Renal

Question 1

Whats the definition of CKD?

Answer 1

EGFR less than 60ml/min present for greater than or equal to 3 months with or without evidence of kidney damage OR Evidence of kidney damage present for greater than or equal to 3 months as evidenced by: Albuminuria Haematuria after exclusion of urological causes Structural abnormalities (Eg on kidney imaging tests) Pathological abnormalities (Eg on renal biopsy)

Question 2

RF’s for CKD?

Answer 2

DM HTN Established CVD Family Hx of Kidney failure Obesity - BMI greater than or equal to 30 Smoker 60 years and older Hx of acute kidney injury ATSI

Question 3

What comprises a kidney health check?

Answer 3

Blood/urine/BP EGFR calculated from serum creatinine Albumin/Creatinine ratio to check for albuminuria BP maintained consistently below BP goals

Question 4

Who should be offered a Kidney health check?

Answer 4

DM HTN Obesity (BMI over 30) ATSI over 30 years Smoking Est. CVD FHx Kidney Failure

Question 5

You perform a Kidney health check on a patient and find their EGFR Is less than 60. Management?

Answer 5

Repeat eGFR in 7 days. If 3 reduced EGFRS in 3 months then CKD

Question 6

You performa a kidney health check and find a male with ACR of 2.4. Is it elevated?

Answer 6

ACR greater than or equal to 2.5 is considered elevated in a male.

Question 7

You perform a kidney health check on a female. What level ACR is considered elevated?

Answer 7

ACR greater than or equal to 3.5 is considered elevated in a female.

Question 8

How many ACR’s need to be elevated to diagnose as albuminuria?

Answer 8

2 out of 3 albumin/creatinine ratios within 3 months must be elevated to dx.

Question 9

What is considered a normal albumin creatinine ratio for a male and a female

Answer 9

For male: Less than 2.5 For female: Less than 3.5

Question 10

What is considered microalbuminuria?

Answer 10

Male: Greater than 2.5-25 Female: Greater than 3.5 - 35

Question 11

What is considered Macroalbuminuria

Answer 11

Male: Greater than 25 Female: Greater than 35

Question 12

Once CKD stage has been determined from repeat EGFR’s and Albumin/Creatinine ratios - how do you progress?

Answer 12

Investigations to determine cause Combine eGFR stage, albuminuria stage and underlying dx to fully specify CKD. Refer to colour coded action plans.

Question 13

What diet and nutrition goals exist for people with CKD?

Answer 13

• Consume varied diet rich in veg, fruits, wholegrain cereals, lean meat, poultry, fish, eggs, nuts, seeds, legumes and beans and low fat dairy products. - Limit salt to less than 6g/day -Limit intake of foods containing saturated fat and trans fats -Drink water to satisfy thirst -Avoid high calorie sweetened carbonated beverages at all costs!!! - Dietary protein no lower than 0.75/kg body weight/ day - Maintain serum albumin greater than or equal to 35g/L

Question 14

What obesity guidelines exist for people with CKD

Answer 14

Ideal weight should less than or equal to 25 BMI Waist circ - less than 94cm in men (90 cm in asian men) or 80cm in women (incl asian).

Question 15

What physical activity guidelines exist for people with CKD?

Answer 15

Be active on most, pref all days, every week. 150-300 mins moderated moderate intensity activity or 75-150mins of vigorous intensity physical activity, or equivalent combo of mod/vig activities. Do muscle strengthening activities on 2 days a week

Question 16

What smoking advice should someone with CKD be given?

Answer 16

Advise stopping smoking using counselling and if required nicotine replacement threapy or other meds.

Question 17

Alcohol guidelines for CKD?

Answer 17

Limit intake to greater than or equal to 2 standard drinks per day to reduce risk of ETOH- related disease or injury Do not drink more than 4 SD on any single occasion.

Question 18

HTN guidelines for CKD?

Answer 18

Maintain BP less than 130/80 for all people with CKD.

Question 19

Glycaemic control for CKD?

Answer 19

Fasting BGL: 6-8mmol/L Post prandial: 8-10 HBA1c - less than or equal to 7% individualise according to patient context.

Question 20

What goals for albuminuria for a patient with CKD?

Answer 20

AIM for 50% reduction in urine ACR

Question 21

LIpids management for pt with CKD?

Answer 21

Use statin or stain/ezetemibe combo in ppl greater than or equal to 50 years with any stage of CKD OR in ppl less than or equal to 50 with any stage of CKD PLUS one or more of: CAD, Previous ischaemic sttroke, DM, estimated high Absolute CVD risk No target chol level is recommended.

Question 22

Anaemia guidelines for ppl with CKD

Answer 22

HB 110-115 Prior to commecnement of erythropoietin stimulating agent - a trial of iron supplementation - maintaining Ferritin over 100. Once ESA commenced, maintain: Ferritin 200-500 micrograms/L; TSAT 20-30%

Question 23

Potassium guidelines for CKD?

Answer 23

Keep Potassium less than or equal to 6

Question 24

Immunisations in CKD?

Answer 24

INfluenza and Invasive pneumococcal disease vaccination recommended for all people with DM and /or End stage Kidney disease

Question 25

How often should individuals with RF's for CKD undergo a Kidney health check?

Answer 25

Every 1-2 years

Question 26

If an older person has an EGFR of less than 60 is that physiological?

Answer 26

NO. Its predictive of significantly increased risks of adverse clinical outcomes.

Question 27

How does kidney disease impact CV risk?

Answer 27

People with moderate or severe CKD - EGFR lower than 45 OR persistently macroalbuminuric (males over 25mg/mmol, women over 35mg/mmol) ARE AUTOMATICALLY considered HIGH CVD Risk - 15% probability in 5 years. Dont assess them with the CVD risk tool - can underestimate their risk

Question 28

How is early CKD managed?

Answer 28

Steps to reduce cardiovascular disease risk. Lifestyle changes Prescribe ACEI or ARBs to lower blood pressure and slow progress of albuminuria.

Question 29

How would you manage a patient with rapidly declining EGFR and/or acute hypertension, oliguria, haematuria and oedema - ?

Answer 29

(The second set of symptoms should be treated as an acute nephritis) - urgent transfer to emergency department for management.

Question 30

Can be Metformin be used in CKD? What are the precautions?

Answer 30

* Stop during periods of illness * If EGFR between 30 and 60 - dose reduce * If EGFR less than 30 - CONTRAINDICATED

Question 31

SGLT2s in CKD?

Answer 31

Contraindicated below EGFR of 45

Question 32

DPP4 I's (Gliptins) in CKD?

Answer 32

Safe with dose adjustment None needed for linagliptin

Question 33

Sulphonylureas and CKD

Answer 33

Usually no dose reduction needed until GFR of 30 Hypo risk increases as GFR declines Don't use glibenclamide below GFR 60

Question 34

GLP1 RA's and CKD

Answer 34

Contraindicated below GFR of 30

Question 35

What are the BGL targets in CKD with DM

Answer 35

6-8 fasting 8-10 postprandial **HBA1c less than or equal to 7**

Question 36

What impact dose CKD have on DM management

Answer 36

**As EGFR decreases risk of hypos increase with medications (effectively doubles risk of hypos)** May need to dose reduce for certain meds as GFR drops Optimal BGL management s**ignificant reduction in risk** of micro/macroalb and nephropathy.

Question 37

What is the key marker of cardiovascular risk in diabetes

Answer 37

kidney disease

Question 38

What percentage of CKD is caused by DM

Answer 38

40%

Question 39

What impact does the presence of DM have on CKD

Answer 39

Worsens outcomes in all stages of CKD (CV outcomes, dialysis survival, post transplant survival)

Question 40

What lipid management would you institute for a patient **over** the age of fifty with an **EGFR of over 60** and evidence of CKD (structural ab/pathological ab/haematuria or microalb)

Answer 40

Commence statin regardless of lipid level

Question 41

What lipid management would you institute for a patient with EGFR less than 60

Answer 41

Either statin or Statin/ezetemibe regardless of lipid level.

Question 42

If a patient presents with _EGFR of 45 or less_ and/or persistent _MACROalbuminuria_ - what meds do they need immediately

Answer 42

They are in high CV risk therefore would need statin AND Ace inhibitor commenced.

Question 43

If a patient presents under the age of 50 with ANY stage of kidney disease and they have ONE of (coronary disease, previous ischaemic stroke, DM or absolute high CV risk)

Answer 43

Start on Statin If absolute CV risk - they should have ACE as well.

Question 44

What causes anaemia in CKD

Answer 44

Decreased erythropoiten produced by kidney Decreased iron absorption Resistance to the action of Erythropoiesis stimulating agent Usually starts at EGFR if 60 or less and then increases as KFunc declines

Question 46

Approach to Anaemia in Kidney disease

Answer 46

**TARGET HB 110-115** 1. Screen for other causes - B12/folate/iron studies - 2. If Iron deficinecy is identified may need gastroscopy to exclude microscopic GI bleeding 3. Prior to ESA - **trial of supplemental IV iron** **to get Ferritin \> 100 and TSAT \> 20%** 4. Assess TSH and PTH as hypo of both can contribute to anaemia 5. Refer to Nephrologist for ESA commencement eg aranesp WARNING - if Malignancy - don't use ESA or use with great caution

Question 47

How is ESA used?

Answer 47

Prefilled syringes Aiming for slow increase of **HB (10g/L/month**) _Check HB every 2-4 weeks and Iron studies every 4 weeks during replacement phase._ If replace too fast - *_can get seizures and hypertension_* **Target 110-115** (Harm can be caused if over 130 in CKD) During maintenance phase check FBE and haematinics three monthly.

Question 48

Whats the relationship between CKD and bone metabolism?

Answer 48

Changes in metab of calcium, phosphate, PTH tend to occur at GFRs less than 60 As kidney function decreases - phosphate clearance is not as good and so **serum phosphate rises** Combo of HIGH phosphate, low calcium, low vitamin D **stimulate PTH** - which then increases reabsorption and release of mineral from bone INCREASED Fracture risk and CV mortality( vascular calcification as well) CKD BONE MINERAL DISORDER (usually doesnt happen in stages 1 - 3b) - that means above **eGFR of 30**

Question 49

How would you manage CKD Bone mineral disorder

Answer 49

Refer to a nephrologist (at EGFR 30 or macroalb) Ostoeoporosis drugs in these patients can cause HYPOcalcaemia - especially DENOSUMAB so needs nephroogist approval first Counsel patients on symptoms of hypocalcaemia: tingling, twitching, paraesthesiae, confusion.