Ama - Part 4 PM4B > (SYNOPTIC) AKI & CKD > Flashcards

(SYNOPTIC) AKI & CKD Flashcards

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1
Q

What term has ‘acute kidney injury’ replaced?

A

Acute renal failure

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2
Q

How is AKI loosely defined?

A

An abrupt/ acute decline in kidney function
- e.g. glomerular filtration

Hours or days

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3
Q

What is the official definition of AKI?

A

How much serum creatinine has increased from its baseline level over a set period of time

OR

How much urine volume has decreased over a set period of time

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4
Q

How is stage 1 of AKI defined?

A

(1) 1.5-1.9 times baseline SERUM CREATININE

(2) <0.5ml/kg/h of urine for 6-12 hours URINE OUTPUT

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5
Q

How is stage 2 of AKI defined?

A

(1) 2.0-2.9 times baseline SERUM CREATININE

(2) <0.5ml/kg/h of urine for ≥12 hours URINE OUTPUT

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6
Q

How is stage 3 of AKI diagnosed?

A

(1) 3 times baseline SERUM CREATININE
(2) Initiation of renal replacement therapy
(3) Anuria ≤12 hours

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7
Q

How many stages of AKI are there?

A

3 stages

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8
Q

How many classifications of AKI are there?

A

3

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9
Q

What are the classifications of AKI?

A

(1) Pre-renal
(2) Post-renal
(3) Intrinsic

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10
Q

What is pre-renal AKI?

A

Reduced blood flow to the kidney

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11
Q

What causes pre-renal AKI?

A
  • Reduced BP
  • Hypovalaemia (decreased blood volume)
  • Dehydration
  • GI bleed
  • Sepsis
  • Cardiac & liver failure
  • Burns
  • Medications
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12
Q

What is post-renal AKI?

A

Obstruction to outflow from the kidneys

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13
Q

What causes post-renal AKI?

A
  • Benign prostatic hypertrophy (BPH)
  • Prostate cancer
  • Renal calculi
  • Retroperitoneal fibrosis
  • Medications
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14
Q

What is intrinsic AKI?

A

Damage to the functional tissues of the kidney

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15
Q

What causes intrinsic AKI?

A
  • Acute interstitial nephritis
  • Myeloma
  • Rhabdomyolysis
  • Immunological renal disease
  • e.g. vasculitis/ medications
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16
Q

What is the most common classification of AKI?

A

Pre-renal

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17
Q

Why is it important to check blood creatinine levels?

A
  • If rising, could indicate kidneys are not functioning correctly
  • Determine sufficiency of kidney function
  • Determine severity of kidney damage
  • Monitor progression of kidney disease
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18
Q

How can GFR be calculated?

A

(1) eGFR (mL/min/1.73m^2)

2) Creatinine clearance (mL/min

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19
Q

What are disadvantages of using eGFR to estimate GFR?

A
  • Does not account for a patient’s bodyweight
  • Can dramatically underestimate the creatinine clearance in renal failure
  • Not interchangeable between labs
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20
Q

How is creatinine clearance measured?

A

Cockcroft + Gault equation

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21
Q

What is the Cockcroft & Gault equation?

A

CrCl = [F(140-age) x weight] / serum creatinine

F = 1.04 in females and 1.23 in males

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22
Q

What is F in females?

A

1.04

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23
Q

What is F in males?

A

1.23

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24
Q

What is eGFR?

A

Estimated glomerular filtration rate

Calculated in labs

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25
What are the units for eGFR?
mL/min/1.73m2
26
Which method of GFR calculation is more accurate?
Creatinine clearance
27
When must creatinine clearance be calculated, instead of eGFR?
Patients who: (1) Are on DOACs (2) Are on nephrotoxic drugs (3) >75yrs (4) Extremes of muscle mass (5) Drugs that are highly renal excreted (6) Narrow therapeutic index drugs
28
What is the action to be taken when eGFR or creatinine clearance is low?
(1) Establish if AKI or CKD (2) Review all medications - Change dose/ frequency - Stop/ hold (3) Does literature suggest dose changes?
29
What is CKD?
Abnormalities of kidney function for >3 months, with implications for health
30
What are some risk factors for CKD?
- Diabetes - HTN - Kidney disorders - CVD - AKI - Infections (of urinary tract) - HIV/ HepC - Medications (lithium, NSAIDs, etc) - Malignancy - Age - Family Hx of CKD
31
What are some prompts/ findings that will lead to checking for CKD?
(1) Persistent microalbuminuria (2) Persistent proteinuria (3) Persistent haematuria (exc. other sources) (4) Ultrasound/ biopsy (imaging)
32
What are three main functions of the kidney?
(1) Homestasis (2) Hormone function (3) Metabolic function
33
What are some clinical complications of CKD?
- Acidosis - Anaemia - Dyslipidaemia - Fluid overload (less able to excrete water) - Hyperkalaemia - HTN - Mineral & bone disorder - Uraemia ø Raised levels of urea in the blood
34
What is acidosis?
Inability of kidneys to maintain blood pH CKD progresses - kidneys are less able to excrete H+ and reabsorb HCO3-
35
How is acidosis managed?
Long-term oral sodium bicarbonate Sodium bicarbonate 1g TDS
36
When is 1g sodium bicarbonate TDS PO an appropriate treatment?
Acidosis
37
What is the acute treatment of metabolic acidosis?
IV sodium bicarbonate
38
What are some side-effects of acidosis?
Secondary increase in sodium retention Be aware of fluid retention
39
What is renal anaemia?
Quality/ quantity of RBCs is below normal
40
What causes renal anaemia?
(1) Lack of circulating iron | (2) Lack of erythropoietin
41
What effects on the patient increase when renal anaemia is corrected?
- Quality of life - Exercise capacity - Endocrine function - Immune function - Muscle metabolism - Sleep patterns - Cognitive function - Nutrition
42
What effects on the patient decrease when renal anaemia is corrected?
- Bleeding tendency - Transfusions - Depression - Hospitalisation
43
What can cause an iron deficiency?
(1) Increased blood loss (2) Dietary inadequacy - Many patients on a renal diet to restrict phosphate intake (3) Poor iron absorption due to uraemia/ use of phosphate binders (4) Reduced/ impaired erythropoiesis (5) Long-term use of immunosuppressants
44
What is the management of a lack of circulating iron in pre-dialysis patients?
Oral iron for a maximum 3 months IV iron if no improvement from oral iron Ferrous sulfate/ ferrous fumarate
45
What is a side-effect of oral iron?
(1) GI irritation | (2) Black stools
46
What is the management of a lack of circulating iron in dialysis patients?
Give IV iron AFTER a dialysis session Usually Ferinject
47
What is Ferinject?
Branded IV iron
48
What is EPO?
Erythropoietin Naturally occurring hormone produced by the kidneys Stimulates the bone marrow to produce RBCs
49
What is erythropoietin?
Naturally occurring hormone produced by the kidneys Stimulates the bone marrow to produce RBCs
50
What happens to circulating erythropoietin in patients with CKD?
Decreases to low-little
51
What is ESA?
Erythropoietin stimulating agents
52
What is the management of a lack of circulating erythropoietin?
Erythropoietin Stimulating Agents (ESA) Erythropoietin stimulating agents
53
What is Eprex?
Branded EPO Recombinant human EPO Erythropoietin Stimulating Agents (ESA)
54
What is Aranesp?
Novel ESA (erythropoietin stimulating agent) Longer half-life of Eprex
55
What is Mircera?
ESA Longest half-life that provides continuous activity
56
What ESA has the longest half-life?
Mircera > Aranesp > Eprex
57
How is Eprex used as treatment?
Given once weekly SC - Usually self-administered Given IV in dialysis, at the end of the session - Given 3 times weekly
58
How is Aranesp used as treatment?
Given IV in dialysis, at the end of the session Can be given once a week due to longer half-life
59
Why can Aranesp be given only once a week?
Longer half-life than other ESAs
60
What is dyslipidaemia?
Abnormal lipid metabolism in CKD | - Mainly hypertriglyceridaemia
61
What is the treatment of dyslipidaemia in CKD?
Atorvastatin 20mg OD
62
Why does oedema occur in CKD?
Kidneys have a decreased ability to maintain sodium/ fluid balance
63
How is oedema (due to CKD) managed?
- Restrict dietary sodium - Restrict fluid intake - Loop diuretics (in higher doses) IF medication is ineffective -> dialysis
64
What is hyperkalaemia in CKD?
Patients are less able to excrete potassium
65
What are some treatment options for hyperkalaemia?
Non-Pharmacological: - Restrict potassium Pharmacological: - Calcium resonium PO TDS - Calcium gluconate IV (hospital setting only) - Actrapid insulin - Dialysis - last option
66
In CKD hypertension, what is a common treatment option if ARBs and ACEis are unsuitable?
Doxazosin
67
What are the FOUR constituents involved in mineral and bone disorder (MBD)?
(1) Calcitriol (active vitamin D) (2) Calcium (3) Phosphorus (4) Parathyroid hormone
68
How is mineral and bone disorder (MBD) caused in CKD?
(1) Production of calcitriol stopped (2) This causes a reduction of calcium in the blood (3) Causes phosphorous levels in the blood to rise
69
What does low levels of phosphorous in the blood in CKD cause?
(1) Vitamin D deficiency - Calcitriol stops existing (2) Hyperphosphataemia (3) Hypocalcaemia
70
How does hyperphosphataemia cause hypocalcaemia?
Stimulates calcium to be released from the bones
71
What does vitamin D deficiency, hyperphosphataemia, and hypocalcaemia lead to?
Hyperparathyroidism
72
What is the treatment for mineral and bone disorder (MBD)?
(1) Alfacalcidol (activated vitamin D) (2) Phosphate binder (decrease absorption of phosphates from GIT) (3) Cinacalcet/ parathyroidectomy - For parathyroid
73
What is uraemia?
Reduced ability to excrete waste products such as urea and nitrogenous compounds
74
What is the treatment for uraemia in CKD?
Dialysis
75
What is the treatment for acidosis?
Sodium bicarbonate 1g TDS
76
What is the treatment for renal anaemia?
(1) Ferrous sulfate 200mg TDS | (2) SC/ IV ESA
77
What is the treatment for dyslipidaemia?
Atorvastatin 20mg ON
78
What is the treatment for fluid overload?
Diuretics Usually high doses of furosemide BD
79
What is the treatment for oedema?
Diuretics Usually high doses of furosemide BD
80
What is the treatment for hyperkalaemia?
Calcium resonium TDS
81
What is the treatment for hypertension?
Antihypertensive e.g. Ramipril OM or doxazosin OM
82
What is the treatment for vitamin D deficiency?
Alfacalcidol OD
83
What is the treatment for hyperphosphataemia?
Sevelamer TDS with meals
84
What is the treatment for hyperparathyroidism?
Cinacalcet OD
85
Are ACEis/ ARBs used in AKI, CKD, or neither?
CKD - because renoprotective Not AKI - because nephrotoxic
86
Which bloods are used to classify CKD stage?
Compare Albumin-Creatinine Ratio and GFR
87
In CKD, how is the albumin-creatinine ratio classified?
(1) A1 (2) A2 (3) A3
88
In CKD, how is GFR classified?
``` G1 G2 G3a1 G3b G4 G5 ```
89
What is a side-effect of phosphate binders?
Decrease absorption of iron
90
When are thiazide diuretics less effective?
When CrCl is <20mL/min
91
In CKD hypertension, what is the first line treatment?
ACEi or ARB Titrated to maximum dose
92
Why are ARBs/ ACEis used in treatment of CKD?
HTN Renoprotective
93
What effect does high phosphate levels in the blood have on the bones?
Causes calcium to come out of the bones
94
What is alfacalcidol?
Activated vitamin D Given to treat low levels of calcitriol
95
What are some examples of phosphate binders used in treatment of CKD?
(1) Sevelamer | (2) Lanthanum carbonate
96
What is the first line treatment for T2DM in CKD?
Insulin Pioglitazone fine in renal failure BUT contraindicated in heart failure Metformin is contraindicated in CrCl <30mL/min Sulphonylureas require caution due to risk of hypoglycaemia
97
When is pioglitazone contraindicated?
Heart failure
98
When is metformin contraindicated?
CrCl <30mL/min
99
When are SGLT2 inhibitors (flozins) contraindicated?
CrCl <60mL/min
100
What is a side-effect of calcium channel blockers for CKD patients?
Cause/ exacerbate fluid overload (oedema)
101
Which type of painkillers accumulate in renal failure?
- Codeine - Tramadol - Morphine
102
What types of painkiller are available for patients with renal failure requiring pain management stronger than paracetamol?
- Fentanyl patch - Oxycodone - Buprenorphine patch - Tapentadol
Ama - Part 4 PM4B
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