Renal Failure Flashcards
Definition of CKD
CKD = eGFR <60 for >3mo
‘Triple whammy’ of meds causing AKI?
Ace Inhibitors/ARBs
NSAIDS
Diuretics
Pre renal causes of AKI
NSAIDs
Ace/ARBs
Hypovolemia (Hemorrhage, Gastrointestinal/Skin/Renal Losses)
Low Cardiac Output (Heart Failure, AAA, Obstructing Masses)
Liver Failure (Cirrhosis)
Sepsis
Third Spacing
Renal Artery Stenosis
Calcineurin Inhibitors
Hypercalcemia
Sx of uremia
Confusion
Seizures
Asterixis
Myoclonus
Peripheral Neuropathy
Hyporeflexia
Pericardial Friction Rub
Shortness of Breath
Fluid Overload
Pleuritic Chest Pains
Headache
Lethargy/Somnolence
Nausea/Vomiting
Loss of Appetite/Taste
Muscle Cramps
Weakness
Meds to hold in AKI
Sulfonylureas
Ace Inhibitors
Angiotensin Receptor Blockers
Diuretics
Biguanides
NSAIDs
SGLT-2 Inhibitors
Complications of renal failure
Uremia
Hyperkalemia
Hypercalcemia
Hypocalcemia
Hyperphosphatemia
Metabolic Acidosis
Hypertension
Osteodystrophy
Gout/Pseudogout
Anemia
Bleeding Disorders
Infections
Sleep Disturbances
Sexual Dysfunction
Death
RF for CKD
DM, HTN, vascular dz (renal artery stenosis), glomerular dz (autoimmune, malignant, infection, renally excreted drugs, neoplasia), tubulointerstitial dx (UTI, stones, obstruction), polycystic kidney dz, age, increased BMI, smoking, CVD
Factors that affect GFR
Extreme wts
Muscle mass
High/ low protein diet
Meds affecting Cr excretion
Ilness
Pregnancy
Paralysis
Amputation
Workup for CKD
BP
BW: Cr, BUN, ex lytes, BG, CBC, ferritin, albumin, serum protein electrophoresis + Bence Jones protein
UA
Albumin/ Cr ratio
Kidney US (stones, mass, cyst, hydronephrosis)
Management of CKD
Lifestyle: smoking cessation, reduce alcohol, wt control, exercise, hydration
Diet: 0.8g/kg/d protein K, Ph, Ca, Na
Meds: ACEi/ARB if proteinuria
Unwell plan: stop ACEi + diuretics, seek r/a
Drugs that need consideration in CKD
ACEi
ARBs
Metformin
Allopurinol
Abx
Nephrotoxins: NSAIDs, COX-2, aminoglycosides, radio contrast, alfalfa, dandelion, aristolchic
LMWH
DOACs
When to refer in CKD
Progressive renal failure (eGFR <45 or decline >5 within 6mo)
Glomerulonephritis or renal vasculitis
Resistant or secondary HTN
Complications of renal dz (anemia, hyperparathyroidism, EPO deficiency)
Bone disease
Young pt
Rx of volume overload
Restrict dietary sodium (eg. <2g/d)
Diuretic therapy (usually daily loop diuretic, eg. furosemide 80mg)
Rx for hyperphosphatemia
Restrict dietary phosphate (<0.8g/d)
Phospate binders (eg. Sevelamer 800mg PO TID meals)
Rx for Metabolic acidosis (low serum bicarbonate)
Sodium Bicarbonate (NaHCO3) 1000 mg BID to maintain normal serum bicarbonate (>20-22mEq/L)
Rx for Hyperparathyroidism in CKD
Treat hyperphosphatemia, vitamin D deficiency
If >150-200pg/mL, consider calcitriol or vitamin D analog
Do not use calcitriol if serum phosphate or corrected serum total calcium is elevated
Adjust dose to maintain PTH <150pg/mL
Rx for HTN in CKD
Sodium restriction
ACEi/ARB
If edema, loop diuretic +/- thiazide diuretic
If no edema, diuretic or CCB (consider non-DHP CCB in proteinuria)
Resistent hypertension, consider spirinolactone
Ix + rx for anemia in CKD
Work-up: CBC, retic, iron studies, ferritin, B12/folate, r/o GI loss
Replete iron stores if TSAT ≤30% and Ferritin ≤500ng/mL
eg. Venofer 300 mg IV q 2 weeks x 3 doses
If Hb<90 and iron replete or treated for iron deficiency consider Erythropoiesis-stimulating agents (ESA)
Aranesp 0.45 mcg/kg/week
Adverse: CVA, AVF clotting hypertension, cancer recurrence
Target Hb 100-115
Monitor Hb monthly until stable, Fe q3 months
Complications of ESRD
Pericarditis/pleuritis
Uremic encephalopathy/neuropathy (confusion, asterixis, myoclonus, wrist/footdrop, seizures)
Uremic bleeding
Fluid overload refractory to diuretics (CHF/LVH)
Hypertension poorly responsive to medications
Metabolic disturbances
Hyperkalemia
Hyponatremia
Hyper/hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Malnutrition
AKI
Drug toxicity
Infection
Hypothyroidism
Management of hyperkalemia
Tx with IV calcium gluconate 1000mg over 2-3 mins, glucose + insulin, loop diuretics, fluids + D/C drugs that increase K
Insulin 10 units + ½ amp D50 IV
RF for kidney stones
dehydration, meat, high sodium, chemo, acetazolamide, gout, hyperparathyroidism, hyperthyroidism, DM, bowel/ pancreatic dz
Sx by location of kidney stones
Kidney: flank pain, hematuria
Proximal ureter: renal colic, flank pain, upper abdo pain
middle section ureter: renal colic, flank pain, anterior abdo pain
Distal ureter: renal colic, urinary frequency, dysuria
Ix for kidney stones
UA + CS
Lytes, CBC, calcium, albumin, uric acid, CRP
If high calcium = test PTH + vit D
KUB XR + US
Rx for kidney stones
Refer to nephro if urosepsis, anuria, renal failure, obstructed kidney, obstructed pyelo
Ureteral stone <5mm = expectant management, FU US 6mo + q1yr
Ureteral stone >5mm = refer to uro
alpha blockers
extracorporeal shock wave lithotripsy
percutaneous nephrolithotomy
ureterorenoscopy
NSAIDs (CI if using extracorporeal shock wave lithotripsy)
Lifestyle:
Increase fluid intake of pH neutral beverage
Reduce salt intake
Reduce animal protein
Moderate calcium intake
Moderate high oxalate foods (spinach, strawberry, nuts, rhubarb, dark choc, brewed tea)
Increase citrate rich foods (orange juice)
Recurrent:
24hr urine collection for volume, pH, calcium, Cr, a, Ph, oxalate, citrate, uric acid + cystine levels
Nephrotic syndrome features vs
Nephritic syndrome features
Nephrotic syndrome features: Proteinruria (>3.5g/d), Edema, Hypoalbuminemia, Hyperlipidemia
Nephritic syndrome features: Hematuria, RBC casts, Hypertension, Proteinuria (<3.5g/d)
When to screen for CKD
HTN, CVD, DM, First nations, FDR w/ CKD
How to screen + diagnose CKD
eGFR + urine ACR, then if eGFR <60 or urine ACR >3, repeat in 3mo, then dx if eGFR is still <60 and/ or ACR >3
When to refer to renal
eGFR <30, ACR >60, eGFR <45 w/ rapid decline >5 in 6mo, BP not at target, abnormal lytes, hematuria, 5 yr KFRE >5%
What is KFRE?
Kidney failure risk - if >5% over 5 yrs, need to refer
If not referring, monitor q6mo (eGFR, ACR, lytes, UA)
CKD management
lifestyle modification, smoking cessation, statins if at risk, avoid nephrotoxins, adjust doses when sick, reduce BP, ACEi
Which meds to reduce doses when dehydrated in CKD
SADMANS sulfonylureas, ACEi, diuretics, metformin, ARBs, NSAIDs, SGLT2i
SGLT2 inhibitors; when are they CI, SE and impact on other organ systems
CI in T1DM, can drop eGFR, can lead to normoglycemic DKA, yeast vaginitis/ balinitis is common
What is AKI spectrum?
Risk (eGFR >75% normal) - Injury (eGFR 50% normal) - Failure (eGFR 25% normal) - Loss (x4wk)- End stage (x3mo) (RIFLE)
AKD vs AKI
AKD is when GFR is not decreasing
What signs would you monitor in a pt with ?Mg toxicity?
Deep tendon reflexes, RR, BP
Rx for Mg toxicity
10% calcium gluconate IV
Rx for hypercalcemia
IVF, bisphosphonates, calcitonin, steroids, denosumab, dialysis
