Renal Flashcards

Question

What are the benefits/disadvantages of ACE inhibitors/ARBs long and short term in AKI?

Answer 1

ACE/ARBs: Prevent angiotensin-II mediated vasoconstriction of the efferent arteriole = vasodilation = decreased hydrostatic pressure and glomerular filtration rate. Long-term this is protective- prevents sustained vasoconstriciton and stenosis of the efferent arteriole and loss of nephron function = good BUT, in AKI states, reduction of hydrostatic pressure worsens AKI as we want to preserve filtration rate = HOLD ACE/ARB IN AKI and restart when treated to preserve ongoing function long-term

Answer 2

4mg/min due to risk of ototoxicity (hearing or balance problems)

Answer 3

Hyperkalemia: >6.5 mmol/L potassium= muscle weakness, ventricular fibrillation, cardiac arrest if >6, want to treat urgently: - Calcium glutinate IV- 30mL 10%- Ants Antagonises K+ at cardiomyocyte membranes- protects heart from arrythmias - Rapid-acting insulin (with glucose to prevent hypoglycaemia) over 15 mins to stimulate sodium potassium transporters to drive k+ uptake into cells. - Nebulised salbutamol (rarely used)

Answer 4

Chronic kidney disease- worsening, progressive, irreversible loss of kidney function

Answer 5

Patients with abnormalities for more than 3 months: - eGFR less than 60mL/minute/1.73m2 on at least 2 occasions 90 days apart - or with markers of kidney damage e.g. albuminuria, haematuria, kidney transplant

Answer 6

- AKI- if irreversible intrinsic damage - Hypertension- vessel thickening and narrowing leads to decreased blood flow - Diabetic nephropathy- fibrosis, membrane thickening - Glomerulopathies - vasculitis - polycystic kidney disease ALL lead to kidney sclerosis (hardening of tissue) = Blood flow is diverted to nephrons that still work causing hyperfiltration in these nephrons. this is good short term but increased pressure ling-term will lead to sclerosis in these nephrons too and loss of the nephron.

Answer 7

- Water and electrolyte imbalance- hyperkalemia, acidosis - uraemia - renal bone disease - renal anemia

Answer 8

Fluid restriction "Turn off tap": - Restrict fluid intake per day to prevent water build up: If not on dialysis and still passing urine + minimum of 1 L per day - on dialysis will decrease to around 500mL per day - Also sodium restriction via dietary measures - Patients must measure their weight and BP daily at home- have a target dry weight IF this is insufficient: "Take plug out"- prescribe diuretics: - first line is loop diuretics e.g. Furosemide up to 2g/day - can use bumetanide- better absorbed patient has a lot of fluid accumulated in the abdomen - Can use Metolazone (Thiazide-like diuretic)- very potent so needs close monitoring Usually, diuretics are stopped when patient starts dialysis

Answer 9

Target potassium = 4-6mmol/L pre-dialysis: - Prescribe potassium binder- Calcium resonium- binds to K+ in GI tract and removed it from the body. But, does release calcium ions in exchange which can cause constipation so co-prescribe lactulose - Sodium Zirconium cyclosilicate- now approved by NICE for high K+ in some circumstances to allow patients o remain on ACE/ARBs for longer and at a higher dose (K+ In blood is increased as a s/e of ACE/ARB) and to increase adherence.

Answer 10

Acidosis = decreased bicarbonate ions in blood - Sodium bicarbonate PO 500mg TDS

Answer 11

Decrease in waste product excretion and so they build up in the blood. This can cause pruritus, Anorexia, n+v, foul metallic taste

Answer 12

Difelikefalin- 0.5mcg/kg 3-4 times a week

Answer 13

Cramps, restlessness especially at night or when on dialysis Treatment: - lifestyle measures- no caffeine or alcohol before bed, better sleep hygiene - check iron levels - Quinine (cramps)- 300mg ON - Ropinorole (restlessness)- 250mcg ON

Answer 14

Increased sodium and water retention causes an increase in circulatory volume, leading to artery stenosis and HTN and increased rate of renal function decline.

Answer 15

<140/90 mm/Hg

Answer 16

If patient has CKD with HTN and ACR >30mg/mmol OR is diabetic and ACR >3 mg/mmol START ACE OR ARB ALSO, of patient doesn't have diabetes or HTN but has an ACR 70mg/mmol+

Answer 17

<130/80mm/Hg

Answer 18

70mg/mmol+

Answer 19

- Potassium levels- before treatment and 1-2 weeks after - creatinine- 1-2 weeks after initiation

Answer 20

Not worried about the effect of the drugs on creatinine more the side effects of toxic accumulation.

Answer 21

In renal artery stenosis- Atheroscelrosis on main arteries supplying nthe kidneys = decreases filtration rate (GFR) due to decreased perfusion. This relies on the RAS sytsem to cause vasoconstriction of the efferent arteriole to maintain pressure in the gomeruls to maintain filtration rate. An ACE or ARB blocks this compensatory mechansim and so leads to worsening of renal failure.

Answer 22

In end-stage renal failure (ESRF) When complications/RF become unmanageable by other options. Symptoms - Extreme fatigue - N+V - Pruritis - Bone pain - Inability to urinate - Weight loss

Answer 23

7ml/minute

Answer 24

Dialysis tries to mimic the natural processes of the kidney: - Mimic the glomerulus's ultra-filtration mechanisms- remove fluid build-up via hydrostatic pressure or osmotic gradient and remove waste product build-up via diffusion. - Mimic reabsorption throughout the nephron- by editing dialysate fluid composition to patients biochemistry to encourage reabsorption/conservation of needed molecules.

Answer 25

Peritoneal dialysis Haemodialysis

Answer 26

Takes blood from the patients body and into. machine that contains an artificial kidney made up of hollow fibres. Thos creates a semi-permeable membrane for diffusion to occur. - It has a pump that generates hydrostatic pressure. - Uses a dialyse filter- this cleans the blood - Arterial blood is taken from the body (patient must be anti-coagulated with heparin so blood doesn't coagulate and block the tubes). Then the blood is passed through the dialyzer- has a countercurrent of dialyse fluid to bathe the blood and maximise the concentration gradient. Clean blood is returned ti the body via a vein and the dialyse fluids discarded.

Answer 27

Uses the patients own peritoneum membrane (lines the internal organs) to mimic the glomerular basement membrane. This membranes very blood rich and we fill the peritoneal space with dialyse fluid = allows exchange. The peritoneal space normally only contains a small amount of fluid, so we drain dialyse fluid gradually into this space and then it drains out via gravity into a drainage bag. uses a high concentration glucose solution = fluid moves out into dialysate fluid via osmosis

Answer 28

Anti-coagulation via heparins so that the blood doesn't coagulate and block the tubes.

Answer 29

Good access to the patients bloodstream with strong flow. May use a temporary catheter (esp in emergent access) into the jugular or femoral vein.

Answer 30

Increased risk of infection Thrombosis- blood clot

Answer 31

An Arteriovenous fistula: Joining of a thick-walled artery and thin-walled vein together in the patients arm. This is placed 6-8 weeks before the start of dialysis to allow it to mature- pressure from the artery joint into the vein so enlarges and thickens the vein so 2 large vessels are available for efficient dialysis. - Blood leaves the hand near the wrist into the machine and then re-enters the body higher up In the arm - is longer lasting than a catheter and has decreased risk of infection and clots - Area must remain clean and protected- covered

Answer 32

- 'Dialysis adequacy' : How well toxins and waste products are being removed from the patients blood. To increase adequacy: - Increased blood flow rate - Increase size/surface of dialyser - Longer/more frequent dialysis sessions

Answer 33

- Increased blood flow rate - Increase size/surface of dialyser - Longer/more frequent dialysis sessions

Answer 34

- Monitor the patients weight before and after a session to assess the fluid removal. We done want to offload too much fluid in one go or the patient may have side effects such as dizziness, hypotension - Session length needs to be worked up gradually- prevents disequilibrium syndrome- headaches, n&v, convulsions

Answer 35

Usually 4 hour sessions, three times a week.

Answer 36

Need to be aware of fluid accumulation: - They should not gain more than 1.5kg between each session - Each patient has a tailored dry weight that they should aim for - If a patient gains 1.5kg+ they are a risk of pulmonary oedema and cardiac failure

Answer 37

- If a patient gains 1.5kg+ they are a risk of pulmonary oedema and cardiac failure

Answer 38

It can be done at home by the patients- more independence. Does require dour exchanges a day everyday- patients need to be aseptic trained.

Answer 39

Requires use of an indwelling Tenckhoff catheter Indwelling Tenckhoff catheter (curly): * Inserted under local/general anaesthetic. Will give prophylactic antibiotics to decrease risk of infection. * Through the abdominal wall and sits in the peritoneal space to deliver fluid. * Cuffs and stitched on either side of the abdominal wall to hold in place – scar tissue will form and become watertight over time * Clean technique required on changing catheter lines

Answer 40

- Continuous ambulatory peritoneal dialysis (CAPD)- This is the 4 x a day procedure as described previously - Automated peritoneal dialysis- Exchanged are carried out automatically overnight via a machine over 8-10 hours. 1-3 L of fluid id drained into the peritoneum and remains there for 1-3 hours before being replaced. this is good as it has more frequent and shorter dwell times than CAPD- increased dialysis adequacy

Answer 41

- Can be done at home-gives patient more independence - Less aggressive so causes less fatigue than in haemodialysis - Better for cardiac stability as gentle rate of fluid removal - Decreased anaemia as less blood loss at needling sites - Diet and fluid restrictions are not as strict

Answer 42

- Risk of peritonitis- infection of the peritoneal membrane. This can present as a cloudy drainage bag which is normally just clear fluid. This is common but serious. - membrane can become fibrosed and inefficient - Risk of hyperglycaemia due to high glucose content solutions - Needs lots of equipment and good technique- this is a lot of responsibility for a patient - Less clearance of smaller molecules e.g. urea, creatinine

Answer 43

- Healthy diet- with low fat and salt and high fibre - Low potassium- found in chocolate, potatoes, caffeine ( patients may eat these just before a dialysis session) - Low phosphate - High protein in CAPD- as can lose protein via CAPD

Answer 44

Fluid restrictions: - Haemodialysis: Urine output in mLs + 500 mL of fluid intake per day - Peritoneal dialysis: Urone output in mLs + 750mL per day Note this includes any liquids e.g. ice cream, gravy (anything that is liquid at room temperature)

Answer 45

Can recommend to suck on an ice cube to quench their thirst and then spit the water out.

Answer 46

- Stop any diuretics- unless residual function to pass urine - Acid:base balance- Stop sodium bicarbonate - Hypertension- monitor pre and post dialysis blood pressure- as usually removing fluid by dialysis causes a decrease in blood pressure. Medical management still required. - Remain on treatment for renal bone disease - Erythropoetin- increased risk of blood loss while on dialysis = anaemia, so erythropoietin is still required and is usually given with IV iron on dialysis

Answer 47

- Low MW weight drug - Low plasma and protein binding - low volume of distribution - High water solubility - High renal clearance Dialysis factors: - Dialysis time- HD more - Duration of dialysis - Fluid composition, conc and volume of dialysis fluid = increased adequacy (PD) - The pathophysiology of the peritoneum- if fibrosed= less effective removal - Blood flow rate = if increased rate = increases pressure and loss (HD)

Answer 48

Renal drug hanboook - For dialysis patients look at the GFR (ml/min) <10 category

Answer 49

Presentation of a cloudy drainage bag- is normally clear. Treatment: IV Vancomycin + oral Ciprofloxacin (bioavailability of IV & PO Cipro is the same)- covers both gram negative and positive bacteria. Vancomycin can be given into port of catheter.

Answer 50

- CCBs- can cause ankle oedema- especially Nifedipine- be aware as often have to manage fluids in kidney patients - Diuretics- mainly for oedema rather than HTN. Thiazide-like are ineffective if CrCl is less than 25mL/minute (don't work). Potassium-sparing- increase the risk oh hyperkalemia further - beta blockers- need to be cardio selective and start low, go slow. Metoprolol is ideal as it is hepatic ally cleared. - Alpha blockers e.g. Doxazosin is hepatically cleared - Vasodilators- last resort as they have side effects that often cause co-prescribing e.g. tachycardia, fluid retention and minoxidil causes hair growth

Answer 51

SGLT2 inhibitors have a renal protective effect and slow the progression of and decrease adverse outcomes. The MOA is not fully known, but is though to: - Prevent the reabsorption of sodium, so that sodium remains in the nephron and can reach the macular denser in the distal tubule. Here it activates adenosine, which causes the gentle vasoconstriction of the afferent arteriole and decreasing the pressure in the glomerulus. This allows for the preserving of the kidney function and decreased damage causes by high hydrostatic pressure.

Answer 52

Dapagliflozin

Answer 53

- Used as an add on when highest dose ACE/ARB is already in place. - only start when eGFR is 25-75 ml/min/1.73m2 at the start of treatment with T2DM - Or urine ACR of at least 22.66 mg/mmol

Answer 54

When the patient is acutely unwell, in dehydration or an acute hospital admission = risk of DKA

Answer 55

- DKA- can be euglycamic- in DKA but blood glucose is normal, therefore need to monitor the patients ketones. - Fournier's gangrene- an unpleasant genital infection- encourage the patient to keep the area dry, clean and to report any itching or pain.

Answer 56

nausea and vomiting, abdominal pain, rapid breathing, excessive thirst, excessive urine production, confusion and “pear-drop” smell on the breath

Answer 57

If either of these side effects occur your SGLT-2 Inhibitor must be stopped immediately and not restarted

Answer 58

CKD, HTN and ACR of 30mg/mmol or less - follow NICE hypertension guidelines

Answer 59

This occurs particularly in CKD stages 4 and 5: - Hyperphosphatemia - Low vitamin D - Hypocalcaemia

Answer 60

Less excretion of phosphate by the kidneys = causes a build up of phosphate in the blood. This can cause pruritus.

Answer 61

Due to less activation of vitamin D- we obtain vitamin D from the sunlight in its inactive version. We convert this to the active version of active Calcitrol by hydroxylation in position 25 in the liver and then position 1 in the kidney. In CKD, this kidney step is impaired = ineffective hydroxylation and activation pf vit D = defective bone mineralisation osteomalacia (bone softening)

Answer 62

This is the main cause- a decrease in vitamin D means less calcium can be absorbed from the GIT and the kidneys. This means less calcium reaches the blood. - Additionally, more phosphate in the blood means an increased sequestering of calcium to calcium phosphate in the bones occurs.

Answer 63

They can leas to issues associated with the parathyroid glands and the metabolism calcium and phosphate is controlled by the parathyroid hormone (PTH). The parathyroid glands detect Low calcium in the blood and then release PTH which stimulates an increase in calcium in the blood by 2 main routes: - Kidney = isn't working in CKD - Bone Therefore, all effort is pushed down the bone route. There is an increased in bone turnover to release Ca2+ from the bone into the bloodstream to counteract hypocalciemia. But this can cause the bone to become damaged: Osteoporosis Osteotis Osteopenis Osteosclerosis and increased fracture risk HOWEVER, this is still insufficient to control the problem and so can lead to secondary hyperparathyroidism = enlargement of parathyroid glands.

Answer 64

- decrease dietary phosphate intake- which is high in foods such as meat, poultry, fish, nuts, beans and a preservative in fast foods. - Prescribe phosphate binders which bind with phosphate in the gut to be removed 1st line: Calcium acetate, can also use Sevlamer, Lanthanum - These should be taken with a meal and dose according to the size of said meal - these currently have adherence issues as they are large tablets, a patient may have to take a few and can have GI side effects e.g. N+V, constipation. Therefore, if phosphate is high, check adherence!

Answer 65

- Vitamin D3 analogue e.g. Calcitrol or Alfracalcidol. CAN'T give Cholecalciferol as it is deactivated and patients with CKD can't activate it - Increased vit D = increased calcium absorption

Answer 66

This is enlargement of PT glands- just requires effective management of phospahate, VitD, calcium - Parathyroidectomy as a last resort - May give Cinacalet - lowers PTH levels by increasing sensitivity of calcium receptors

Answer 67

PTH: >2 x and <4 x the upper limit of normal Phosphate: 1/1.5 mmol/L Calcium: 2.2-2.6 mmol/L

Answer 68

In CKD sated 3+

Answer 69

- Low levels of the hormone erythropoietin- a hormone synthesised by the kidney in response to low oxygen levels in this tissue = stimulates RBC proliferation in the bone marrow = more RBCs to carry oxygen to. tissues and solve hypoxia BUT In CKD, there is a decreased erythropoietin production so there is a decreased in RBC proliferation in the bone marrow and this leads to aneamia. Symtpomd: Fatigue, breathlessness,

Answer 70

Recombinant erythropoietin by iV/SC injection e.g. Epoetin Alfa (Eprex) Epoetin beta Darbopoetin - Side effects (not many): HTN, Eprex can cause red cell aplasia - Or Roxadustat (rarely used)- is a hypoxia inducible factor stabiliser- boosts the gene expression of erythropoiesis to increase haemoglobin production and improve iron response.

Answer 71

100-120 g/L

Answer 72

MUST have sufficient iron stores before giving an Epo injection as Epo stimulates the production of RBCs and iron is necessary to form the haem group to transport the oxygen to tissues. If the patient has low iron, there is decreased epo efficacy. = Therefore, give an iron replacement first

Answer 73

200-500 mcg/L

Answer 74

In earlier stages of CKD, oral iron is sufficient, but often an IV replacement e.g. Ferinject is needed- if serum ferritin is <200mcg/L

Answer 75

Because these patients may be/become a candidate for a kidney transplant, and blood transfusions increase the risk of a graft rejection.

Answer 76

- Renavit- contains all water-soluble vitamins needed Especially in dialysis patients as these vitamins get removed. - Also give dietary advice

Answer 77

- 5 yearly booster for all CKD patients with blood manipulation, particularly haemodialysis (monitored yearly for antibodies) - Doses are doubled at 3x 40mcg doses

Renal Flashcards

(101 cards)