Renal failure & its management symposium Flashcards
What stimuli contribute to causing the following?
- Glomerulosclerosis
- Interstitial Scarring
- Tubular atrophy
- Diabetes
- Hyperfiltration
- Vascular disease
- Hypertension
What is the classification of Chronic Kidney Disease
How should proteinuria be measured?
- Spot urine sample for protein: creatinine or albumin: creatinine ratio
- all patient with CKD stage 3+ should have proteinuria measured at least once
What is normal and abnormal Proteinuria in non-diabetics?
Normal
- ACR <_ 30 mg/mmol
- PCR <_ 50mg/mmol
Abnormal
- ACR > 30 mg/mmol
- PCR > 50mg/mmol
What is normal and abnormal Albuuminuria in diabetics (men and women)?
What is the target BP and treatment in CKD in patients with PCR <50 mg/mmol?
- BP target:140/90
- NICE 120-139/<90
- ACE inhibitors optional
What is the target BP and treatment in CKD in patients with PCR between 50-99 mg/mmol?
- BP target 140/90
- NICE 120-139/<90
- Use ACE inhibitors as the first line
- Refer only if haematuria also present, or progressive GFR decline
What is the target BP and treatment in CKD in patients with PCR >_ 100 mg/mmol?
- BP target <130/80
- NICE 120-129/<80
- Use ACE inhibitors as first line
- Refer
What is staging/ classification of Acute Kidney Injury?
What is ESRF?
End-stage Renal Failure
- mortality increase with age and in incidents of diabetes in younger patients (around 45)
What assessment can be made for AKI?
- using an acronym
- Sepsis: identity/screen and teat
- Toxins: drugs/ iv contrast
- Optomis BP/volume statute: withhold diuretics/ antihypertensive?
- Prevent harm: identify other causes i.e obstruction, review medication and fluid does and prescription
What are the 3 main categories/ types of AKI?
- Pre-renal AKI
- Intrinsic AKI
- Post-renal AKI
What is the cause of Pre-renal AKI?
- Sepsis
- TOxins: IV contrast
- Hypotension: V&D, Diuretics, Haemorrhage, burns, medication ACEi, cardiac failure
- Hepatorenal syndrome: linked with portal hypertension and liver cirrhosis
- Renal artery stenosis
What is the cause of Post-renal AKI?
- Kidney stones
- Prostatic hypertrophy (enlarged prostate causes occlusion of the urethra)
- Tumours
- Retroperitoneal fibrosis (Ormand’s disease): excess fibrous tissue develops in the space behind your stomach and intestine- the retroperitoneal area
What is the cause of Intrinsic AKI?
- Acute tubular injury: prolonge pre-renal, nephrotoxins
- Tubulointerstitial injury
- Glomerulonephritis
- Myeloma
- Lupus Nephritis (an autoimmune disease)
- Vasculitis: ANCA ( antineutrophil cytoplasmic antibody-associated) autoimmune disease
- Haemolytic uraemic syndrome (HUS): the destruction of platelets, also affects blood vessels and RBC
- TTP: Thrombotic Thrombocytopenic Purpura- blood clots found in small blood vessels, a severe decrease in platelets, and destruction of RBC
What symptoms would indicate urgent renal replacement?
- Uncontrollable fluid overload
- Uncontrollable, severe metabolic acidosis
- Uncontrollable hyperkalaemia
- Uraemic pericarditis/encephalopathy
(poisoning ethylene glycol, lithium NSAIDs)
What drug would cause issues at stage 3A CKD?
- eGFR 45-59
- Metformin: used in diabetes
- increased lactate production
- results in lactic acidosis
- most other drugs would be fine to metabolism at this level
What needs to be considered in drug distribution when administering drugs?
- whether the drug needs to be protein-bound e.g warfarin and phenytoin
- both bound to albumin
- if albumin level is low as they may be in renal failure, the free phenytoin or warfarin is increased which isn’t effective
How is Vitamin D absorbed?
What needs to be assessed for kidney patients?
- the trend of the BLood results
- type of kidney disease and the stage
- type of treatment the patients is on: dialysis transplant, conservative management
- Fluid balance: weight, urine output, observation
- Malnutrition risk (MUST
- other heat conditions: diabetes, CVD
- the medications the patients are on
How should fluid be balanced in renal patients?
- No kidney function 500-750mls per day
- Impaired kidney function- generally encourage to drink
- Transplant- Generally drink lots post-transplant, to make sure transplant is well perfused (can be difficult for previous dialysis patients)
- Haemodialysis- 500mls plus the amount of urine passed over 24-hour
- Peritoneal dialysis- 750mls plus 24-hour urine
What differentials may impact a patients fluid balance?
- poor diabetic control can make a patient more thirsty
- decreased urine output (rapid weight gain due to water retention)
- the patient is unaware of fluid restriction
What is the target potassium levels for dialysis and low clearance levels?
and what is the importance of K
- Dialysis: 4-6mmol/L
- Low clearnace: 3.2-5.5mmol/L
- muscle and cardiac function
What are some other differential causes for high potassium levels?
- Acidosis
- Inadequate dialysis dose
- Medications (especially ACE inhibitors), some diuretics as well
- Poor diabetic control
- Constipation
- Blood transfusions
- Haemolysed samples
- Catabolism/sepsis/ infection
What are the targets for phosphate for dialysis and low clearance patients?
what is the treatment for high and low levels?
- 1.1 – 1.7 mmol/L dialysis.
- 0.9 – 1.5 mmol/L low clearance
high phosphate- Low phosphate diet plus phosphate binders (these can be difficult to adhere to check up on patient)/ alfacalcidol (PTH)
low phosphate - Low PO4: Assess malnutrition risk, especially in renal patients
What are the target protein levels?
- Targets: 0.8g/ kg ideal body weight low clearance and transplant patients
- 1-1.2g/ kg ideal body weight dialysis patients
What nutrient advice is useful for end-stage kidney disease?
- avoid fat-soluble vitamins, e.g A, D E and K
- routine supplementation of water-soluble vitamins for all dialysis patients
How can kidney function be preserved?
- Avoiding excess protein and salt
- Optimising blood glucose
- Optimising blood pressure
- Weight management
- Optimising nutrition
- Keeping active
What needs to be considered for managing nutrition for multiple health conditions?
- what conditions need nutrition to be managed?
• Special diet burnout
- Diabetes
- Malnutrition
- Obesity
- Gastro complications
• Depression
What are the 3 categories of renal patients?
- Stable poor renal patients
- Renal function deteriorating
- Renal patient deteriorating, chosen conservative management
