Renal Health Maintenance

Question 1

In renal failure patients preventive strategies usually focus on renal-disease-related issues of:
4

Addressing more general health issues such as:
4

Answer 1

1. Anemia
2. Mineral metabolism
3. HTN
4. Vascular access for dialysis
5. Vaccinations
6. Cancer screening
7. Control of DM
8. Lipid management

Question 2

However, general health issues are postponed in order to prioritize acute issues like:
6

Answer 2

1. Infection
2. Bleeding
3. Malnutrition
4. Volume overload
5. Vascular thrombosis
6. Unstable blood pressure

Question 3

With abnormalities of immune function, patients with kidney disease are more susceptible to what? 2

Answer 3

1. infection

2. malgnancies

Question 4

Medicare patients with CKD and diabetes who progressed to end-stage renal disease, only 50% had their lipid or HbA1c levels tested the year before or after starting dialysis

Renal Preventive strategies include what? 7

Answer 4

1. Infection screening
2. Immunizations
3. Lipid management
4. DM control
5. HTN management
6. Cancer screening
7. Smoking cessation

Question 5

National Kidney Foundation recommends testing all patients with:
5

Answer 5

1. Diabetes
2. HTN
3. Family history of kidney disease
4. Age >60 years
5. Ethnic minorities
   African Americans, Native Americans, Asians

Question 6

How should do accomplish screening (what tests)?

3

Answer 6

It’s recommended that minimal screening include

1. assessment of GFR and
2. proteinuria
3. Microalbuminuria is now an essential component

Question 7

Health Maintenance
Testing for urinary protein
As part or the initial assessment: 4

As part of annual monitoring: 2

As part of routine monitoring for patients receiving nephrotoxic agents

Answer 7

1. New HTN,
2. hematuria, or
3. decreased GFR
4. DM
5. Biopsy proven glomerulonephritis
6. Reflux nephropathy

Question 8

1. Health Maintenance: What should we use together to assess kidney funciton?
2. Also think about testing for what?
3. Also what are you looking for? 3

Answer 8

1. Serum Creatinine and GFR
2. microalbuminuria-Special dipstick and inexpensive
3. • Blood in urine
   • Edema
   • Fatigue

Question 9

1. Why are renal failure pts at high risk for infeciton?
2. Hospitalization for infection are ___ times worse in patients with CKD
3. Other risk
   Bacterial infection where commonly? 5
4. Infections secondary to skin excoriations from what? 3
5. Common microorganisms are what?

6.

Answer 9

3

#1. Renal failure patients have immune insufficiency
#2. 3-4

1. Lungs,
2. intestines,
3. peritoneum,
4. urinary tract
5. skin

1. pruritus,
2. xerosis
3. atrophy of sweat glands

1. Staphylococcus sp. and
2. E-coli

Question 10

Health Maintenance
infection risk: Morbidity/Mortality
1. Sepsis in ESRD has a mortality that is ____- _____ fold higher than general population
2. Pulmonary infections have a _____-fold higher mortality rate

Answer 10

1. 100-300

2. 14-16

Question 11

Infection risk
Screening and Prophylaxis for bacterial infections
7

Answer 11

1. Examine skin
2. Placement of AV fistulas before initiation of hemodialysis
3. Screen for Staphylococcal nasal colonization
4. Consider use of mupirocin ointment
5. Consider applying mupirocin or gentamicin ointment to catheter exits
6. Educate on dental evaluations
7. Endocarditis prophylaxis (2g amoxicillin or 600mg clindamycin) 1 hour before invasive dental procedures

Question 12

What immunizations do we want to make sure they have?

5

Answer 12

1. Influenza
2. Pneumococcus
3. Hep A
4. Hep B
5. Hep C

Question 13

1. Influenza immunization decreases what?
2. Pneumococcus vaccine: what do we have to remember in renal pts?
3. Hep A
4. Hep B
5. Hep C

Answer 13

1. Influenza
   - Decrease chance of hospitalizations
2. Can give titers every 2 years in ESRD when titers decrease below 200μg/l.
   Complication of Arthus-type reaction with frequency

Question 14

1. What is the Hep A vaccination schedule?
2. Before what do we need the Hep B surface antigen testing for (HBsAg)?
3. How are seroconversion rates are affected how as renal disease progresses?
4. Hep B schedule?
5. Hep C will be affected how on pts with dialysis?
6. What do we have to do with pts who have Hep C and are up for a tranplant?

Answer 14

1. Vaccination on a schedule of 0, 1, and 6 months
2. Need surface antigen testing for HBV (HBsAg) and HBV antibody testing before initiation of dialysis
3. Seroconversion rates worsen as renal disease progresses
4. Series of 3 injections 0, 1-2, and 4-6 months

Hepatitis C
Not a vaccine, however good idea to screen for

5. Increase seroconversion with patients on dialysis
6. ESRD patients with Hep C must be treated before transplant d/t rejection

Question 15

Lipid management
Risk of CVD in renal failure is high
1. How often should we check lipid levels?
2. Who should they go see?
3. Meds?

Answer 15

1. Fasting LDL, HDL, triglyceride and total cholesterol levels should be checked once a year for patients with CKD
2. Renal dietician
   Medications
3. Statins (Simvastatin 20mg qday)

Question 16

Blood glucose control

1. Progression of ___ complications with poor glycemic control
2. HbA1c level should be controlled to what levels?
3. HbA1c should be checked how often? 2
4. Metformin should be avoided with creatinine___in men and ___ in women b/c of concern for what?

Answer 16

1. CV
2. less than 7.0
3. every 6 months, unless a change in treatment, then every 3 months until goal is reached
4. > 1.5 men
   1.4 woman
   lactic acidosis

Question 17

Blood Pressure Control
Strict pressure control is a high priority

1. What are commonly used as initial medications? 2
2. Blood pressure goal is ______, the NKF suggest BP be _______?

Tight BP control can halt the progression of renal failure

Answer 17

1. ACE inhibitors or ARBs
2. less than 130/80
   less than 125/75

Question 18

Tobacco cessation
1. Cigarette smoking is associate with what in renal failure?

2. Medication 3

Answer 18

1. more rapid decline in renal failure
2. -Nicotine patch (21mg, 14mg, 7mg)
   -Wellbutrin/Bupropion
   -Chantix
   Black Box Warning

Question 19

Cancer screening

1. Tumors of the Genitourinary tract develop ___ times more frequently than lung, colon, or breast
2. Which cancers specifically? 2
3. When would we screen for cancer?
4. 50 years and older with life
   expectancy of 10 years get annual ?
5. Patients at high risk?

Answer 19

1. 4-5
2. • Renal Cell Carcinoma
   • Prostate cancer
3. If they are on the tranplant list
4. DRE and PSA
5. at age 40 with DRE and PSA

PSA 0.6 or > if Africa American/Family history get annual DRE/PSA
PSA 0.6 at age 45, repeat annually
PSA

Question 20

Cancer screening
Colorectal cancer
1. Colonscopy when?
2. What should we test annually?
3. Every 5 years?

Breast cancer

1. We should screen high risk pts whose life expectancy is what?
2. What age or annual mammograms?
3. What age if they are on the tranplant list?
4. What should all groups do?

Answer 20

Screening similar to general population

1. Colonoscopy at age 50 and repeat every 10 years if the initial was negative
2. Annual fecal occult blood test
3. Flexible sigmoidoscopy every 5 years
4. High risk patients who life expectancy is 5 years
5. Women >50 years old have screening mammograms
6. Women >40 years old on transplant list
7. Both groups do periodic self-exams

Question 21

Cancer screening
Cervical cancer
1. High risk patients with life expectancy of___years or more should be screened.

2. Screening pap smears at age ___ years old
3. ___ ____ testing and ____ ______ in transplant patients
4. ______ ____ test for those on transplant list

Answer 21

1. 5
2. 21
3. • HPV DNA
   • HPV vaccine
4. Yearly Pap

Question 22

Anemia screening
Work-up should include
4

What should our hemoglobin target be?

Answer 22

1. CBC
2. Reticulocyte count
3. Serum ferritin
4. Transferrin saturation (TSAT)

Hemoglobin target should be 11.0-12.0 g/L

Question 23

Bone Metabolism
Work-up should include
3

How should we treat?
2

Answer 23

1. Intact PTH
2. Phosphorus
3. Calcium
4. Dietary phosphorus to 800-1000 mg/day
5. Phosphate binders

Question 24

Screening for urinary protein
Should be part of the initial assessment with patients with what?
6

Answer 24

1. New HTN,
2. hematuria, or
3. decreased GFR
4. Unexplained edema
5. Suspected multi-system disease (SLE, vasculitis)
6. DM

Question 25

Screening for urinary protein As part of annual monitoring of patients with? 3

Answer 25

1. Biopsy proven glomerulonephritis 2. Reflux nephropathy 3. Urological unexplained hematuria or proteinuria

Question 26

First clinical sign of diabetic nephropathy and associated with poor glycemic control and elevated BP is what?

Answer 26

microalbuminuria

Question 27

Medication control: What should we avoid? Be careful with what antibiotics? 4 Also careful with Magnesium containing medicines such as? 2

Answer 27

1. NSAIDS 1. PCN 2. Cephalosporin’s 3. Sulfonamide’s 3. Fluoroquinolones 1. Laxatives 2. antacids

Question 28

``` Referral to Nephrologist GRF 1. Less than 15? 2. 15-29? 3. 30-59? 4. 60-89? ``` Know patients information like? 6

Answer 28

1. less than 15 Immediate referral 2. 15-29 Urgent referral (routine if known to be stable) 3. 30-59 Routine referral 4. 60-89 Referral not required unless high risk issues present 1. Complete medical history 2. Urinary symptoms 3. Medications 4. Exam findings 5. Labs: UA, CBC, CMP, Phosphorus, Lipids, HgA1C, SCr 6. Renal ultrasound

Question 29

Take Home Message Chronic kidney disease is a growing public health problem Outcomes include what?

Answer 29

loss of kidney function and cardiovascular events (which are fatal)

Question 30

Critical assessment from laboratory test for screening is required. What should we screen with? 2

Answer 30

1. SCr to estimate GFR | 2. Microalbuminuria

Question 31

You can help improve outcomes. How? | 2

Answer 31

1. Treat comorbid conditions aggressively to slow the progression 2. Educate the patient

Question 32

Health Maintenance education summary | 9

Answer 32

1. Exercise regularly 2. Don’t overuse OTC painkillers, NSAIDs or nephrotoxic drugs 3. Control weight 4. Get annual physical 5. Healthy diet 6. Know family’s medical history 7. Monitor blood pressure and cholesterol 8. Education about kidney disease 9. Don’t smoke or abuse alcohol