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Part 4 – PM4B Ali > (SYNOPTIC) AKI & CKD > Flashcards

(SYNOPTIC) AKI & CKD Flashcards

1
Q

What term has ‘acute kidney injury’ replaced?

A

Acute renal failure

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2
Q

How is AKI loosely defined?

A

An abrupt/ acute decline in kidney function
- e.g. glomerular filtration

Hours or days

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3
Q

What is the official definition of AKI?

A

How much serum creatinine has increased from its baseline level over a set period of time

OR

How much urine volume has decreased over a set period of time

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4
Q

How is stage 1 of AKI defined?

A

(1) 1.5-1.9 times baseline SERUM CREATININE

(2) <0.5ml/kg/h of urine for 6-12 hours URINE OUTPUT

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5
Q

How is stage 2 of AKI defined?

A

(1) 2.0-2.9 times baseline SERUM CREATININE

(2) <0.5ml/kg/h of urine for ≥12 hours URINE OUTPUT

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6
Q

How is stage 3 of AKI diagnosed?

A

(1) 3 times baseline SERUM CREATININE
(2) Initiation of renal replacement therapy
(3) Anuria ≤12 hours

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7
Q

How many stages of AKI are there?

A

3 stages

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8
Q

How many classifications of AKI are there?

A

3

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9
Q

What are the classifications of AKI?

A

(1) Pre-renal
(2) Post-renal
(3) Intrinsic

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10
Q

What is pre-renal AKI?

A

Reduced blood flow to the kidney

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11
Q

What causes pre-renal AKI?

A
  • Reduced BP
  • Hypovalaemia (decreased blood volume)
  • Dehydration
  • GI bleed
  • Sepsis
  • Cardiac & liver failure
  • Burns
  • Medications
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12
Q

What is post-renal AKI?

A

Obstruction to outflow from the kidneys

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13
Q

What causes post-renal AKI?

A
  • Benign prostatic hypertrophy (BPH)
  • Prostate cancer
  • Renal calculi
  • Retroperitoneal fibrosis
  • Medications
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14
Q

What is intrinsic AKI?

A

Damage to the functional tissues of the kidney

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15
Q

What causes intrinsic AKI?

A
  • Acute interstitial nephritis
  • Myeloma
  • Rhabdomyolysis
  • Immunological renal disease
  • e.g. vasculitis/ medications
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16
Q

What is the most common classification of AKI?

A

Pre-renal

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17
Q

Why is it important to check blood creatinine levels?

A
  • If rising, could indicate kidneys are not functioning correctly
  • Determine sufficiency of kidney function
  • Determine severity of kidney damage
  • Monitor progression of kidney disease
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18
Q

How can GFR be calculated?

A

(1) eGFR (mL/min/1.73m^2)

2) Creatinine clearance (mL/min

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19
Q

What are disadvantages of using eGFR to estimate GFR?

A
  • Does not account for a patient’s bodyweight
  • Can dramatically underestimate the creatinine clearance in renal failure
  • Not interchangeable between labs
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20
Q

How is creatinine clearance measured?

A

Cockcroft + Gault equation

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21
Q

What is the Cockcroft & Gault equation?

A

CrCl = [F(140-age) x weight] / serum creatinine

F = 1.04 in females and 1.23 in males

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22
Q

What is F in females?

A

1.04

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23
Q

What is F in males?

A

1.23

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24
Q

What is eGFR?

A

Estimated glomerular filtration rate

Calculated in labs

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25
Q

What are the units for eGFR?

A

mL/min/1.73m2

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26
Q

Which method of GFR calculation is more accurate?

A

Creatinine clearance

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27
Q

When must creatinine clearance be calculated, instead of eGFR?

A

Patients who:

(1) Are on DOACs
(2) Are on nephrotoxic drugs
(3) >75yrs
(4) Extremes of muscle mass
(5) Drugs that are highly renal excreted
(6) Narrow therapeutic index drugs

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28
Q

What is the action to be taken when eGFR or creatinine clearance is low?

A

(1) Establish if AKI or CKD

(2) Review all medications
- Change dose/ frequency
- Stop/ hold

(3) Does literature suggest dose changes?

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29
Q

What is CKD?

A

Abnormalities of kidney function for >3 months, with implications for health

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30
Q

What are some risk factors for CKD?

A
  • Diabetes
  • HTN
  • Kidney disorders
  • CVD
  • AKI
  • Infections (of urinary tract)
  • HIV/ HepC
  • Medications (lithium, NSAIDs, etc)
  • Malignancy
  • Age
  • Family Hx of CKD
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31
Q

What are some prompts/ findings that will lead to checking for CKD?

A

(1) Persistent microalbuminuria
(2) Persistent proteinuria
(3) Persistent haematuria (exc. other sources)
(4) Ultrasound/ biopsy (imaging)

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32
Q

What are three main functions of the kidney?

A

(1) Homestasis
(2) Hormone function
(3) Metabolic function

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33
Q

What are some clinical complications of CKD?

A
  • Acidosis
  • Anaemia
  • Dyslipidaemia
  • Fluid overload (less able to excrete water)
  • Hyperkalaemia
  • HTN
  • Mineral & bone disorder
  • Uraemia
    ø Raised levels of urea in the blood
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34
Q

What is acidosis?

A

Inability of kidneys to maintain blood pH

CKD progresses - kidneys are less able to excrete H+ and reabsorb HCO3-

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35
Q

How is acidosis managed?

A

Long-term oral sodium bicarbonate

Sodium bicarbonate 1g TDS

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36
Q

When is 1g sodium bicarbonate TDS PO an appropriate treatment?

A

Acidosis

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37
Q

What is the acute treatment of metabolic acidosis?

A

IV sodium bicarbonate

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38
Q

What are some side-effects of acidosis?

A

Secondary increase in sodium retention

Be aware of fluid retention

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39
Q

What is renal anaemia?

A

Quality/ quantity of RBCs is below normal

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40
Q

What causes renal anaemia?

A

(1) Lack of circulating iron

(2) Lack of erythropoietin

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41
Q

What effects on the patient increase when renal anaemia is corrected?

A
  • Quality of life
  • Exercise capacity
  • Endocrine function
  • Immune function
  • Muscle metabolism
  • Sleep patterns
  • Cognitive function
  • Nutrition
42
Q

What effects on the patient decrease when renal anaemia is corrected?

A
  • Bleeding tendency
  • Transfusions
  • Depression
  • Hospitalisation
43
Q

What can cause an iron deficiency?

A

(1) Increased blood loss

(2) Dietary inadequacy
- Many patients on a renal diet to restrict phosphate intake

(3) Poor iron absorption due to uraemia/ use of phosphate binders
(4) Reduced/ impaired erythropoiesis
(5) Long-term use of immunosuppressants

44
Q

What is the management of a lack of circulating iron in pre-dialysis patients?

A

Oral iron for a maximum 3 months

IV iron if no improvement from oral iron

Ferrous sulfate/ ferrous fumarate

45
Q

What is a side-effect of oral iron?

A

(1) GI irritation

(2) Black stools

46
Q

What is the management of a lack of circulating iron in dialysis patients?

A

Give IV iron AFTER a dialysis session

Usually Ferinject

47
Q

What is Ferinject?

A

Branded IV iron

48
Q

What is EPO?

A

Erythropoietin

Naturally occurring hormone produced by the kidneys

Stimulates the bone marrow to produce RBCs

49
Q

What is erythropoietin?

A

Naturally occurring hormone produced by the kidneys

Stimulates the bone marrow to produce RBCs

50
Q

What happens to circulating erythropoietin in patients with CKD?

A

Decreases to low-little

51
Q

What is ESA?

A

Erythropoietin stimulating agents

52
Q

What is the management of a lack of circulating erythropoietin?

A

Erythropoietin Stimulating Agents (ESA)

Erythropoietin stimulating agents

53
Q

What is Eprex?

A

Branded EPO

Recombinant human EPO

Erythropoietin Stimulating Agents (ESA)

54
Q

What is Aranesp?

A

Novel ESA (erythropoietin stimulating agent)

Longer half-life of Eprex

55
Q

What is Mircera?

A

ESA

Longest half-life that provides continuous activity

56
Q

What ESA has the longest half-life?

A

Mircera > Aranesp > Eprex

57
Q

How is Eprex used as treatment?

A

Given once weekly SC
- Usually self-administered

Given IV in dialysis, at the end of the session
- Given 3 times weekly

58
Q

How is Aranesp used as treatment?

A

Given IV in dialysis, at the end of the session

Can be given once a week due to longer half-life

59
Q

Why can Aranesp be given only once a week?

A

Longer half-life than other ESAs

60
Q

What is dyslipidaemia?

A

Abnormal lipid metabolism in CKD

- Mainly hypertriglyceridaemia

61
Q

What is the treatment of dyslipidaemia in CKD?

A

Atorvastatin 20mg OD

62
Q

Why does oedema occur in CKD?

A

Kidneys have a decreased ability to maintain sodium/ fluid balance

63
Q

How is oedema (due to CKD) managed?

A
  • Restrict dietary sodium
  • Restrict fluid intake
  • Loop diuretics (in higher doses)

IF medication is ineffective -> dialysis

64
Q

What is hyperkalaemia in CKD?

A

Patients are less able to excrete potassium

65
Q

What are some treatment options for hyperkalaemia?

A

Non-Pharmacological:
- Restrict potassium

Pharmacological:

  • Calcium resonium PO TDS
  • Calcium gluconate IV (hospital setting only)
  • Actrapid insulin
  • Dialysis - last option
66
Q

In CKD hypertension, what is a common treatment option if ARBs and ACEis are unsuitable?

67
Q

What are the FOUR constituents involved in mineral and bone disorder (MBD)?

A

(1) Calcitriol (active vitamin D)
(2) Calcium
(3) Phosphorus
(4) Parathyroid hormone

68
Q

How is mineral and bone disorder (MBD) caused in CKD?

A

(1) Production of calcitriol stopped
(2) This causes a reduction of calcium in the blood
(3) Causes phosphorous levels in the blood to rise

69
Q

What does low levels of phosphorous in the blood in CKD cause?

A

(1) Vitamin D deficiency
- Calcitriol stops existing

(2) Hyperphosphataemia
(3) Hypocalcaemia

70
Q

How does hyperphosphataemia cause hypocalcaemia?

A

Stimulates calcium to be released from the bones

71
Q

What does vitamin D deficiency, hyperphosphataemia, and hypocalcaemia lead to?

A

Hyperparathyroidism

72
Q

What is the treatment for mineral and bone disorder (MBD)?

A

(1) Alfacalcidol (activated vitamin D)
(2) Phosphate binder (decrease absorption of phosphates from GIT)

(3) Cinacalcet/ parathyroidectomy
- For parathyroid

73
Q

What is uraemia?

A

Reduced ability to excrete waste products such as urea and nitrogenous compounds

74
Q

What is the treatment for uraemia in CKD?

75
Q

What is the treatment for acidosis?

A

Sodium bicarbonate 1g TDS

76
Q

What is the treatment for renal anaemia?

A

(1) Ferrous sulfate 200mg TDS

(2) SC/ IV ESA

77
Q

What is the treatment for dyslipidaemia?

A

Atorvastatin 20mg ON

78
Q

What is the treatment for fluid overload?

A

Diuretics

Usually high doses of furosemide BD

79
Q

What is the treatment for oedema?

A

Diuretics

Usually high doses of furosemide BD

80
Q

What is the treatment for hyperkalaemia?

A

Calcium resonium TDS

81
Q

What is the treatment for hypertension?

A

Antihypertensive

e.g. Ramipril OM or doxazosin OM

82
Q

What is the treatment for vitamin D deficiency?

A

Alfacalcidol OD

83
Q

What is the treatment for hyperphosphataemia?

A

Sevelamer TDS with meals

84
Q

What is the treatment for hyperparathyroidism?

A

Cinacalcet OD

85
Q

Are ACEis/ ARBs used in AKI, CKD, or neither?

A

CKD - because renoprotective

Not AKI - because nephrotoxic

86
Q

Which bloods are used to classify CKD stage?

A

Compare Albumin-Creatinine Ratio and GFR

87
Q

In CKD, how is the albumin-creatinine ratio classified?

A

(1) A1
(2) A2
(3) A3

88
Q

In CKD, how is GFR classified?

A 
G1
G2
G3a1
G3b
G4
G5
89
Q

What is a side-effect of phosphate binders?

A

Decrease absorption of iron

90
Q

When are thiazide diuretics less effective?

A

When CrCl is <20mL/min

91
Q

In CKD hypertension, what is the first line treatment?

A

ACEi or ARB

Titrated to maximum dose

92
Q

Why are ARBs/ ACEis used in treatment of CKD?

A

HTN

Renoprotective

93
Q

What effect does high phosphate levels in the blood have on the bones?

A

Causes calcium to come out of the bones

94
Q

What is alfacalcidol?

A

Activated vitamin D

Given to treat low levels of calcitriol

95
Q

What are some examples of phosphate binders used in treatment of CKD?

A

(1) Sevelamer

(2) Lanthanum carbonate

96
Q

What is the first line treatment for T2DM in CKD?

A

Insulin

Pioglitazone fine in renal failure BUT contraindicated in heart failure

Metformin is contraindicated in CrCl <30mL/min

Sulphonylureas require caution due to risk of hypoglycaemia

97
Q

When is pioglitazone contraindicated?

A

Heart failure

98
Q

When is metformin contraindicated?

A

CrCl <30mL/min

99
Q

When are SGLT2 inhibitors (flozins) contraindicated?

A

CrCl <60mL/min

100
Q

What is a side-effect of calcium channel blockers for CKD patients?

A

Cause/ exacerbate fluid overload (oedema)

101
Q

Which type of painkillers accumulate in renal failure?

A
  • Codeine
  • Tramadol
  • Morphine
102
Q

What types of painkiller are available for patients with renal failure requiring pain management stronger than paracetamol?

A
  • Fentanyl patch
  • Oxycodone
  • Buprenorphine patch
  • Tapentadol

Part 4 – PM4B Ali (19 decks)

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