Treatment

Question 1

What is the treatment for diabetic nephropathy?

Answer 1

• Intensive DM control prevents progression of microalbuminuria to macroalbuminuria
• ACEi and ARB for CV and renal protection above BP control
• sodium restriction to <2g/day
• Statins to reduce CV risk

Question 2

How do you treat the complications of CKD?

Answer 2

• Anaemia - EPO (<110g/L Hb), oral or IV iron or B12/folate deficiency
• Acidosis - sodium bicarbonate (eGFR <30 + low serum bicarbonate)
• Bone health - alfacalcidol +/- phosphate binders (phosphate >1.5mmol/l). Also vitD supplements if deficient (cholecalciferol)
• Volume status - fluid and salt restriction, diuretics

Question 3

What is the adequate BP control for CKD?

Answer 3

• 130/80 or less in all stages
• 125/75 or less in proteinuric states (uPCR >100)
• Use ACEi/ARBs
• Check K + creatinine 2/52 after starting dose change/increasing diuretics
• GFR <30ml/min, withdraw diuretic before ACEi/ARB
• Stop ACEi/ARB temporarily in acute hypovolaemia

Question 4

What is the management for stage 1+2/3 CKD?

Answer 4

• Stop smoking
• Exercise
• Manage cholesterol

Question 5

What is the management for stage 3/4?

Answer 5

• Aspirin
• EPO
• Alfacalcidol
• Bicarbonate
• Diuretic

Question 6

What is the management for stage 4/5?

Answer 6

• Choice of modality
• Vascular access
• Transplant work-up

Question 7

What are the drug interactions of amlodipine and simvastatin?

Answer 7

Increased risk of myopathy and rhabdomyolysis

Question 8

What is given in DKA?

Answer 8

• Fluid resuscitation

- Insulin - drive glucose into cells (need to monitor K too)

Question 9

What are osmotic diuretics?

Answer 9

e. g. mannitol, urea, dosorbide
- Limit water reabsorption in the tubule by increasing osmolality
- Increase excretion of Na, K, Ca, Mg, H2O

Question 10

What are loop diuretics?

Answer 10

e. g. furosemide, bumetanide
- Increase urine flow
- Increase Na, Cl, K, H2O, Ca, Mg excretion
- Inhibiting Na reabsorption - decreases H2O reabsorption
- Induces renin release due to plasma volume depletion

Question 11

What are thiazides diuretics?

Answer 11

e. g. hydrochlorothiazide
- Increases Na excretion and Cl, K, H2O
- Long term - decrease Ca, increase Mg secretion
- Increase reabsorption of urea in proximal tubule > increase plasma uric acid > gout

Question 12

What are potassium sparing diuretics?

Answer 12

e. g. amiloride, trimeterine
- Inhibits Na reabsorption, prevents K excretion e.g. spironolactone
- Inhibits aldosterone receptor so inhibits Na/K pump

Question 13

What is HD?

Answer 13

• Blood passed through a dialyser
• 4hrs 3x/week
• Dietary changes
• Fistula - 3 months to be ready

Question 14

What is PD?

Answer 14

• Dialysate solution - diffuses waste product out blood
• CAPD - 4 exchanges per day
• APD - exchanges for 7-10hrs at night

Question 15

What drugs are used in immunosuppression?

Answer 15

1. Cyclosporine + tacrolimus (T cells)
2. Prednisolone
3. MMF + azathioprine (T and B cells)

Question 16

When should ACEi be stopped?

Answer 16

• K > 6mmol/l
• Decreased eGFR > 25%
• Decreased creatinine >30%

Question 17

What are long term dialysis indications?

Answer 17

• Inability to control volume status, including pulmonary oedema
• Inability to control BP
• Acid base or electrolyte abnormalities
• Pruritis
• N+V/deterioration in nutritional status
• Cognitive impairment

Question 18

How is CKD-MBD treated?

Answer 18

• Cholecalciferol (inactive form of vitD)
• Calcichew (calcium supplement between meals + phosphate binder with meals)
• Alfacalcidol (increases Ca and phosphate)
• Parathyroidectomy or calcimimetic (cinacalcet)