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PHAR 255 > Kidney 2 > Flashcards

Kidney 2 Flashcards

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1
Q

What is the leading cause of CKD?

A

Diabetes

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2
Q

What are many CKD guidelines nes based on?

A

Opinion or preference of doctor due to limited evidence from lack of RCTs

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3
Q

What is CKD

A

Progressive loss of kidney function occurring over several months to years

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4
Q

How is CKD characterized?

A

By gradual replacement of normal kidney architecture with fibrosis

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5
Q

What are the two main causes of CKD?

A

Diabetes and hypertension

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6
Q

Definition of CKD by kidney function or kidney structure

A

GFR </= 60mL/min/1.73m2 for 3 months or more, with or without kidney damage OR
Kidney damage for >/= 3 months, with or without decreased GFR, as evidenced by pathological abnormalities, abnormalities in blood or urine, or as seen by renal imaging

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7
Q

What are the markers of kidney damage?

A

Albuminuria (ACR >/= 3mg/mmol)
Urine sediment abnormalities
Abnormalities detected by histology (from biopsy)
Structural abnormalities detected by imaging
History of kidney transplantation

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8
Q

What are the new “rethought” GFR thresholds for CKD?

A

<40yrs = < 75ml/min
40-65yrs = <60ml/min
>65yrs = <45ml/min (because we see a decline with age and it doesn’t always mean its CKD)

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9
Q

What are the stages of CKD with their related GFR?

A

G1 = >/= 90ml/min
G2 = 60-89ml/min
G3a = 45-59ml/min
G3b = 30-44ml/min
G4 = 15-29ml/min
G5 = <15ml/min

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10
Q

What are the stages of CKD by albuminuria category(ACR)?

A

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

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11
Q

To determine the GFR category, what equation would you use to estimate GFR?

A

CKD-EPI

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12
Q

What is the clinical presentation of CKD?

A

Often asymptomatic which is why screening is important
- low energy, fatigue, confusion
- foaming, tea-colored, blood or cloudy urine
- edema
- SOB
- pruritis

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13
Q

What are the goals for overall care in CKD?

A

Delay progression of CKD
CV risk reduction
Treat complications of CKD
Renal replacement therapies (RRT)

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14
Q

What type of CKDs may undergo remission?

A

Autoimmune

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15
Q

What is associated with seeing a faster decline in GFR?

A

Lower GFR and greater albuminuria

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16
Q

Which CKD etiologies of CKD tend to progress more quickly?

A

Diabetic nephropathy
Glomerular diseases
Polycystic kidney disease
Kidney disease in transplant recipients

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17
Q

Which CKD etiologies tend to progress more slowly?

A

Hypertensive kidney disease
Tubulointerstitial diseases

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18
Q

What factors are associated with faster progression of CKD?

A

African-American race
Male
Advanced age
Family history
-
Uncontrolled HTN
Poor BG control
Proteinuria
Smoking
Obesity

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19
Q

What are the interventions to delay progression of CKD?

A

BP control
RAAS blockade - ACEi/ARB or non-steroidal MRAs
BG control in diabetes - SGLT2i and GLP-1 agonists
Smoking cessation
Avoidance of nephrotoxins

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20
Q

What is the difference in decline of GFR between controlled vs. Uncontrolled HTN?

A

Controlled BP <130/80 = GFR declines by 1-2ml/min/year
Uncontrolled BP = GFR declines by 12ml/min/year

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21
Q

What are the BP targets as per the HTN guidelines?

A

<130/80 for diabetic CKD
SBP <110 for adults with polycystic kidney disease
SBP <120 for “high risk” patients
SBP <140 for all other patients

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22
Q

What are the BP targets based on the KDIGO HTN guidelines?

A

SBP <120 for patients with high BP and CKD(not on dialysis), when tolerated
SBP <130/80 for kidney transplant recipients

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23
Q

Which of the following criteria were excluded from the SPRINT trial?
A. eGFR 20-59ml/min
B. Proteinuria <1g/d
C. Framingham risk score >/= 15%
D. Diabetes mellitus
C. Clinical CVD

A

D. Diabetes mellitus

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24
Q

What are the clinical indications for SBP <120?

A

AARF* (high risk patients)
Age > 75
Atherosclerosis (CVD disease)
Renal (CKD)
Framingham risk score >15%

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25
What are the cautions and CI for SBP <120?
HF or recent MI Diabetes mellitus Previous stroke eGFR < 20ml/min (includes dialysis and transplant) *Standing SBP < 110 *Inability to measure SBP accurately *Known secondary cause of HTN
26
What was the result of the SPRINT trial?
SBP <120 did not slow CKD progression (perhaps worsening, no impact on ESRD)
27
What is the lifestyle recommendation for BP control from HTN Canada?
Salt restriction: reduce sodium intake towards 2000mg (5g of salt) per day Exercise: 30-60 minutes of moderate intensity 4-7 days/week, in addition to the routine acts of daily living Weight reduction: in overweight/obese patients Limited alcohol consumption: 1-2 drinks/day
28
How many BP drugs are often required for BP control as CKD progresses?
3-4
29
What are the 1st line BP control drugs per KDIGO?
ACEi/ARB Diuretics Long-acting CCBs
30
What is the first line treatment in CKD for HTN if a patient has proteinuria?
ACEi/ARB Diabetic - ACR >3mg/mmol Non-diabetic - ACR >30mg/mmol
31
What are ACEi/ARB role in therapy for CKD?
Reduce BP and glomerular capillary pressure Reduce proteinuria more than any other antihypertensive Improvement of kidney outcomes and CV outcomes
32
CI of ACEi/ARB
Bilateral renal artery stenosis Angioedema Pregnancy
33
Precautions with ACEi/ARB
Intravascular fluid depletion eGFR <30ml/min Hypotension (if BP <110/70) Hyperkalemia (K+ >5.5mmol/L)
34
What are the monitoring parameters for ACEi/ARB
*2-4 weeks following initiation, or any dose increase - SCr (dont want an increase >30% from baseline) - K+ (if high restriction dietary K+, add diuretic) - BP - urinary albumin: creatinine ratio (ACR)
35
Dosing for ACEi/ARB
Reduction in albuminuria is dose-dependent Start at low dose and titrate to maximum tolerated dose(or highest approved dose)
36
What are the steroidal (non-selective) MRAs used for HTN in CKD?
Spironolactone** Eplerenone
37
What are the non-steroidal (selective) MRAs used for HTN in CKD?
Finerenone - reduction in albuminuria, while having less side effects
38
When should we use non-steroidal MRAs with proven kidney or CV benefit?
T2DM, eGFR >/=25mL/min, Normal K+ levels, and Albuminuria (ACR >/= 3) despite maximum tolerated dose of a RAASi
39
What are the limitations of finerenone?
Biggest risk is hyperkalemia Not covered by SK drug plan or NIHB Less evidence in patients who are also taking a SGLT2i Not to use in combo with a steroidal(Spironolactone) MRA in patients with HF (and not to replace steroidal)
40
Why are diuretics used in CKD?
Fluid retention is an important contributor to HTN in CKD so most patients require diuretic therapy
41
What diuretics are used in CKD?
Start with a thiazide Generally avoid potassium-sparing diuretics in stage 3-5 CKD
42
What is of note for diuretic use when GFR<30ml/min?
Thiazide diuretic will lose its diuretic effect but maintain BP benefit - may switch to or combine with loop diuretic for volume control or if BP becomes resistant to therapy - may prefer combo with metolazone, chlorthalidone, or indapamide (effective diuresis at GFR<30ml/min)
43
What is the most common thiazide?
Hydrochlorothiazide
44
What did chlorthalidone improve in the CLICK trial?
Significant improvements in BP, and 30-40% reduction in ACR for patients with stage 4 CKD(GFR 15-30ml/min)
45
Which type of CCB would be used in CKD?
DHP-CCBs are used most often(amlodipine)
46
When are CCBs preferred over thiazides?
In combo with an ACEi/ARB in patients with diabetes
47
Downside of CCBs for CKD
May cause fluid retention and edema (problematic in CKD patients)
48
When would we use a non-DHP CCB(diltiazem and verapamil) in CKD?
May provide benefit when added to ACEi/ARB for decreasing proteinuria
49
When would we have a compelling indication to use a beta-blocker in CKD?
In HF, post MI, angina
50
Which beta-blockers would we use in CKD?
Atenolol and bioprolol - may require dose adjustment once CrCl approaches 30ml/min because they are renally eliminated
51
What are some other drugs used for HTN in CKD?
Clondine - adjunctive therapy Terazosin, prazosin - adjunctive (might consider in patients with prostatic hypertrophy) Hydralazine - adjunctive (use limited by side effects)
52
Why is proteinuria a concern for CKD?
Damages the glomerulus High risk of progressing to kidney failure
53
What does microalbuminuria predict?
Loss of kidney function
54
Classifications of proteinuria
>150mg protein lost in urine per day (albumin or other plasma proteins) Mild: 150-500mg - category A2 Moderate: >500mg - category A3 Nephrotic range: >3000mg = 3g or albumin excretion >2200mg/24h
55
What is nephrotic syndrome?
Associated with hyperlipidemia, hypoalbuminemia, generalized edema, thromboembolic risk, foamy urine
56
What are the kidney diseases associated with proteinuria?
Diabetic nephropathy Hypertensive kidney disease Primary glomerular diseases Lupus nephritis Post-streptococcal glomerulonephritis
57
What is the first line treatment for CKD with proteinuria and why?
ACEi/ARB Reduce glomerular capillary pressure and volume Possible direct effect on podocytes to decrease proteinuria (protective benefit to kidney)
58
What is an SGLT2i place in therapy for CKD?
Cardiovascular risk reduction in adults with ACR>20mg/mmol and eGFR >/=25ml/min, by reducing decline in eGFR
59
What % of patient with T2DM have CKD?
40%
60
How often should screening be done in people with diabetes?
At least annually in stable patients Begin 5 years after diagnosis of T1DM and at time of diagnosis for T2DM - do random urine ACR, SCr, and eGFR
61
How does BG control help in CKD?
Prevents and delays progression of diabetic nephropathy
62
What is the first line therapy for BG control in diabetic CKD?
Metformin + SGLT2i Preferred add on would be a GLP-1 agonist
63
What is the concern with Metformin in CKD patients?
Accumulation because it is cleared by the kidney, and this could lead to lactic acidosis which has a high mortality rate (~50%) Recommended to avoid in eGFR <30ml/min and dose is halved for eGFR of 30-44ml/min
64
What are the benefits for Metformin in diabetic CKD?
Primarily for CV benefit Lack evidence for kidney protective effects
65
What are the benefits of SGLT2i for diabetic CKD?
CV benefits and reducing the progression of CKD
66
When is an SGLT2i the first line agent?
For patients with T2DM, CKD, and eGFR>20ml/min Recommended regardless of the patients A1C (even if targets are met) *trial done using lowest dose
67
Which drugs may be effected when starting an SGLT2i?
Loop diuretics - may want to reduce dose when starting Insulin - might need to lower to prevent hypoglycemia
68
What are the benefits of GLP-1 agonists for diabetic CKD?
CV benefits and kidney benefits Appear to reduce albuminuria or an extent Weight loss Decrease A1C (SGLT2i does not)
69
When is a GLP-1 agonist(semaglutide) used for diabetic CKD?
Use if A1C targets not achieved with Metformin/SGLT2i
70
How can smoking cessation help with CKD progression?
Smoking increased progression of CKD so we want to avoid this - increased BP and heart rate, decreased renal blood flow(construction), vascular injury Smoking is also a risk factor for CV events
71
What are the nephrotoxic drugs that should be avoided in CKD?
NSAIDs, COX-2 inhibitors Lithium Aminoglycosides Amphotericin B Calcineurin inhibitors Cisplatin **especially avoid combo of ACEi/ARB, NSAIDs, and diuretic**
72
What is sick day management?
When patients with CKD become acutely ill and and are unable to maintain adequate fluid intake, it is recommended to hold potentially nephrotoxic or renally excreted drugs
73
Which drugs should be held for sick day management?
(SAD MANS) Sulfonylureas ACEi Diuretics, direct renin inhibitors Metformin ARBs NSAIDs SGLT2i
74
What are the common CV risk factors?
DM Dyslipidemia HTN LVH Smoking Obesity
75
Is CKD a statin indicated condition?
Yes
76
What is the recommendation with statins in CKD?
Patient >/=50 with eGFR<60 (NOT ON DIALYSIS) should ne on a low-dose statin or statin/ezetimibe combo irrespective of LDL level >/= 50 with CKD and eGFR>/=60 should be on a statin
77
What is the benefit of statins in CKD?
CV risk reduction and mortality, no benefits to slowing CKD progression
78
What would be the low dose statins used in CKD?
Atorvastatin 20mg Rostuvastatin 10mg Simvastatin/ezetmibe 20/10mg
79
What are the four first line drugs for CKD?
SGLT2i (T2DM ONLY) Metformin (T2DM ONLY) ACEi/ARB Statin
80
What are the RRTs?
Dialysis - hemodialysis - peritoneal dialysis Kidney transplant**preferred option
81
What should RRT be initiated?
No set GFR Based on symptoms: - serositis, acid-based or electrolyte abnormalities - Inability to control volume status or BP - Malnutrition refractory to dietary intake - cognitive impairment Most patients require RRT at GFR ~10ml/min
82
What is the most common RRT?
Hemodialysis
83
What is hemodialysis?
Patient blood is passed through an external filter to remove wastes and fluid - solutes removed by diffusion - filtered blood returned to patients body
84
Where is hemodialysis done?
At home or in dialysis clinic
85
How often is hemodialysis done?
3x per week (3-5 hours each visit)
86
What are the types of hemodialysis?
Arteriovenous (AV) fistula**preferred** Insertion of a synthetic AV graft Catheter in neck
87
What is required during hemodialysis?
Systemic anticoagulation
88
Complications of hemodialysis
Fatigue Hypotension Hypertension Cramps N/V *vascular access problems - infection, clotting, bleeding
89
What should hemodialysis patients be taking?
Replavite tablets (renal vitamins) because water soluble vitamins are removed during treatment
90
What needs to be monitored during hemodialysis?
Serum folate, vitamin B12 every 6-12 months
91
What should be avoided in hemodialysis patients?
Multivitamins containing minerals Vitamin A or D
92
What is peritoneal dialysis?
Relies on patient own peritoneal membrane to act as a filter for fluid and wastes
93
What is instilled in the peritoneal cavity for peritoneal dialysis?
2-3L of dialysate
94
How often is peritoneal dialysis done?
Continuous ambulatory: 4-5x per day for 30-45 minutes each time Automated: 8-10 hours while you sleep (using cycler)
95
What is the most common complication of peritoneal dialysis?
Peritonitis: inflammation and infection of the peritoneal lining
96
What is CRRT recommended?
For hemodynamically unstable patients requiring RRT for an AKI - patients who cannot tolerate abrupt fluid shifts

PHAR 255 (8 decks)

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