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IPFC 4 Midterm 1 > Risk Assessment/Med management/Delaying progression > Flashcards

Risk Assessment/Med management/Delaying progression Flashcards

1
Q

How is CKD classified as?

A

Cause
GFR (G1-G5)
Albuminuria (A1, A2, A3)

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2
Q

Define “true” mGFR. Define marker.

A

measures clearance of a filtration marker
(like inulin, radiolabelled marker) -

marker is ONLY filtered not secreted/reabsorbed

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3
Q

Can serum creatinine be used alone for eGFR estimation?

A

No, many factors impact variation
- must be accounted for with variables in estimating equations

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4
Q

What are the effect of the following factors on SCr
Older age
Female
Less protein
More cooked meats
Muscular
Malnutrition/muscle wasting/amputation
Obesity

A

Older age: Dec
Female: Dec
Less protein: Dec
More cooked meats: Inc
Muscular: Inc
Malnutrition/muscle wasting/amputation: Dec
Obesity: NO CHANGE

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5
Q

According to to CKD-EPI equation, who will have a higher GFR? 58-yr old man vs 80-yr old women with the same SCr

A

Man

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6
Q

Why is CKD-EPI 2021 the gold standard? (factors)

A

Took Race out of the equation

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7
Q

Why do we use the indexed BSA standardized eGFR for CKD staging?

A

Bigger people will have bigger kidneys therefore increased GFR
- need to divide by 1.73m2 to standardize BSA
- to compare to a “normal value”
- For CKD staging

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8
Q

When do we use the non-indexed eGFR and “adjusted for BSA”

A

Most accurate for drug dosing

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9
Q

What is the eGFR if you have a smaller BSA under 1.73?
Over 1.73?
Smaller/larger

A

Under 1.73
- smaller eGFR than indexed

OVer 1.73
- larger eGFR than indexed

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10
Q

Why is Cockcroft-Gault not recommended for CKD staging

A

Overestimates renal function at lower levels

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11
Q

What does eGFR vs CrCl estimate?

A

eGFR
- glomerular filtration rate

CrCl
- urinary clearance of Serum Creatinine
- SCr is BOTH filtered and secreted

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12
Q

What is the eGFR for the following categories
G1
G2
G3a
G3b
G4
G5

A

G1: 90+
G2: 60-89
G3a: 45-59
G3b: 30-44
G4: 15-29
G5: <15

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13
Q

Define albuminuria

A

Abnormal loss of albumin in urine

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14
Q

Why measure albumin and not total protein in urine?

A
  • Albumin is more accurate for early CKD detection
  • more specific and sensitive
  • total protein are insensitive and imprecise at low concentrations
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15
Q

Are there clear thresholds that define a clinically relevant change in eGFR or albuminuria? what change warrants evaluation?

A

No
- eGFR change >20%
- ACR doubling

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16
Q

Name and level of the following albuminuria categories
A1
A2
A3

A

A1: normoalbuminuria <3mg/mmol
A2: microalbuminuria 3-30 mg/mmol
A3: macroalbuminuria over 30 mg/mmol

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17
Q

When should you take the time to adjust the CKD-EPI for BSA, eGFR in mL/min (2)

A
  • BSA significantly different (+/- 10%) of 1.73
    AND
  • Drug dosing decision borders between 2 ranges ex. 15-30 vs 30-60
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18
Q

When would you use CG equation? (3)

A
  • When it is usual practice in the clinical setting
  • When you don’t have access to an online calc or app
  • When you would like a 2nd estimate of renal function for comparison (extreme weight, drug dosing decision borders)
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19
Q

How should you interpret eGFR/CrCl when provided a renal dosing reference

A

Equally

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20
Q

What to do if there are no renal dosing recommendations?

A

Check if the drug is renally cleared
- 30-50% is significant

Check if the drug is hepatically metabolized
- are the active metabolites removed by the kidney

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21
Q

Should you calculate eGFR for dialysis patients?

A

No
- assume <15 eGFR between dialysis sessions

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22
Q

What should you do if drug is removed by hemo dialysis?

A

Dose should be scheduled AFTER dialysis
- Create a schedule where patient will administer at the same time on both dialysis and non-dialysis days

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23
Q

What should you do if drug is removed by peritoneal dialysis?

A

Usually done everyday
- dose drug AFTER

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24
Q

Which is hepatically eliminated? ACE or ARB

A

ARB
- ACEi are partly renally cleared depending on drug

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25
Which ACEi are removed by dialysis (3)
Perindopril Ramipril Enalapril
26
Which ACE is use is not generally recommended in eGFR <30?
Perindopril
27
If a patient is already on an ACE, should you switch to a less renally cleared ACE?
No - assess clinical response vs toxicity
28
If renal patient is about to start an ACEi what should you start with
Elanapril
29
What to do with antimicrobials if unsure of renal clearance in a hospitalized patient?
Dose aggressively for 24 hours (normal dose) - reassess based on SCr and clinical status of patient
30
What exceptions of antimicrobials are not renally cleared? (4)
Clindamycin Cloxacillin Metronidazole Moxifloxacin
31
Which antimicrobials are potentially nephrotoxic?
Aminoglycosides Vancomycin
32
What is the preferred anticoagulant in renal impairment? Why?
Tinzaparin - can be used down to CrCl 20+ mL/min
33
What should you monitor if LMWH are used in renal impairment?
Anti-factor Xa levels to monitor accumulation
34
Which anticoagulants do not need renal adjustment?
Warfarin UFH
35
Which DOACs have the most renal clearance, least?
Most: Dabigatran Least: Apixaban
36
Do you dose adjust apixaban in renal impairement?
to ensure efficacy, do not dose-reduce for renal function
37
What eGFR should you AVOID NSAID use?
eGFR <60 ml/min
38
What are risk factors for AKI with an NSAID
- pre-renal state (diarrhea, vomiting) - NSAIDs with ACEi/ARB, diuretics, SGLT2i - CHF, valvular disease (reduces blood flow to kidneys)
39
Should patients stop ASA if there is renal impairment?
No, safe - CV benefit is clear
40
What is the limit for acetaminophen use in renal impairment
4g/day for short term 3g/day for any long-term use with risk factor
41
Which laxatives should you avoid in eGFR <30mL/min?
Any containing magnesium and phosphorous - milk of mag - citro-mag - magnolax - pico salax - fleet enema
42
What is the safest option for bowel preparation in renal impairment?
PEG solutions
43
Is Vitamin C recommended in high doses? Limit?
No - limit 500mg/day
44
Is a multi recomended eGFR <30 eGFR
No
45
When should you start replavite?
On dialysis - administer after dialysis
46
NHPs in renal impairment
(very few products with safety data in renal impairment - tell the patients this) * Watch for additives/preservatives (ex. Potassium) listed as "non-medical" ingredients
47
What is recommended protein intake and sodium intake in CKD?
Protein: 0.8/kg/day Sodium: less than 2000mg/day
48
What are BP targets for Low risk Diabetes CKD + high BP(high risk of CV)
Low risk: 140/90 Diabetes: 130/80 CKD (high risk of CV): <120 systolic
49
Which CKD patients should be on a RASi? (3)
- CKD patients with HF with low EF - CKD patients 120+ BP - CKD with ACR 3+ (regardless of BP) All CKD patients should be on ACE/ARB
50
What should you monitor for ACE/ARB? How long?
Changes in BP SCR K q2-4 weeks of initiation or dose titration
51
When should you consider reducing dose/d/c RASi? (2)
- symptomatic hypotension - Uncontrolled hyperkalemia
52
What drugs can you give to help lower hyperkalemia? (3)
- Diuretics - Sodium bicarb - GI cation exchangers (anything that binds sodium)
53
What are other causes of 30%+ inc in creatinine
- Causes of AKI - correct volume depletion - Reassess (diuretics, NSAIDs) - consider renal artery stenosis
54
What to expect in day 3-5 when you start ACE/ARB
Inc in SCr up to 30% - stabilizes in 1-2 weeks K may increase - try to maintain dietary restriction
55
When to avoid initiation of ACEi/ARB? Can you rechallenge?
if they have poor renal blood flow "pre-renal state" - dehydration, acute HF Yes
56
What are benefits in CKD for ACE/ARB? Background?
Cause less vasoconstriction in EFFERENT arterioles - less pressure in the glomerulus --> less pressure pushing the proteins through (reduces proteinuria) --> more time for the glomerulus to heal Background: The pressure in the glomerulus needs to be optimal (not too high/low) - Damage to the glomerulus membrane increases proteins passing through, further damage
57
What is the risk of AKI in ACE/ARB
In AKI, the renal perfusion is low, if you further vasodilate the efferent arteriole (with ACE/ARB), there won't be ENOUGH pressure to actually filter things in the glomerulus in AKI (low perfusion) GFR is maintained by ANG II induced vasocontriction of efferent arteriole - this becomes blocked if they are on an ACE/ARB
58
How are NSAIDs harmful to the kidney?
PGs are major determinant of afferent vasodilation - by inhibiting PG production (NSAIDs), they can cause afferent vasoconstriction & reduce GFR
59
Should you use ACE and ARB together?
No, greater antiproteinuric effect
60
If patient on an ACE/ARB and their eGFR falls under 30, what do you do?
Do not stop - no difference between groups and similar rate of adverse events
61
Patients initiating ACE/ARB when eGFR<30?
No study to answer this, would be judged on a case-by-case basis
62
When to start SGLT-2i?
If CKD and eGFR >20 AND - T2DM - HF - ACR 20+
63
MOA of SGLT2i (3) Explain each?
Reduced glucose reabsorption - increased glycosuria - lower BG Reduced sodium reabsorption - inc natriuresis (more Na out in urine) - Reduced intravascular vol - Reduced BP Reduced sodium delivery to macula densa - reduces intrglomerular pressure through constriction of afferent arteriole - reduced glomerular hyperfiltration
64
**C**REDENCE study drug? Patient population? diabetic/non-diabetic eGFR ACR
Canagliflozin Group - DIABETIC ONLY - eGFR 30-90 - ACR 34+ (only MACROalbuminuria)
65
DAPA-CKD study drug? Patient population? diabetic/non-diabetic eGFR ACR
Dapagliflozin Group - diabetic/non-diabetic - eGFR 25-75 - ACR 22.6+
66
EMPA-kidney study drug? Patient population? diabetic/non-diabetic eGFR ACR
Empagliflozin Group - diabetic & non-diabetic - eGFR 20 - 90 - ACR 22.6+
67
What are underlying conditions that may inc adv effect of SGLT2i?
- Hypotension/hypovolemia - concomitant diuretic - prior UTI/genital mycotic infections - concomitant hypoglycemia agents
68
When to stop SGLT2i?
High risk of DKA: acute serious illness, surgery - temporarily stop (part of SADMANS) Patient on dialysis - STOP completely
69
What are the steroidal Mineralcorticoid receptor Antagonists? What are the non-steroidal? Benefit of non-steroidal?
Steroidal - eplernone - spironolactone Non-steroidal (lower risk of hyperkalemia) - finerenone
70
When do we consider finerenone use? Criteria to meet? (5)
Add on to RASi and SGLT2i in diabetic patients - or alternative if intolerant to RAS or SGLT2i Criteria - DIABETIC TYPE 2 - eGFR 25+ - ACR over 3mg/mmol - No HF with reduced EF (would use spironolactone) - Not in combo with another MRA
71
FIDELIO vs FIGARO study for finerenone Group? Difference in outcome and group ADRs?
Group - T2DM - Albuminuria - already on ACE/ARB FIDELIO (what we use more) - mod albuminuria, eGFR 25-60, AND diabetic retinopathy - severe albuminuria, eGFR 25-75 Outcome: primary RENAL, secondary CV, ADR FIGARO - mod albuminuria, eGFR 25-90 - sever albuminuria, eGFR 60+ Outcome: primary CV, secondary RENAL, ADR Both had more incidence of hyperkalemia
72
Finerenone and K monitoring. When to... Initiate finerenone Continue finerenone Hold finerenone
Initiate finerenone: less than 4.8 mmol/L Continue finerenone: 4.9-5.5 Hold finerenone: over 5.5
73
When do we consider NDHP CCB (diltiazem, verapamil) in CKD?
Consider as ALTERNATIVE to ACE/ARB for patients who cannot tolerate
74
When do we consider DHP CCB (amlodipine, felodpine, nifedipine) in CKD?
Consider DHP-CCBs as the first ADD ON to ACE/ARB in diabetic/non-diabetic CKD
75
Is there evidence for thiazides in CKD?
No, only HTN
76
Is there evidence of risk reduction in hard clinical outcomes with loop diuretics? What is furosemide used for?
No - only symptomatic relief of edema in CKD or HF
77
Mineralocorticoid receptor antagonists (potassium sparing) benefit in CKD?
Steroidal (spironolactone, elperinone) - small studies for reduction in proteinuria Non-steroidal (finerenone) - BETTER evidence (need to be diabetic)
78
Is there evidence for beta blockers in CKD?
No, continue if still on it Indication in - stable angina pectoris - recent MI - HF
79
Are A1C's usually falsely lower or higher in CKD. What is the target?
Falsely lower A1C <7%
80
eGFR with metformin?
45+: regular metformin dose 30-44: Half the dose and titrate up under 30: STOP
81
How often should you monitor eGFR for 45-59 on metformin? eGFR 60+
at least every 3-6 months anually
82
What is the suggested criteria for using metformin <30 mL/min
MUST be prescribed under nephrologist MUST have stable renal function
83
Which GLP1 has reduction in renal outcome primarily driven by nephropathy? Trial name?
Liraglutide LEADER
84
Which GLP1 has diabetic retinopathy complications that were common? Trial name?
semaglutide SUSTAIN
85
Which DPP4 do not need renal dosing adjustment
Linagliptin
86
Is insulin renally or hepatically cleared?
Hepatically cleared - may need to dec insulin to avoid risk of hypo
87
How to manage glycemic control in CKD. Order the glycemic drugs used in order
All patients should be metformin + SGLT2i if insufficient - add GLP1RA - then DPP4i - then secretagogues - then insulin

IPFC 4 Midterm 1 (7 decks)

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