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### > Week 10: Renal Biochemistry > Flashcards

Week 10: Renal Biochemistry Flashcards

1
Q

Explain the main functions of the kidneys. (7)

A
  1. Regulates water and electrolyte in the body.
  2. Glucose + protein retention.
  3. Maintains acid/base balance.
  4. Regulates BP via RAAS system.
  5. Excretes waste products, toxic substances and medicines.
  6. Endocrine functions (Vit. D activation)
  7. Needs cardiac output for perfusion.
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2
Q

What is the ref. range for Urea?

A

3.0-6.5mmol/L

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3
Q

Where is urea produced? (1)

A

Protein/Amino acid breakdown via liver.

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4
Q

What process does urea undergo for elimination? (1)

A

Glomerular Filtration

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5
Q

Where in the body is urea reabsorbed? (1)

A

Kidney Tubules

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6
Q

What can cause high urea levels? (3)

A
  1. Dehydration
  2. Concurrent Infection
  3. Gastric blood loss
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7
Q

What can cause low urea levels? (5)

A

Oedema
Low Protein Diet
Pregnancy
Chronic nutrition status
Low liver function

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8
Q

What is the reference range for creatinine? (1)

A

50-120umol/L

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9
Q

Where is creatinine produced? (1)

A

Muscle

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10
Q

What is the main function of creatinine? (1)

A

Maintains muscle mass.

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11
Q

What is creatinine? (1)

A

Waste product of muscle catabolism (breakdown)

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12
Q

How is creatinine cleared from the body? (1)

A

Glomerular Filtration

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13
Q

Explain how creatinine is used. (1)

A

Determines kidney function.

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14
Q

What is the Cockroft-Gault equation? (1)

A

(140 - Age) x weight (kg) x Constant / serum creatinine (umol/L)

Female = 1.04
Male = 1.23

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15
Q

What is AKI? (1)

A

A rapid deterioration of kidney function over hrs or days.

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16
Q

Explain why creatinine is used rather than eGFR in patients with AKI. (1)

A

e stands for estimated in eGFR. Hence, it’s more accurate to use creatinine.

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17
Q

What is the SCr criteria for stage 1 AKI. (2)

A

Increase >26umol/L within 48 hrs

OR

Increase ≥ 1.5-1.9 x ref. SCr

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18
Q

What is the urine output criteria for stage 1 AKI? (1)

A

<0.5ml/kg/hr for > 6 consecutive hrs.

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19
Q

What is the SCr criteria for stage 2 AKI. (1)

A

Increase ≥ 2-2.9 x ref. SCr.

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20
Q

What is the urine output criteria for stage 2 AKI? (1)

A

<0.5ml/kg/hr for > 12 hrs.

21
Q

What is the SCr criteria for stage 3 AKI? (3)

A

Increase ≥ 3 x ref. SCr OR
Increase ≥ 354umol/L OR
Commenced on renal replacement therapy (RRT) irrespective of stage.

22
Q

What is the urine output criteria for stage 3 AKI? (2)

A

<3ml/kg/hr for > 24 hrs

OR

Anuria for 12 hrs

23
Q

What information do you need for interpreting SCr levels?

A

Baseline.

24
Q

What are the consequences of AKI? (4)

A

Increased risk of morbidity/mortality.
Small rise in SCr = poor px outcomes.
Increase hospital stay/no. of admissions.
Px needing long-term renal replacement therapy.

25
Q

What are the pre-renal causes of AKI? (3)

A

Reduced perfusion: Hypovolaemia - dehydration/burns, Cardiac/vascular disease, reduced CO/low BP.
Sepsis/ Infection
Haemorrhage

26
Q

What are the intrinsic causes of AKI? (4)

A

Kidney disease
Vasculitis
Necrosis
Rhabdomyolysis

27
Q

What are the post-renal causes of AKI? (3)

A

Fluid retention
Obstruction (renal stones)
Prostate cancer.

28
Q

What are the risk factors for AKI? (12)

A

Elderly
Sepsis, Hypovolaemia + Hypotension
Diabetes
HF
Liver Disease
Atherosclerotic PVD
CKD
Hx of AKI (monitor renal function)
Surgical procedure
Medications (avoid nephrotoxic)
Use of contrast media
Low Albumin

29
Q

Give e.g. of medicines you need to avoid in px with AKI. (4)

A

Contrast Media
Diuretics
ACEi/ARBs
Metformin/SGLT2i (not nephrotoxic but dangerous in low CrCl)
NSAIDs

30
Q

What type of monitoring do you need to consider in AKI? (2)

A

Renal function
Electrolytes (U&E)

31
Q

What are the sick day rules in AKI?

A

Withold contrast media and DAMN drugs.

32
Q

What is CKD?

A

Reduction in kidney function or structural damage (or both) present for > 3 months.

33
Q

Explain the CKI GFR classification. (3)

A

G1 = Normal/High = ≥ 90ml/min/1.73m
G2 = 60-89ml/min/1.73m
G3a/b = 30-60ml/min/1.73

34
Q

Explain the CKI’s albumin classification. (3)

A

A1 = <30mg/g or <3mg/mmol
A2 = 30-300mg/g or 3-30mg/mmol
A3 = >300mg/g or >30mg/mmol

35
Q

What are the risk factors for CKD? (10)

A

Diabetes (cause of G5)
Hypertension
Proteinuria / Albuminuria
Obesity
Smoking
Hyperlipidaemia
Age
CVD
NSAIDs use
AKI

36
Q

What are the signs and symptoms of kidney disease? (10)

A

Puffy eyelids
High BP
Loin Pain
Blood/tea colour/frothy/cloudy urine
Discomfort/pain when passing urine.
Difficulty in passing urine
Passing urine frequently
Nocturia
Passing stone / sand with urine
Swollen ankles

37
Q

What are the signs and symptoms of kidney failure? (8)

A

Poor appetite
N+V
Tiredness
Anaemia (Paleness)
SOB
Drowsiness
Coma
Convulsion

38
Q

Provide examples of preventative measures against kidney disease. (8)

A

Maintain adequate fluid intake (2L a day)
Good personal hygiene (prevents UTI)
Avoid excessive meat and salt intake.
Px with kidney stones, avoid high calcium intake.
Good control of diabetes + BP.
Px with kidney stones/UTO, seek early and adequate tx.
Early detection of kidney disease by routine urine examination and blood test for kidney function.
Early tx of kidney disease.

39
Q

Explain the management process of CKD with persistent proteinuria without diabetes. (2)

A

If ACR = ≥70ng/mmol, refer for nephrology assessment and offer ACEi/ARB (titrated to highest licensed dose that they can tolerate).

If ACR = 30-70mg/mmol, consider discussing with nephrologist if eGFR declines/ACR increases. Give Dapagliflozin/Empagliflozin.

40
Q

Explain the interventions introduced in patients with cardiovascular risk. (4)

A

Primary/Secondary prevention (Statins/hypertension)
Diabetes control
Exercise
Smoking

41
Q

What are the complications of CKD? (3)

A

Renal Anaemia = Folate/B12/Fe/Epoetin stimulating agents.

CKD Mineral and bone disorder = reduce phosphate: diet, phosphate binders, cinacalcet, vit. D.

Metabolic acidosis = sodium bicarbonate.

42
Q

What do you need to consider regarding medications and adjustments? (3)

A

Refer to renal drug handbook.

Dose changes occur at <30ml/min

Effect on medication = accumulation in reduced eGFR (normally when >25% of drug renally excreted), altered drug distribution (protein binding) and decrease in drug metabolism - digoxin, insulin, vitamin D.

43
Q

Explain the management process of CKD patients with hypertension. (5)

A

ACEi/ARBs
Slow progression proteinuria + CKD
Risks = hypotension + falls, hypoperfusion of kidneys - AKI = stop in AKI but good for CKD
Monitoring = initial drop but slow prgression.

44
Q

Explain the management process of CKD patients with diabetes. (4)

A

SGLT2i beneficial in CKD = risk of DKA.
Metformin = risk of lactic acidosis (reduce dose 1g <45ml/min, stop <30ml/min)
DPP4i (low eGFR) - no minimum for linagliptin.
Insulin.

45
Q

Explain the use of NSAIDs in renally impaired px. (3)

A

Caution in CKD = only use if absolutely necessary @ lowest dose and monitoring.
Increase risk of AKI
Fluid retention.

46
Q

Explain the management process of CKD patients presenting with pain. (3)

A

Step 1: Mild pain (Paracetamol 1-2 tabs QDS)

Step 2: Moderate pain (Regular paracetamol + weak opioid +/-adjuvant)
Acute Pain: Codeine/Tramadol with caution or low dose oxycodone 2.5-5mg

Step 3: Severe Pain
Regular paracetamol + strong opioid +/- adjuvant
Acute pain: oxycodone IR titrate to effect.
Chronic pain: Oxycodone M/R or Fentanyl patch (unlikely to accumulate vs. morphine)

47
Q

Explain which medications would you need to consider monitor in patients with AKI .

A

Metformin = increased risk of lactic acidosis. (Stop temporarily, if renal returns to baseline, reintroduce)

ACEi/ARB/Diuretics = stop temporarily and review renal function (detrimental to recovery of kidney function)

Statins - withold temporarily due to increased risk of myopathy.

Aspirin - continue

DOACs - withold consider LMWH.

SGLT2i - withold due to risk of DKA.

48
Q

Explain which medications would you need to consider monitor in patients with CKD.

A

Metformin - Avoid if SCr >150umol/L or eGFR <30ml/min, caution if SCr is between 130-150umol/L or eGFR <45ml/min (lactic acidosis risk)
ACEi/ARB/Diuretics = Renal function stable so no reason to alter current dose, monitor renal function.
Simvastatin - tolerating dose, renal drug handbook suggests dose used in practice.
Aspirin - continue
DOACs - dose adjust acc. to renal function via handbook.

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