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104 theme 3 > renal failure symposium > Flashcards

renal failure symposium Flashcards

1
Q

what is chronic kidney disease

A

GFR <60ml/min/1.73m2 for >3 months with or without kidney damage and/or
kidney damage >3 months with/without dec GFR via path abnormalities (markers like proteinuria) or UACR >30mg/g

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2
Q

what happens to the kidney in chronic disease

A 
multiple injurious stimuli 
diabetes
hypertension
vascular disease
hyperfiltration
eg glomerulosclerosis, interstitial scarring or tubular atrophy
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3
Q

pathogenesis of manifestations of CKD

A

slow progressive loss of nephrons unnoticed
silent disease
maladaptive compensatory func
loss of renal func/adaptations lead to manifestations for failure

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4
Q

how is CKD classified

A 
Stage 1 baseline 
2 Mild reduction (WRT normal for young adult)
3 mild-mod
4 sev reduction
5 Failure/ESRD
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5
Q

survival in ESRD

A

Dec with age

much less in diabetics

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6
Q

How does CVD affect CKD

A

can lead to uremic cardiomyopathy from atherosclerosis

heart failure and sudden cardiac death as a result

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7
Q

Benefits of good management of CKD

A

Prevent or slow progression to renal failure
Reduce morbidities
Improve quality of life
Reduce costs

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8
Q

how is kidney function measured

A

measured by serum creatinine clearance

relationship not linear - not completely accurate

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9
Q

what is eGFR

A 
rough measure of the number of functioning nephrons
Actual GFR (by inulin clearance) not routinely measured in clinical settings
GFR is equal to the sum of the filtration rates in all of the functioning nephrons
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10
Q

what is MDRD

A

An equation used to estimate GFR in adults
uses Cr, Age, ethnicity & gender
Association of estimated GFR with measured iGFR in outpatients

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11
Q

how does cock-croft Gault estimate GFR

A

Age, Cr and Wt

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12
Q

Flaws with creatinine

A

indicator of excretory func
renal func more complicated eg acid-base, fluid, electrolyte, endocrine etc
eGFR only for stable CKD

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13
Q

Signs of kidney disease

A 
accumulation of waste (uraemia)
fluid balace (oedema)
endocrine (anaemia or bone chemistry)
electrolyte (hyperkalaemia)
acid-base (metabolic acidosis with normal AG)
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14
Q

significance of proteinuria

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

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15
Q

how is proteinuria measured

A

Dipstick inaccurate, and can miss sig proteinuria
Different range for people without diabetes
No 24 hr urine collection
Spot urine sample for protein:creatinine or albumin:creatinine ratio usually sufficient
All patients with CKD stage 3 or worse should have proteinuria measured at least once

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16
Q

Estimating 24 hour urine protein excretion from the ACR & PCR

A

PCR/ACR (mg/mmol) x 10 ≈ 24 hour excretion (mg/24 hrs)

protein: creatinine ratio of 110 mg/mmol ≈ 1100mg proteinuria/ 24 hours (1.1g/24 hrs)
albumin: creatinine ratio of 15mg/mmol ≈ 150mg albuminuria/24 hrs (0.15g/24 hrs)

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17
Q

what is normal proteinuria in non diabetics

A

<30 ACR and <50 PCR

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18
Q

what is normal albuminuria in diabetics

A

<2.5
microalbuminuria 2.5-30
clinical proteinuria >30
3.5 women

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19
Q

lifestyle measures for CKD

A

dietetic history
salt restriction
no smoking

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20
Q

how does proteinuria related to BP targets

A

PCR <50 140/90
50-99 140/90 refer if haematuria present or GFR declines
>100 <130/80 and refer

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21
Q

how is Intraglomerular pressure effected at the afferent and efferent glomerular arterioles

A 
afferent - NSAIDS relax
efferent - ACE inhibitors effect
RAS
Dehydration
Sepsis
Pump failure/hypoperfusion
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22
Q

how do ace inhibitors effect diabetic neuropathy

A

slow

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23
Q

what should be given to diabetics with CKD

A

statins to lower lipids

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24
Q

what is AKI

A 
a rapid (hours to days) decline in excretory kidney function
Sig mortality (often CVD or infection)
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25
Q

classification of AKI

A 
Serum Cr
AKIN 
1 1.5-2fold inc from baseline
2 >2-3
3 >3
26
Q

are classifications of AKI useful

A

Diagnosis of AKI could be made
Within 6h of onset of oliguria
Within 48h of 50% rise in Cr OR Cr rise by at least 26.5 µmol/l

27
Q

what are most cases of AKI from

A

community
missed diagnosed/lack of intervention
on the inc

28
Q

how can AKI predict mortality

A

inc risk of mortality and morbidity

predicts progression to advanced CKD, ESRD

29
Q

How does AKI link to CKD

A

recovery from AKI predicts outcome and likely progression to CKD

30
Q

Why is AKI associated with terrible morbidity and mortality

A

distant organ effects - inflammatory disease

bone, heart, brain, lungs, liver

31
Q

who is at risk of AKI

A 
Pre-existing CKD
Age >60
Comorbidity
Diabetes
Cardiac failure
Liver disease
Iatrogenic/Pathological derangements
Sepsis
Hypovolaemia
Hypotension
Contrast 
Post-op
Drugs
32
Q

Potentially Reversible/Actively Treatable Causes of AKI

A

Obstruction
Rapidly progressive glomerulonephritis
Multiple myeloma

33
Q

Type and cause of AKI

A

Pre renal eg sepsis, hypotension, HF
post renal eg stones, tumours
intrinsic AKI eg injury, myeloma, nephrotoxins

34
Q

how is AKI assessed

A 
Sepsis - screen and test 
Toxins - drugs/iv contrast 
Optimise BP/vol status
Prevent harm eg identify cause and treat complications
AKI
35
Q

how is hypotension treated

A

Clinical fluid assessment
Maintain BP and therefore renal blood flow
filling – crystalloid (unless haemorrhagic shock)
Inotropes in patients with vasomotor shock

36
Q

how is fluid overload treated

A 
When full give diuretics
maintain urine flow
reduces metabolism of tubular cells 
protects from ischaemia
no diuretics to prevent or treat, only to manage
37
Q

how is acidosis treated

A

Treat with NaHCO3 (isotonic)

38
Q

how is hyperkalaemia treated

A

Correct acidosis
Insulin/Dextrose is only a temporary measure
Other electrolytes
Ca, Mg

39
Q

when should AKI be taken to a specialist

A

AKIN 2 & 3
AKIN 1 unresolving despite simple measures
Worried about Inflammatory disease/RPGN/Myeloma

40
Q

Indications for urgent renal replacement therapy

A

Uncontrollable fluid overload
Uncontrollable, severe metabolic acidosis
Uncontrollable hyperkalaemia
Uraemic pericarditis / encephalopathy

Poisoning – ethylene glycol, lithium, NSAIDs

41
Q

role of nurse specialist in CKD

A

prolong renal function
Empower patients to make appropriate treatment choices
Prepare patients physically and psychologically for their treatment choice

42
Q

Treatment choices for CKD

A

transplant
peritoneal/haemodialysis
physidia - new tech
max conservative care - support, symptom control

43
Q

how is anaemia treated with CKD

A 
Target Hb 100-120 g/L
transferrin sat >20%
serum ferritin 100-140 mcg/L
oral iron - GI upset
IV iron
44
Q

what is ESA

A

Erythropoietin stimulating agent
injections or pen when req + monitoring
3 monthly iron stores

45
Q

dietary interventions for renal patients

A 
energy
protein
potassium
phosphate
fluid/salt
fibre
vits and mins
other
46
Q

individual patient assessment for dietary needs

A 
bloods
type (AKI, CKD, Stage)
Type of treatment
fluid balance 
MUST 
other health conditions
medications
47
Q

role of nutrition in preserving kidney function

A 
avoiding xs protein/inc diet quality as inefficient filtering inc net endogenous acid and accelerates nephron damage 
optimising blood glucose 
BP
weight management 
keep active
48
Q

modifiable risk factors for CKD

A 
glucose in diabetes
hypertension 
anti-hypertensiive agents 
DASH/med diet 
less sodium
no smoking
reg exercise
weight loss
lower lipids
49
Q

CKD related malnutrition

A 
dietary and fluid restrictions
poor appetite (uraemia and taste change)
long treatment restricts time
multiple morbidities 
XS protein catabolism
micronutrient def due to dialysis/meds
50
Q

protein recommendations for renal patients

A

0.8g per kg in low clearance/transplant pts
1-1.2g dialysis
conservative management - protein restriction

51
Q

fluid for renal patients

A

No kidney function 500-750mls per day
Impaired kidney function- generally encourage to drink
Transplant- Generally drink lots post transplant
Haemodialysis- 500mls plus 24 hour urine
Peritoneal dialysis- 750mls plus 24 hour urine
Hypervolemia = Oedema, pleural effusions, hypertension, congestive Heart failure (CHF)
Sodium- A no added salt diet advised

52
Q

important differentials for fluid

A

Poor diabetes control
Urine output has decreased
Patient is unaware of fluid restriction

53
Q

potassium in renal patients

A

4- 6mmol/l dialysis
3.2- 5.5mmol/l Low clearance
K balance for muscle/cardiac function

54
Q

high potassium food

A

Bananas, dried fruit, exotic fruits
Mushrooms, parsnips, sprouts, spinach, tomatoes
Chips, jacket potato
Coffee, hot chocolate, milk, fruit juice, cider, strong beer and stout
Chocolate, nuts
Lo salt, Marmite, Bovril

55
Q

important differentials for potassium

A 
Acidosis
Inadequate dialysis dose
Medications (especially ACE inhibitors), 
Poor diabetic control
Constipation
Blood transfusions
Haemolysed samples
Catabolism/sepsis
56
Q

phosphate in renal patients

A

1.1 – 1.7 mmol/L dialysis.
0.9 – 1.5 mmol/L low clearance
Low phosphate diet plus phosphate binders/ alfacalcidol (PTH)
Low PO4 = Assess malnutrition risk.
Ca and PO4 homeostasis required for bone health.
Pruritis (Itchiness).

57
Q

high phosphate foods

A 
Dairy products
Reduce or switch to lower phosphate alternatives
Oily fish with bones 
Shellfish 
Offal 
Nuts/chocolate
Processed foods- additives
dark fizzy drinks eg. Coke, Pepsi, Dr Pepper
58
Q

what are phosphate binders

A

Often required in addition to a low phosphate diet.
Prescribed to take with meals.
Difficult to remember for some patients.
Lots of different types/ preparations.

59
Q

important differentials for phosphate

A

Binders taken at the wrong time
Unable to swallow binders
Forgetting to take binders
Binder dose needs titrating up

60
Q

micronutrients in renal patients

A

Avoid fat soluble vitamins in end stage kidney disease (A, D, E and K)
Routine supplementation of water soluble vitamins for all dialysis patients.

61
Q

Managing nutrition for multiple health conditions

A 
Diabetes 
Malnutrition
Obesity 
Gastro complications
Depression
Special diet burnout

104 theme 3 (15 decks)

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