Renal Health Maintenance Flashcards
In renal failure patients preventive strategies usually focus on renal-disease-related issues of:
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Addressing more general health issues such as:
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- Anemia
- Mineral metabolism
- HTN
- Vascular access for dialysis
- Vaccinations
- Cancer screening
- Control of DM
- Lipid management
However, general health issues are postponed in order to prioritize acute issues like:
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- Infection
- Bleeding
- Malnutrition
- Volume overload
- Vascular thrombosis
- Unstable blood pressure
With abnormalities of immune function, patients with kidney disease are more susceptible to what? 2
- infection
2. malgnancies
Medicare patients with CKD and diabetes who progressed to end-stage renal disease, only 50% had their lipid or HbA1c levels tested the year before or after starting dialysis
Renal Preventive strategies include what? 7
- Infection screening
- Immunizations
- Lipid management
- DM control
- HTN management
- Cancer screening
- Smoking cessation
National Kidney Foundation recommends testing all patients with:
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- Diabetes
- HTN
- Family history of kidney disease
- Age >60 years
- Ethnic minorities
African Americans, Native Americans, Asians
How should do accomplish screening (what tests)?
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It’s recommended that minimal screening include
- assessment of GFR and
- proteinuria
- Microalbuminuria is now an essential component
Health Maintenance
Testing for urinary protein
As part or the initial assessment: 4
As part of annual monitoring: 2
As part of routine monitoring for patients receiving nephrotoxic agents
- New HTN,
- hematuria, or
- decreased GFR
- DM
- Biopsy proven glomerulonephritis
- Reflux nephropathy
- Health Maintenance: What should we use together to assess kidney funciton?
- Also think about testing for what?
- Also what are you looking for? 3
- Serum Creatinine and GFR
- microalbuminuria-Special dipstick and inexpensive
- Blood in urine
- Edema
- Fatigue
- Why are renal failure pts at high risk for infeciton?
- Hospitalization for infection are ___ times worse in patients with CKD
- Other risk
Bacterial infection where commonly? 5 - Infections secondary to skin excoriations from what? 3
- Common microorganisms are what?
6.
3
#1. Renal failure patients have immune insufficiency #2. 3-4
- Lungs,
- intestines,
- peritoneum,
- urinary tract
- skin
- pruritus,
- xerosis
- atrophy of sweat glands
- Staphylococcus sp. and
- E-coli
Health Maintenance
infection risk: Morbidity/Mortality
1. Sepsis in ESRD has a mortality that is ____- _____ fold higher than general population
2. Pulmonary infections have a _____-fold higher mortality rate
- 100-300
2. 14-16
Infection risk
Screening and Prophylaxis for bacterial infections
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- Examine skin
- Placement of AV fistulas before initiation of hemodialysis
- Screen for Staphylococcal nasal colonization
- Consider use of mupirocin ointment
- Consider applying mupirocin or gentamicin ointment to catheter exits
- Educate on dental evaluations
- Endocarditis prophylaxis (2g amoxicillin or 600mg clindamycin) 1 hour before invasive dental procedures
What immunizations do we want to make sure they have?
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- Influenza
- Pneumococcus
- Hep A
- Hep B
- Hep C
- Influenza immunization decreases what?
- Pneumococcus vaccine: what do we have to remember in renal pts?
- Hep A
- Hep B
- Hep C
- Influenza
- Decrease chance of hospitalizations - Can give titers every 2 years in ESRD when titers decrease below 200μg/l.
Complication of Arthus-type reaction with frequency
- What is the Hep A vaccination schedule?
- Before what do we need the Hep B surface antigen testing for (HBsAg)?
- How are seroconversion rates are affected how as renal disease progresses?
- Hep B schedule?
- Hep C will be affected how on pts with dialysis?
- What do we have to do with pts who have Hep C and are up for a tranplant?
- Vaccination on a schedule of 0, 1, and 6 months
- Need surface antigen testing for HBV (HBsAg) and HBV antibody testing before initiation of dialysis
- Seroconversion rates worsen as renal disease progresses
- Series of 3 injections 0, 1-2, and 4-6 months
Hepatitis C
Not a vaccine, however good idea to screen for
- Increase seroconversion with patients on dialysis
- ESRD patients with Hep C must be treated before transplant d/t rejection
Lipid management Risk of CVD in renal failure is high 1. How often should we check lipid levels? 2. Who should they go see? 3. Meds?
- Fasting LDL, HDL, triglyceride and total cholesterol levels should be checked once a year for patients with CKD
- Renal dietician
Medications - Statins (Simvastatin 20mg qday)
Blood glucose control
- Progression of ___ complications with poor glycemic control
- HbA1c level should be controlled to what levels?
- HbA1c should be checked how often? 2
- Metformin should be avoided with creatinine___in men and ___ in women b/c of concern for what?
- CV
- less than 7.0
- every 6 months, unless a change in treatment, then every 3 months until goal is reached
- > 1.5 men
1.4 woman
lactic acidosis
Blood Pressure Control
Strict pressure control is a high priority
- What are commonly used as initial medications? 2
- Blood pressure goal is ______, the NKF suggest BP be _______?
Tight BP control can halt the progression of renal failure
- ACE inhibitors or ARBs
- less than 130/80
less than 125/75
Tobacco cessation
1. Cigarette smoking is associate with what in renal failure?
- Medication 3
- more rapid decline in renal failure
- -Nicotine patch (21mg, 14mg, 7mg)
-Wellbutrin/Bupropion
-Chantix
Black Box Warning
Cancer screening
- Tumors of the Genitourinary tract develop ___ times more frequently than lung, colon, or breast
- Which cancers specifically? 2
- When would we screen for cancer?
- 50 years and older with life
expectancy of 10 years get annual ? - Patients at high risk?
- 4-5
- Renal Cell Carcinoma
- Prostate cancer
- If they are on the tranplant list
- DRE and PSA
- at age 40 with DRE and PSA
PSA 0.6 or > if Africa American/Family history get annual DRE/PSA
PSA 0.6 at age 45, repeat annually
PSA
Cancer screening Colorectal cancer 1. Colonscopy when? 2. What should we test annually? 3. Every 5 years?
Breast cancer
- We should screen high risk pts whose life expectancy is what?
- What age or annual mammograms?
- What age if they are on the tranplant list?
- What should all groups do?
Screening similar to general population
- Colonoscopy at age 50 and repeat every 10 years if the initial was negative
- Annual fecal occult blood test
- Flexible sigmoidoscopy every 5 years
- High risk patients who life expectancy is 5 years
- Women >50 years old have screening mammograms
- Women >40 years old on transplant list
- Both groups do periodic self-exams
Cancer screening
Cervical cancer
1. High risk patients with life expectancy of___years or more should be screened.
- Screening pap smears at age ___ years old
- ___ ____ testing and ____ ______ in transplant patients
- ______ ____ test for those on transplant list
- 5
- 21
- HPV DNA
- HPV vaccine
- Yearly Pap
Anemia screening
Work-up should include
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What should our hemoglobin target be?
- CBC
- Reticulocyte count
- Serum ferritin
- Transferrin saturation (TSAT)
Hemoglobin target should be 11.0-12.0 g/L
Bone Metabolism
Work-up should include
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How should we treat?
2
- Intact PTH
- Phosphorus
- Calcium
- Dietary phosphorus to 800-1000 mg/day
- Phosphate binders
Screening for urinary protein
Should be part of the initial assessment with patients with what?
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- New HTN,
- hematuria, or
- decreased GFR
- Unexplained edema
- Suspected multi-system disease (SLE, vasculitis)
- DM
Screening for urinary protein As part of annual monitoring of patients with?
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- Biopsy proven glomerulonephritis
- Reflux nephropathy
- Urological unexplained hematuria or proteinuria
First clinical sign of diabetic nephropathy and associated with poor glycemic control and elevated BP is what?
microalbuminuria
Medication control:
What should we avoid?
Be careful with what antibiotics? 4
Also careful with Magnesium containing medicines such as? 2
- NSAIDS
- PCN
- Cephalosporin’s
- Sulfonamide’s
- Fluoroquinolones
- Laxatives
- antacids
Referral to Nephrologist GRF 1. Less than 15? 2. 15-29? 3. 30-59? 4. 60-89?
Know patients information like? 6
- less than 15 Immediate referral
- 15-29 Urgent referral (routine if known to be stable)
- 30-59 Routine referral
- 60-89 Referral not required unless high risk issues present
- Complete medical history
- Urinary symptoms
- Medications
- Exam findings
- Labs: UA, CBC, CMP, Phosphorus, Lipids, HgA1C, SCr
- Renal ultrasound
Take Home Message
Chronic kidney disease is a growing public health problem
Outcomes include what?
loss of kidney function and cardiovascular events (which are fatal)
Critical assessment from laboratory test for screening is required. What should we screen with? 2
- SCr to estimate GFR
2. Microalbuminuria
You can help improve outcomes. How?
2
- Treat comorbid conditions aggressively to slow the progression
- Educate the patient
Health Maintenance education summary
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- Exercise regularly
- Don’t overuse OTC painkillers, NSAIDs or nephrotoxic drugs
- Control weight
- Get annual physical
- Healthy diet
- Know family’s medical history
- Monitor blood pressure and cholesterol
- Education about kidney disease
- Don’t smoke or abuse alcohol
