Renal Flashcards by X X

what do the kidneys aim to maintain in body?

remove wastes and extra fluid also acid produced by cells of body and maintain healthy balance of water, salts, and minerals e.g. sodium, calcium, phosphorus and potassium in blood.

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list some different things that can be used for the diagnosis/ detection of AKI/ CKD

signs
symptoms
risk factors
urine output
serum creatinine

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What algorithm is endorsed by nhs england and used in labs to identify potential cases of AKI based on creatinine levels

AKI

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how is an AKI warning stage test result result communicated once identified

to GP clinical systems

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what is the benefit of communicating aki warning stage test results to gp clinical systems

allows primary care team to take action based on clinical judgement

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list some of the different measures for renal function that may be used selectively for different patient groups depending on appropriateness

creatinine
24 hr urine collection
51 chromium edta test
cystatin c
egfr

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list some different patient groups where gfr may appear BETTER than it actually is

elderly
low protein diet
amputees
muscle wasting disorders

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list some populations in which gfr may appear WORSE than it actually is

high muscle mass
high protein diet
muscle breakdown

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name of the equation that is used to calculate creatinine clearance

cockcroft gault

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whilst creatinine clearance is not good for diagnosis what is it good for

bedside calculation and drug dosing

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Modification of Diet in Renal Disease (MDRD eGFR) becomes more useful in <60ml/min function or stage 3/4 of CKD, why is is not useful at lower level

overestimates renal function

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give some patient populations where mdrd egfr is useful for bedside calc and drug dosing but not diagnosis

obesity
muscle mass
fluid overload

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give a brief description of CKD

abnormalities of kidney structure or function present for greater than 3 months with implications for health

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why is ckd more prevalent in elderly populations

ageing process causes loss of nephrons and natural decline of renal function

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UK kidney association has classified ckd as individuals with an egfr of below x on at least 2 occasions y days apart with or without markers of kidney damage

X = 60
Y = 90

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list some different markers of kidney damage

albuminuria
haematuria
electrolyte abnormalities
renal histological abnormalities
structural abnormalities
kidney transplant Hx

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examples of structural abnormalities detected by imaging

e.g. polycystic kidneys, reflux nephropathy

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There are several causes of CKD, give examples 7

intrinsic kidney disease conditions
kidney infections
polycystic kidney disease
glomerulonephritis
meds impacting kidneys
obstructive kidney disease conditions
multi-system diseases involving kidneys

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give examples of intrinsic kidney disease conditions that may cause CKD

ashypertension
T1,T2DM
hypercholesterolaemia

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polycystic kidney disease is inherited t/f?

true… cysts develop in kidney

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give examples of meds impacting kidneys –> CKD

lithium
ciclosporin
calcineurin inhibitors (such as tacrolimus)
aminoglycosides
mesalazine

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ckd is classified according to what 3 things

cause
gfr
albuminuria

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name a tool that is used to predict the risk of kidney failure

kfre kidney failure risk equation

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the kfre tool determines a persons risk of developing kidney failure within x years

2-5

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why is it important to have a tool that accurately predicts a patients risk of developing kidney failure

helps dr and patient plan best pathway of care and highlight which patients need to be referred to hospital because their disease is more severe

true or false, aki is a term used to a cover a spectrum of injury to the kidneys

true

aki is characterised by a decline in renal function over hrs or days that can result in failure to

maintain fluid, electrolyte and acid base homeostasis

in the early stages aki can be symptomless, what might some people experience in the early stages however

produce less urine than usual

what symptoms can develop rapidly in someone with aki

nausea, vomiting, diarrhoea reduced urine output changes to urine colour new or worsening confusion, fatigue, drowsiness

in the context of aki what are nausea, vomiting and diarrhoea all evidence of

dehydration

list some different risk factors for aki/ renal hypoperfusion

hypotension hypovolaemia drugs sepsis haemodynamic disturbances ischaemic aki intense sodium and water retention

what effect does haemodynamic disturbance have on the kidneys

endothelial and epithelial injury and immune activation

during ischaemic aki what does the kidney lose

autoregulatory capacity

elderly patients and those that are taking medication deemed nephrotoxic or those that cause dehydration are at a greater or lesser risk of developing aki

greater

true or false, nsaids and cox II inhibitors do not need to be avoided in patients at high risk of AKI

false

what effect do nsaids have on the kidney that would be problematic in aki

altered haemodynamics leading to underperfusion and reduced glomerular filtration

what action should be taken towards opioid analgesics in the presence of aki

avoid long acting preparations reduced dose and frequency use opiates with minimal renal excretion

list some opiate options that have minimal renal excretion

fentanyl oxycodone hydromorphone tramadol

what change in side effect profile would you expect if using opioid analgesics like morphine, pethidine and codeine in the presence of aki

accumulation of active metabolites, increased cns side effects and respiratory depression

what changes in side effects would you expect in patients taking pregabalin or gabapentin in the presence of aki

accumulation leading to increased cns side effects

what action should be taken towards use of pregabalin or gabapentin the case of aki

reduce dose

in aki what effect might antihypertensives including alpha beta and ca channel blockers have

hypotension may exacerbate renal hypoperfusion

what change is side effect profile occurs when using beta blockers in states of reduced renal function

risk of bradycardia

what action is required towards antihypertensive drugs in the presence of aki

consider withholding or reduce dose depending on blood pressure

what effects can acei/arbs/aliskiren have on the kidneys in aki

hypotension and hyperkalaemia

in aki withholding acei/arbs and aliskiren can be considered however in some situations continuing them may be helpful, name on situation where this may be the case

what effect might loop or thiazide diuretics have on the kidneys in aki

volume depletion and acute interstitial nephritis (rare)

in aki why are loop diuretics such as furosemide and bumetanide preferred

thiazides less effect if gfr below 25 ml/min

action in presence of AKI for diuretics?

withold if volume depleted

potassium sparing diuretics such as amiloride, spironolactone and eplerenone can cause volume depletion and hyperkalaemia in aki, what action should be taken if a patient is on these drugs

stop

statins may cause aki if rhabdomylolysis is present and can generally increase the risk of developing it, what action would be taken if patient develops unexplained or persistent muscle pain

stop

diigoxin can cause hyperkalaemia and accumulate in AKI -> bradycardia, visual disturbances, mental confusion action in presence of AKI

reduce dose monitor L+ and drug levels

DOACS INFECTION DIABETES OTHER AGENTS ...

3 categories that aki causes can be divided into

pre renal intrinsic renal post renal

pre renal aki is caused by reduced blood flow to the kidneys, give some causes of this

hypovolemia reduced cardiac output hypotension medicines

how might loop diuretics cause pre renal aki

reduce blood pressure and circulating volume

acei and arbs and nsaids may cause pre renal aki by affecting

renal blood flow

pre renal aki can also be caused by systemic vasodilation, give a condition where this may be the case

sepsis

which type of aki cause is due to structural damage to the kidney tissues and may be a result of persistent pre and post renal causes

Intrinsic renal (or intrarenal)

what medicines can also cause intrinsic renal aki

antibiotics x ray contrast media chemo

types of structural damage that result in intrinsic renal aki can be grouped into what different categories depending on the area of the kidneys that are affected

vascular glomerular tubular interstitial

what is the least common cause of aki that is due to obstruction of the flow of urine out of the kidneys

post renal

give some different causes for post renal aki

renal stones blocked catheters enlarged prostate genitourinary masses

Classification of AKI NICE clinical guideline Acute kidney injuryLinks to an external site.: prevention, detection and management recommends defining acute kidney injury by any of the following criteria:

a rise in serum creatinine of 26 micromol/litre or greater within 48 hours a 50 percent or greater rise in serum creatinine known or presumed to have occurred within the past seven days a fall in urine output to less than 0.5 mL/kg/hour for more than six hours in adults and more than eight hours in children and young people a 25 percent or greater fall in eGFR in children and young people within the past seven days. AKI can be staged based on severity, and increasing severity of AKI correlates with higher risk of worse outcomes. Kidney Disease: Improving Global Outcomes (KDIGO) has produced a Clinical practice guideline for acute kidney injury which includes AKI staging information. The information in the following table is taken from this guideline. There are two classification systems used in practice:

At risk patients in primary care

Diabetes Mellitus Chronic Kidney Disease – if become acutely unwell, unable to maintain fluid intake, should contact GP to withhold medication ACE/ARB Dementia –inability to self-care and fluid intake Heart Failure – often have CKD and on ACE/diuretics Maintaining optimal fluid intake Older people Most at risk Dementia/frailty/risks of dehydration Psychiatric Patients Self-neglect - dehydration Laxative or diuretic abuse Recreational drugs Paediatric Patients with CKD Patients with Cancer Awareness in community, management is secondary care AKI known complication of cancer therapy – drugs/type of cancer/risks of sepsis

what is the treatment and management of aki dependent on

site staging presence of complicating factors

what are sick day rules

withholding nephrotoxic drugs to prevent the development of aki in patients that start vomiting, diarrhoea, fevers, sweats or shaking

aim of treatment is to manage the progression and complications of ckd and patients should be provided with information and education, what should they be encouraged to do non pharmacologically

exercise achieve healthy weight smoking cessation dietary advice

The mainstay of treatment of CKD is based around the management of the multimorbidities associated with CKD,...

Complications of CKD include: cardiovascular disease (hypertension, peripheral vascular disease and heart failure) cardiovascular events (stroke and myocardial infarction) anaemia or chronic disease renal bone disease malnutrition neuropathy (nerve pain) lipid abnormalities increased risk of acute kidney injury end-stage renal disease that requires renal replacement therapy (RRT) risk of acidosis (to learn about acidosis, access this Lab Tests Online article Acidosis and Alkalosis) increased risk of infection – those with CKD have been shown to be at increased risk of hospitalisation due to infections such as pneumonia, sepsis, and urinary tract infections.TIs

at end stage ckd renal replacement therapies may be more appropriate, give some examples

peritoneal dialysis, haemodialysis, kidney transplant

the main pharmacological treatments offered to those with ckd are?

blood pressure renal bone disease renal anaemia preservation of kidney function metabolic acidosis

why might patients with ckd be offered statin or oral antiplatelet therapy

secondary prevention of cvd

what is the rationale behind using an sglt2 inhibitor ckd

blocks sglt2 in kidneys reduces pressure and inflammation stops protein leaking into urine reduces blood pressure and weight so reduces damage

adding x to the current standard care for ckd has been shown to significantly reduce the risk of having declining kidney function end stage kidney disease dying from causes related to kidney or cv system

dapagliflozin

name the drug that is recommended as an option for treating end stage 3 and 4 ckd with albuminuria and associated with t2dm in adults

finerenone

what 2 things have to be measured to determine if finerenone treatment can be initiated and to determine the starting dose

serum potassium and egfr

CASE STUDIES

Renal Flashcards

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