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CCFP 3 > Renal Failure > Flashcards

Renal Failure Flashcards

1
Q

Definition of CKD

A

CKD = eGFR <60 for >3mo

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2
Q

‘Triple whammy’ of meds causing AKI?

A

Ace Inhibitors/ARBs
NSAIDS
Diuretics

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3
Q

Pre renal causes of AKI

A

NSAIDs
Ace/ARBs
Hypovolemia (Hemorrhage, Gastrointestinal/Skin/Renal Losses)
Low Cardiac Output (Heart Failure, AAA, Obstructing Masses)
Liver Failure (Cirrhosis)
Sepsis
Third Spacing
Renal Artery Stenosis
Calcineurin Inhibitors
Hypercalcemia

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4
Q

Sx of uremia

A

Confusion
Seizures
Asterixis
Myoclonus
Peripheral Neuropathy
Hyporeflexia
Pericardial Friction Rub
Shortness of Breath
Fluid Overload
Pleuritic Chest Pains
Headache
Lethargy/Somnolence
Nausea/Vomiting
Loss of Appetite/Taste
Muscle Cramps
Weakness

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5
Q

Meds to hold in AKI

A

Sulfonylureas
Ace Inhibitors
Angiotensin Receptor Blockers
Diuretics
Biguanides
NSAIDs
SGLT-2 Inhibitors

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6
Q

Complications of renal failure

A

Uremia
Hyperkalemia
Hypercalcemia
Hypocalcemia
Hyperphosphatemia
Metabolic Acidosis
Hypertension
Osteodystrophy
Gout/Pseudogout
Anemia
Bleeding Disorders
Infections
Sleep Disturbances
Sexual Dysfunction
Death

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7
Q

RF for CKD

A

DM, HTN, vascular dz (renal artery stenosis), glomerular dz (autoimmune, malignant, infection, renally excreted drugs, neoplasia), tubulointerstitial dx (UTI, stones, obstruction), polycystic kidney dz, age, increased BMI, smoking, CVD

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8
Q

Factors that affect GFR

A

Extreme wts
Muscle mass
High/ low protein diet
Meds affecting Cr excretion
Ilness
Pregnancy
Paralysis
Amputation

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9
Q

Workup for CKD

A

BP
BW: Cr, BUN, ex lytes, BG, CBC, ferritin, albumin, serum protein electrophoresis + Bence Jones protein
UA
Albumin/ Cr ratio
Kidney US (stones, mass, cyst, hydronephrosis)

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10
Q

Management of CKD

A

Lifestyle: smoking cessation, reduce alcohol, wt control, exercise, hydration
Diet: 0.8g/kg/d protein K, Ph, Ca, Na
Meds: ACEi/ARB if proteinuria
Unwell plan: stop ACEi + diuretics, seek r/a

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11
Q

Drugs that need consideration in CKD

A

ACEi
ARBs
Metformin
Allopurinol
Abx
Nephrotoxins: NSAIDs, COX-2, aminoglycosides, radio contrast, alfalfa, dandelion, aristolchic
LMWH
DOACs

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12
Q

When to refer in CKD

A

Progressive renal failure (eGFR <45 or decline >5 within 6mo)
Glomerulonephritis or renal vasculitis
Resistant or secondary HTN
Complications of renal dz (anemia, hyperparathyroidism, EPO deficiency)
Bone disease
Young pt

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13
Q

Rx of volume overload

A

Restrict dietary sodium (eg. <2g/d)
Diuretic therapy (usually daily loop diuretic, eg. furosemide 80mg)

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14
Q

Rx for hyperphosphatemia

A

Restrict dietary phosphate (<0.8g/d)
Phospate binders (eg. Sevelamer 800mg PO TID meals)

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15
Q

Rx for Metabolic acidosis (low serum bicarbonate)

A

Sodium Bicarbonate (NaHCO3) 1000 mg BID to maintain normal serum bicarbonate (>20-22mEq/L)

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16
Q

Rx for Hyperparathyroidism in CKD

A

Treat hyperphosphatemia, vitamin D deficiency
If >150-200pg/mL, consider calcitriol or vitamin D analog
Do not use calcitriol if serum phosphate or corrected serum total calcium is elevated
Adjust dose to maintain PTH <150pg/mL

17
Q

Rx for HTN in CKD

A

Sodium restriction
ACEi/ARB
If edema, loop diuretic +/- thiazide diuretic
If no edema, diuretic or CCB (consider non-DHP CCB in proteinuria)
Resistent hypertension, consider spirinolactone

18
Q

Ix + rx for anemia in CKD

A

Work-up: CBC, retic, iron studies, ferritin, B12/folate, r/o GI loss
Replete iron stores if TSAT ≤30% and Ferritin ≤500ng/mL
eg. Venofer 300 mg IV q 2 weeks x 3 doses
If Hb<90 and iron replete or treated for iron deficiency consider Erythropoiesis-stimulating agents (ESA)
Aranesp 0.45 mcg/kg/week
Adverse: CVA, AVF clotting hypertension, cancer recurrence
Target Hb 100-115
Monitor Hb monthly until stable, Fe q3 months

19
Q

Complications of ESRD

A

Pericarditis/pleuritis
Uremic encephalopathy/neuropathy (confusion, asterixis, myoclonus, wrist/footdrop, seizures)
Uremic bleeding
Fluid overload refractory to diuretics (CHF/LVH)
Hypertension poorly responsive to medications
Metabolic disturbances
Hyperkalemia
Hyponatremia
Hyper/hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Malnutrition
AKI
Drug toxicity
Infection
Hypothyroidism

20
Q

Management of hyperkalemia

A

Tx with IV calcium gluconate 1000mg over 2-3 mins, glucose + insulin, loop diuretics, fluids + D/C drugs that increase K
Insulin 10 units + ½ amp D50 IV

21
Q

RF for kidney stones

A

dehydration, meat, high sodium, chemo, acetazolamide, gout, hyperparathyroidism, hyperthyroidism, DM, bowel/ pancreatic dz

22
Q

Sx by location of kidney stones

A

Kidney: flank pain, hematuria
Proximal ureter: renal colic, flank pain, upper abdo pain
middle section ureter: renal colic, flank pain, anterior abdo pain
Distal ureter: renal colic, urinary frequency, dysuria

23
Q

Ix for kidney stones

A

UA + CS
Lytes, CBC, calcium, albumin, uric acid, CRP
If high calcium = test PTH + vit D
KUB XR + US

24
Q

Rx for kidney stones

A

Refer to nephro if urosepsis, anuria, renal failure, obstructed kidney, obstructed pyelo
Ureteral stone <5mm = expectant management, FU US 6mo + q1yr
Ureteral stone >5mm = refer to uro
alpha blockers
extracorporeal shock wave lithotripsy
percutaneous nephrolithotomy
ureterorenoscopy
NSAIDs (CI if using extracorporeal shock wave lithotripsy)
Lifestyle:
Increase fluid intake of pH neutral beverage
Reduce salt intake
Reduce animal protein
Moderate calcium intake
Moderate high oxalate foods (spinach, strawberry, nuts, rhubarb, dark choc, brewed tea)
Increase citrate rich foods (orange juice)
Recurrent:
24hr urine collection for volume, pH, calcium, Cr, a, Ph, oxalate, citrate, uric acid + cystine levels

25
Q

Nephrotic syndrome features vs
Nephritic syndrome features

A

Nephrotic syndrome features: Proteinruria (>3.5g/d), Edema, Hypoalbuminemia, Hyperlipidemia

Nephritic syndrome features: Hematuria, RBC casts, Hypertension, Proteinuria (<3.5g/d)

26
Q

When to screen for CKD

A

HTN, CVD, DM, First nations, FDR w/ CKD

27
Q

How to screen + diagnose CKD

A

eGFR + urine ACR, then if eGFR <60 or urine ACR >3, repeat in 3mo, then dx if eGFR is still <60 and/ or ACR >3

28
Q

When to refer to renal

A

eGFR <30, ACR >60, eGFR <45 w/ rapid decline >5 in 6mo, BP not at target, abnormal lytes, hematuria, 5 yr KFRE >5%

29
Q

What is KFRE?

A

Kidney failure risk - if >5% over 5 yrs, need to refer
If not referring, monitor q6mo (eGFR, ACR, lytes, UA)

30
Q

CKD management

A

lifestyle modification, smoking cessation, statins if at risk, avoid nephrotoxins, adjust doses when sick, reduce BP, ACEi

31
Q

Which meds to reduce doses when dehydrated in CKD

A

SADMANS sulfonylureas, ACEi, diuretics, metformin, ARBs, NSAIDs, SGLT2i

32
Q

SGLT2 inhibitors; when are they CI, SE and impact on other organ systems

A

CI in T1DM, can drop eGFR, can lead to normoglycemic DKA, yeast vaginitis/ balinitis is common

33
Q

What is AKI spectrum?

A

Risk (eGFR >75% normal) - Injury (eGFR 50% normal) - Failure (eGFR 25% normal) - Loss (x4wk)- End stage (x3mo) (RIFLE)

34
Q

AKD vs AKI

A

AKD is when GFR is not decreasing

35
Q

What signs would you monitor in a pt with ?Mg toxicity?

A

Deep tendon reflexes, RR, BP

36
Q

Rx for Mg toxicity

A

10% calcium gluconate IV

37
Q

Rx for hypercalcemia

A

IVF, bisphosphonates, calcitonin, steroids, denosumab, dialysis

CCFP 3 (67 decks)

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