renal failure and its management Flashcards
1
Q
what is chronic kidney disease? 2
A
- Kidney function- GFR <60mL/min/1.73 m2 for > 3 months with or without kidney damage
- AND/ OR
kidney damage- >3 months, with or without decreased GFR, manifested by either pathological abnormalities (markers of kidney damage) or urine albumin to creatinine ratio
2
Q
what happens in the kidney in chronic kidney disease? 7
A
- Diabetes
- Hypertension
- Vascular disease
- Hyperfiltration
- Glomerulosclerosis
- Interstitial scarring
- Tubular atrophy
3
Q
whaat is the pathogenesis of the manifestations of CKD? 6
A
- We have a large physiologic reserve of renal functional mass
- Each kidney has at least 1 million nephrons
- Slow, progressive loss of functioning nephrons may not be noticeable
- This triggers maladaptive compensatory mechanisms
- Either the loss of renal function or the adaptations to reduced renal function led to the manifestations of kidney failure
- The person with CKD may not feel different (silent disease)
4
Q
describe cardiovascular disease in CKD? 3
A
- Atherosclerosis
- Arteriosclerosis
- Uremic cardiomyopathy
5
Q
what are the benefits of good CKD management? 4
A
- Prevent or slow progression to renal failure
- Reduce morbidities
- Improve quality of life
- Reduce costs
6
Q
describe the relationship between Cr and actual clearance?
A
not linear
7
Q
describe GFR vs estimated GFR? 4
A
- GFR is equal to the sum of the filtration rates in all of the functioning nephrons
- Actual GFR (inulin clearance) is not routinely measured in clinical settings
- Estimated GFR gives a rough measure of the number of functioning nephrons
- The normal range for population is not the normal range for an individual with plasma creatinine
8
Q
what is the significance of proteinuria? 4
A
- Indicative of glomerular disease (leaky glomerular basement membrane)
- Proteinuria is nephrotoxic (causes downstream renal tubular cell damage)
- Marker for increased risk of progression of renal disease
- Major benefit from lower BP target, and ACE inhibitors
9
Q
how do we measure proteinuria? 4
A
- Dipstick is inaccurate and can miss significant proteinuria
- Different ranges of normal for people with or without diabetes
- No need for 24-hour urine collection
- Spot urine sample for protein: creatinine or albumin: creatinine ratio is usually sufficient
10
Q
what are the lifestyle measures for CKD?3
A
- Careful diuretic history
- Salt restriction
- Stop smoking
11
Q
what is acute kidney injury? 2
how do we diagnose it?
distant organ effects? 2
A
- A rapid decline in excretory kidney function
- Has a significant mortality risk from infection and CVD
- Could be made within 6hours of oliguria or within 48hours of 50% rise in Cr
- AKI morbidity and mortality remains high
- Inflammatory condition which leads to distant organ dysfunction
12
Q
what patients are at increased risk of AKI? 8
A
- Pre-existing CKD >60 - Diabetes, cardiac failure, liver disease - Sepsis - Hypovolaemia - Hypotension - Contrast - Post-op - Drugs
13
Q
what are the reversible and treatable causes of AKI? 3
A
- Obstruction
- Rapidly progressive glomerulonephritis
- Multiple myeloma
14
Q
what are the 3 different types of AKI and 3 things that cause each one?
A
- pre-renal AKI= sepsis, toxins, hypotension
- post-rena AKI= kidney stones, prostatic hypertrophy, tumours
- intrinsic AKI= acute tubular injury, glomerulonephritis, myeloma
15
Q
what is the AKI assessment?
A
- S- sepsis- screen and test
- T- toxins- drugs/ iv contrast
- O- optimise BP/ volume status
- P-prevent harm (identify cause, treat complications)
16
Q
describe a targeted approach to physiological disturbances? 6
A
- Hypotension- clinical fluid assessment, maintain blood pressure and therefore renal flow, filling with crystalloid (unless haemorrhagic shock), inotropes in patients with vasomotor shock
- Fluid overload- give full diuretics, maintain urine flow, reduces metabolism of tubular cells and protects from ischaemia
- Do not use diuretics to prevent AKI
- Do not use diuretics to treat AKI except in the management of volume overload
- Acidosis- treat with NaHCO3 (isotonic)
- Hyperkalaemia- correct acidosis, insulin is only a temporary measure, other electrolytes
17
Q
what are the indications for urgent renal replacement therapy? 5
A
- Uncontrollable fluid overload
- Uncontrollable, sever metabolic acidosis
- Uncontrollable hyperkalaemia
- Uraemic pericarditis/ encephalopathy
- Poisoning
18
Q
what is eGFR?
A
estimated GFR- mathematically derived from the serum creatinine level, age, sex and race
19
Q
what are the treatment choice for renal failure? 7
A
- Kidney transplant- live related, transplant sharing scheme, deceased donor or kidney pancreas
- Home first:
- Peritoneal dialysis
- Home haemodialysis
- Physidia
- Unit haemodialysis and satellite haemodialysis
- Maximum conservative care- supportive and symptom control
20
Q
describe patient education? 8
A
:1
- Group
- Discussion map
- Peer group
- Leaflets
- Websites
- YouTube
- Expert patient
21
Q
describe a bloods review? 9
A
- eGFR (is it deteriorating) urea (30-40 causes symptoms) - creatinine (59-104) - Hb (target=100-120g/l) - Transferrin saturation (>20%) - Potassium (3.5-5.3) - Phosphate (>1.5) - Vaccinations - Hep B surface antibody
22
Q
describe dialysis access and transplant referral? 4
A
- Arteriovenous fistula formed > 3 months before starting Hdx
- Peritoneal dialysis catheter inserted 2 weeks before dialysis started
- Referred to pre-transplant team when eGFR 15-20
- Start dialysis when eGFR= 5-10- symptomatic, uncontrolled potassium, fluid balance not responding to diuretics
23
Q
what is the doctors tole in nutrition in renal disease? 5
A
- Order bloods
- Interpret results
- Make a first nutrition diagnosis including differentials with support from a dietician when needed
- Refer on to the dietician
- Support patients with current dietary messages
24
Q
what is the individual patient assessment for renal disease? 7
A
- Trend blood results
- Type and stage of kidney disease
- Type of treatment
- Fluid balance
- Malnutrition risk
- Other health conditions
- Medications
25
what is the role of nutrition in preserving kidney function? 6
- Avoiding excess protein and improving diet quality
- Inefficient filtering increases net endogenous acid and accelerates nephron damage
- Optimising blood glucose
- Optimising blood pressure
- Weight management
- Keeping active
26
```
How much fluid is advised for
Ø No kidney function
Ø Impaired kidney function
Ø Transplant
Ø Haemodialysis/ Peritoneal dialysis?
```
Ø No kidney function 500-750mls per day
Ø Impaired kidney function- generally encourage to drink
Ø Transplant- Generally drink lots post transplant
Ø Haemodialysis- 500mls plus 24 hour urine
Ø Peritoneal dialysis- 750mls plus 24 hour urine
27
name some high potassium foods? 6
| why is potassium balance so important?
- Bananas
- Mushrooms
- Jacket potato
- Coffee
- Chocolate
- Marmite
essential for muscle and cardiac function
28
what are the differentials for potassium? 9
- Acidosis
- Inadequate dialysis dose
- Medications
- Poor diabetic control
- Constipation
- Blood transfusions
- Haemolysed samples
- Catabolism/ sepsis
29
what are phosphate binders? 4
| what foods are high in phosphate?
- Required in addition to a low phosphate diet
- Prescribed to take with meals
- Difficult forms some patients to remember
- Lots of different types
dairy
30
what are the differentials for phosphate? 4
- Binders taken at the wrong time
- Unable to swallow binders
- Forgetting to take binders
- Binder dose needs increasing
31
what should be avoided in end stage kidney disease?
fat soluble vitamines (A, D, E, K)
32
what do we need to consider when making a patient assessment to help decide on appropriate dietary advice? 3
- bloods
- fluid
- renal treatment
33
what are the main dietary interventions that may be necessary for renal patients? 5
- fluid
- potassium
- phosphate
- protein
- micronutrients
