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Year 3 - GP > SLA 16 - Hypertension, CKD and Hyperlipidaemia > Flashcards

SLA 16 - Hypertension, CKD and Hyperlipidaemia Flashcards

1
Q

What is chronic kidney disease (CKD)?

A

The abnormal kidney function based on the presence of kidney damage (ie. albuminuria) or decreased kidney function for three months or more.

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2
Q

Give the diagnostic criteria for CKD.

A
  • albuminuria (ACR>3mg/mmol)
  • eGFR <60ml/min
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3
Q

Give the diagnostic criteria for accelerated progression of CKD.

A
  • sustained decrease in GFR >25% within 12 months
  • sustained decrease in GFR of >15ml/min within 12 months
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4
Q

Give some risk factors for CKD.

A
  • hypertension
  • diabetes mellitus
  • glomerular disease
  • AKI
  • neprhotoxic drugs
  • gout
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5
Q

Name some drug classes that are potentially nephrotoxic.

A
  • ACE-inhibitor
  • ARBs
  • bisphosphonates
  • diuretics
  • NSAIDs
  • aminoglycosides
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6
Q

Presentation of CKD.

A

Usually asymptomatic and discovered by chance following a routine blood or urine test.

Specific symptoms only usually develop in severe CKD, including:

  • anorexia
  • nausea
  • vomiting
  • fatigue
  • weakness
  • peripheral oedema
  • sexual dysfunction
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7
Q

What are the different classifications of CKD?

A

Classified based upon GFR (G score) and ACR (A score).

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8
Q

Give some possibly complications of CKD.

A
  • AKI
  • hypertension
  • CVD
  • renal anaemia
  • end-stage renal disease
  • electrolyte imbalance
  • malnutrition
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9
Q

What are some investigations you may perform if you suspect a patient has CKD?

A
  • blood test for serum creatinine and eGFR
  • early morning urine sample for ACR
  • urine dipstick for haematuria
  • renal USS
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10
Q

How should CKD be monitored in primary care to look for disease progression?

A
  • annual review of eGFR and ACR
  • FBC to exclude renal anaemia
  • serum calcium phosphate, vitamin D, PTH test to exclude renal metabolic and bone disorder
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11
Q

When should CKD patients be referred to a nephrology specialist?

A
  • uncontrolled hypertension
  • renal anaemia
  • metabolic acidosis
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12
Q

What lifestyle advice can be given to a patient with CKD?

A
  • provide sources of information and support (e.g. patient.info, NHS, Kidney Care UK)
  • healthy lifestyle and diet (e.g. smoking cessation, alcohol reduction, exercise)
  • tell patient to avoid NSAIDs, protein supplements and herbal remedies
  • advise on risk of AKI
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13
Q

How are patients with CKD managed in primary care beside monitoring?

A
  • assess for and manage risk factors (e.g. nephrotoxic drugs, disease progression)
  • assess for hypertension
  • prescribe statin
  • offer flu and pneumovax vaccines
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14
Q

What is the pathophysiology behind CKD?

A
  1. Renal damage is caused by diabetes or hypertension
  2. Loss of nephrons or glomerulosclerosis reduces glomerular filtration (low eGFR)
  3. Glomerular pressure increases thus glomerular hypertrophy
  4. Increased glomerular permeability due to inflammation, fibrosis and scarring (increased ACR)
  5. Overall loss of kidney function
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15
Q

What are the sick day rules for CKD?

A

When a patient has acute illness, stop any nephrotoxic medication (DAMN mneumonic)

This is done to prevent an AKI.

DAMN:

  • diuretics
  • ACE inhibitors
  • metformin
  • NSAIDs
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16
Q

How do you treat a patient with CKD plus the following comorbidities:

a) metabolic acidosis

b) anaemia

c) secondary hyperparathyroidism

A

a) oral sodium bicarbonate

b) iron and EPO injections

c) phosphate binding agent + active vitamin D

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17
Q

Why may secondary hyperparathyroidism occur as a consequence of CKD?

A

CKD reduces kidneys ability to synthesis vitamin D, causing a reciprocal hyperparathyroidism.

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18
Q

Give the blood pressure ranges for:

a) normal blood presssure

b) prehypertension

c) stage 1 hypertension

d) stage 2 hypertension

e) hypertensive crisis

A

a) <120/80mmHg

b) >120/80mmHg

c) >140/90mmHg

d) >160/100mmHg

e) >180/120mmHg

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19
Q

What is the definition of hypertension?

A

Persistently raised arterial blood pressure.

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20
Q

Outline the first line management of hypertension for:

a) patient with T2DM

b) age <55years

c) age >55years

d) black-African or African-Carribbean family origin (any age)

A

a) ACEi or ARB

b) ACEi or ARB

c) CCB

d) CCB

21
Q

When is drug therapy indicated for hypertension?

A
  1. Stage 1 hypertension + QRisk>10%
  2. Stage 2 hypertension
22
Q

What are some risk factors for developing hypertension?

A
  • increasing age
  • male sex
  • African-Carribbean ethnicity
  • family history
  • social deprivation
  • smoking
  • alcohol
  • obesity
  • lack of physical exercise
  • emotional stress
23
Q

Give some complications of hypertension.

A

Hypertension is the single biggest risk factor for CVD (e.g. stroke, heart attack).

Other complications include:
- heart failure
- coronary artery disease
- chronic kidney disease
- vascular dementia

24
Q

What is the cause of primary hypertension?

A

No clear, identifiable cause (most common).

25
Q

What is the cause of secondary hypertension?

A

A clear cause can be identified:
- renal artery stenosis
- phaeochromocytoma
- diabetic nephropathy
- renal cell carcinoma
- coarctation of the aorta
- Cushing’s syndrome

26
Q

What further examination should be performed if a patient’s blood pressure is >180/120mmHg?

A

Fundoscopy, looking for signs of:
- retinal haemorrhage
- papilloedema

27
Q

When would a phaeochromocytoma be suspected in hypertensive patients?

A

Hypertension AND:
- headache
- palpitations
- pallor
- abdominal pain
- diaphoresis

28
Q

When does a hypertensive patient need to be receive a same-day referral?

A
  • BP >180/120mmHg
  • suspected phaeochromocytoma
29
Q

How is hypertension officially diagnosed?

A
  • measure BP in both arms with appropriate cuff size
  • if difference >15mmHg repeat measurements
  • if BP >140/90mmHg repeat

Note check the pulse before taking a reading as if irregular a manual reading must be taken.

30
Q

Beside antihypertensive medication, what advice can be given to patients to control hypertension?

A
  • lifestyle advice (e.g. improve diet, increase exercise, reduce caffeine intake, reduce alcohol)
  • patient leaflets (e.g. British Heart Foundation)
  • review annually
31
Q

What is included in the annual review of hypertension?

A
  • take BP
  • encourage adherence to treatment
  • check eGFR, U&Es and serum creatinine
  • check urine for proteinuria
  • assess QRISK
32
Q

Describe the following types of hypertension that can exist in pregnancy:

a) chronic hypertension

b) gestational hypertension

c) pre-eclampsia

A

a) a pre-existing hypertension that was present or diagnosed before pregnancy.

b) a new hypertension presenting after 20 weeks gestation without significant proteinuria

c) a new hypertension presenting after 20 weeks gestation with significant proteinuria.

33
Q

How should a woman with pre-existing chronic hypertension be managed once she becomes pregnant?

A

Refer to a specialist and stop ACEi, ARBs and thiazides.

Treat with labetolol first line or nifedipine.

Review antihypertensives 2/52 after birth.

34
Q

What is the inheritance pattern of familial hypercholesterolaemia?

A

Autosomal dominant

35
Q

When should familial hypercholesterolaemia be suspected?

A

Total cholesterol >7.5mmol/L

and/or

FHx of premature CHD

36
Q

How is familial hypercholesterolaemia managed??

A
  • baseline ECG
  • address modifiable risk factors for CVD (e.g. smoking, hypertension)
  • baseline bloods
  • atorvastatin 20mg OD
  • information and support groups (e.g. HEART UK)
  • genetic counselling
  • review annually
37
Q

How can you diagnose familial hypercholesterolaemia?

A
  • measure serum LDL
  • look for clinical signs (e.g. xanthoma, corneal arcus, xanthelasma)
  • use Simon Broome criteria
38
Q

What lipid modifying drugs are used in familial hypercholesterolaemia?

A
  • 20mg OD atorvastatin
  • 10mg OD rosuvastatin (do not use in CKD)
  • 10mg OD ezetimibe if statins contraindicated
39
Q

What baseline drugs are needed before starting lipid modifying treatment?

A
  • creatine kinase
  • LFTs
  • renal function
  • HbA1c
  • TFTs
40
Q

Give some medications that can induce hypercholesterolaemia.

A
  • beta-blockers
  • prednisolone
  • amiodarone
  • anabolic steroids
  • diuretics
  • oral oestrogen
  • antidepressants
41
Q

Give some conditions that can induce hypercholesterolaemia.

A
  • T2DM
  • pregnancy
  • hypothyroidism
  • menopause
  • nephrotic syndrome
  • anorexia nervosa
42
Q

What dosages of atorvastatin would be considered:

a) medium intensity

b) high intensity

A

a) 10mg OD

b) >20mg OD

43
Q

What are some comorbidities that increase the risk of CVD?

A
  • hypertension
  • diabetes mellitus
  • CKD
  • dyslipidaemia
  • RA
44
Q

What is the NHS health check programme?

A

Everyone aged >40years who has not already been diagnosed with CVD, diabetes or CKD is invited every 5 years for a free health check.

Includes:
- CVD risk assessment
- assessment of alcohol consumption
- physical activity level
- cholesterol level
- BMI
- screening of DM
- QRISK score calculation

45
Q

Give the first line medication for a patient who’s QRISK >10%.

A

Atorvastatin 20mg OD

46
Q

When should you offer lipid-modifying drugs for the primary prevention of CVD?

A
  • QRISK >10%
  • all T1DM
  • familial hypercholesterolaemia
  • age >85 years
47
Q

What medication is indicated as secondary prevention of CVD?

A

80mg OD atorvastatin

48
Q

If someone has hypertension with the following comorbidities, what would be your first line antihypertensive?

a) anxiety

b) prostatism

A

a) beta-blocker (labetolol)

b) alpha blocker (doxazosin)

49
Q

When should statins be taken?

A

Nightime - the enzyme that makes cholesterol is more active at night.

Year 3 - GP (17 decks)

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