (Digoxin, Insulin, Vitamin D)
Explain the management process of HPT in CKD. (4)
ACEi/ARBs
Slow progression proteinuria and CKD.
Risk:
- Hypotension + Falls
- Hypoperfusion of kidneys - AKI
- Stop in AKI but beneficial in CKD.
Monitoring:
- Expect initial drop but slows progression.
Explain the risks of using NSAIDs in AKI/CKD. (3)
Caution in CKD:
- Only if absolutely necessary, lowest dose and monitoring.
Increased risk of AKI.
Fluid retention
Explain the management of pain in CKD. (3)
1: Mild
- Paracetamol 0.5-1g QDS
- Moderate:
- Regular paracetamol + weak opioid +/adjunct
- Acute pain: Codeine/Tramadol with caution or low dose oxycodone 2.5-5mg
- Chronic pain: M/R preparation and breakthrough. - Severe:
- Regular paracetamol + strong opioid +/Adjuvant.
- Acute pain: oxycodone IR titrated to effect.
- Chronic pain: Oxycodone M/R or Fentanyl Patches (reduced risk of metabolite accumulation than morphine)
Explain how you would manage medications for AKI. (6)
Metformin:
- Increased risk of lactic acidosis (rare but serious complication of Metformin)
- Stop temporarily
- If renal returns to baseline, consider adding back into therapy.
ACEi/ARB/Diuretics:
- Detrimental to the recovery of the kidney.
- Stop temporarily and review renal function.
Statin:
- Acutely withhold due to increased risk of myopathy.
Aspirin: Continue
DOAC: withhold, consider LMWH
SGLT2i: Withhold risk of DKA.
Explain how you would manage certain medication for CKD. (5)
Metformin:
- Avoid SCr > 150umol/L or eGFR = < 30ml/min
- Caution = SCr: 130-150umol/L or eGFR < 45ml/min (Lactic Acidosis risk)
ACEi/ARB/Diuretics:
- Renal function = stable no reason to alter current dose and monitoring renal function.
Simvastatin:
- Tolerating dose
- Renal Drug Handbook suggests dose used in practice.
Aspirin: Continue
DOAC: Dose adjustment?
