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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Specialconsiderations
Contrast-inducedAKI
ThisisdefinedasAKIoccurringwithin48hoursofapatientreceivingiodinatedcontrast. As such, the following may be considered when managing a patient at high risk of contrast-inducedAKI:
Discusspatientsathighriskofcontrast-inducedAKIwithanephrologisttoassessthebenefitsand risksofproposedimaging,butdonotdelayemergencyimaging Unenhancedoralternativescanningtechniquesinpatientswithriskfactors Considerwithholdingnephrotoxicmedicationspreandpostscan Encourageoralhydrationpreandpostscan Volume expansionwith IV normal saline or isotonic sodium bicarbonate at 1mL/kg/hour for 12
hourspreandpostprocedureifthepatientishighrisk,e.g.eGFR<30mL/min/1.73m2,theyhavea renaltransplant,alargevolumeofcontrastisduetobeused,orthecontrastwillbeinjectedintra­arteriallywithfirst-passrenalexposure.
Furtherreading
1.HertzbergD, RydénL,Pickering JW,etal. (2017). Acutekidneyinjury—an overview ofdiagnostic
methodsandclinicalmanagement.ClinKidneyJ.10:323–31.
2.Steddon S,AshmanN,ChesserA,etal.(2014).Acutekidneyinjury(AKI).In:OxfordHandbookof
Nephrologyand Hypertension,2nded(pp. 87–190).Oxford:OxfordUniversity Press. Availableat:
https://doi.org/10.1093/med/9780199651610.003.0002
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Chapter47
Chronickidneydisease
Guidelines: NICE NG203 (Chronic kidney disease: assessment and
management): https://www.nice.org.uk/guidance/ng203 UK Kidney Association (Anaemia of chronic kidney disease):
https://ukkidney.org/sites/renal.org/files/Updated-130220-Anaemia-of­Chronic-Kidney-Disease-1-1.pdf
UK Kidney Association (Sodium-glucose co-transporter-2 (SGLT-2) inhibition in adults with kidney disease):
https://ukkidney.org/sites/renal.org/files/UKKA%20guideline_SGLT2i%20in%20adults%20with%20kidney%20disease%20v1%2018.10.21.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Chronic kidney disease (CKD) refers to an abnormality of renal function or structure, present for >3 months. The underlying cause of CKD should be established to ensure optimalmanagement.
Terminology
eGFR: this refers to estimated glomerular filtration rate, which is the standardized result
calculatedbylaboratorieswhenaserumcreatininelevelisrequested GFR category: this refers to the internationally approved GFR categories of CKD which are explainedinFig.47.1.
Diagnosis
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History/diagnosticcriteria
The causes of CKD are broad and the symptoms may be non-specific. Diagnoses that increasetheriskofCKDinclude:
Diabetesmellitus(DM) Hypertension PreviousAKIinthelast3years Cardiovasculardisease Structuralrenaltractdisease,recurrentrenalcalculi,orprostatichypertrophy Multisystemdiseasewithpotentialforrenalinvolvement,e.g.systemiclupuserythematosus Gout Familyhistoryofend-stagekidney disease(GFRcategoryG5)or hereditarykidney disease,e.g. polycystickidneydisease Incidentalfindingofhaematuriaorproteinuria.
AllpatientswiththeseriskfactorsshouldbetestedforCKDatpresentation.
Patients on nephrotoxic drugs (e.g.ciclosporin, tacrolimus, lithium, NSAIDs) should havetheireGFRmonitoredatleastannually.
CKDisclassifiedaccordingtoeGFRandACR(Fig.47.1):
↑ACRand↓eGFRareindependentlyassociatedwithadverseoutcomes Interpret the eGFR with caution at extremes of muscle mass (↓ muscle mass leads to overestimationoftheeGFRandtheconverseistrueof↑musclemass) PatientswithDM,CKD,orsuspicionofCKDshouldbemonitoredforproteinuria UseurineACRtodetectproteinuria(>3mg/mmol):
IfinitialACRis3–70mg/mmol,confirmwithanearlymorningsample IfinitialACRis>70mg/mmol,arepeatsampleisnotrequired
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Fig.47.1ClassificationofCKDandriskofadverseoutcome.
ReprintedwithpermissionfromKidneyDisease:ImprovingGlobalOutcomes(KDIGO)CKDWork Group.KDIGO2012ClinicalPracticeGuidelinefortheEvaluationandManagementofChronicKidney Disease.Kidneyinter.,Suppl.2013;3:1–150.
Examination
Thepatientmayhaveexaminationfindingsrelatedto theunderlyingcause,signsrelated tomanagement,orstigmataofcomplicationsofCKD:
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Signsrelatedtotheunderlyingcause:
Polycystic kidney disease (MR, bilateral palpable flank masses with hepatomegaly if liver cysts) Obstructiveuropathy(palpable,distendedbladder)
Signsrelatedtomanagement:
Cushingoidfromsteroids Peritonealdialysiscatheter Fistulaorvascularaccessrouteforhaemodialysis Parathyroidectomyscar;abdominalscarorpalpabletransplantedkidneyfromtransplant
Signsrelatedtocomplications:
Anaemia:pallor,angularstomatitis,koilonychia Fluidstatus:signsofperipheralorpulmonaryoedema Uraemia: excoriations, Lindsay’s nails (proximal half of the nail appears white while the distalhalfappearsreddishbrownwithasharpdemarcationbetweenthehalves) Cachexiaormalnutrition.
Investigations
Bedside
Bloodpressure Urine(urinalysis,MC&S,ACR,BenceJonesprotein). Ifproteinuriaisfoundincidentallyonurinalysis,calculateeGFRandcheckurineACR:
Persistent microscopic haematuria (1+ or greater) should raise a suspicion ofurinary tract malignancyandbefollowedupannually.
Bloods
SeeTable47.1.
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Table47.1RationaleforbloodsfordiagnosisandassessmentofCKD
Test Rationale
FBC AnaemiaiscommoninCKD.Screen6–12-monthly
Ironstudiesandhaematinics;testsforhaemolysis; serumelectrophoresisandfreelightchains
Importantinthedifferentiationofthecauseofanaemia AnaemiashouldbeinvestigatedifHb<110g/L,orifthe patientissymptomatic CKDshouldalwaysbeconsideredasapossiblecauseof anaemiawheneGFR<60mL/min/1.73m
2
Creatinineandurea Fordiagnosisandmonitoring
LFT ALPmaybe↑inrenalosteodystrophy
HbA1c DiabetesisariskfactorforCKD
Calcium,phosphate,vitaminD,PTH,andcalcidiol IdentifiesmineraldisturbancesandvitaminDandPTH
derangement
C-reactiveprotein Assessesforinflammation
ANA,ANCA,anti-glomerularbasementmembrane, complement
AssessesforautoimmunecausesofCKD
Imaging
Considerrenalultrasoundif:
Symptomsofobstructiveuropathy Macroscopic,orpersistentmicroscopic,haematuria AcceleratedprogressionofCKD:
DecreaseineGFRof≥25%andachangeinGFRcategorywithin12monthsOR SustaineddecreaseineGFRof15mL/min/1.73m2peryear
Familyhistoryofpolycystickidneydiseaseandaged>20years eGFR<30mL/min/1.73m
2
Renalbiopsyisconsiderednecessary:
Progressivedisease,nephroticsyndrome,systemicdisease,AKInotimproving.
Management
Patienteducation
Patients should be prepared for the possibilityof needingrenal replacement therapy in progressiveCKD.
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Lifestyleandsimpleinterventions
Exercise Achieveahealthyweight Stopsmoking All patients should receive dietaryadvice aboutpotassium, phosphate, salt,and calorie intake. Patients with GFR category G4–5 should be seen by a specialist renal dietician to receive individualizedinformationandsupportondietaryphosphateandproteinmanagement.
Pharmacologicalmanagement
General
ReviewpotentiallynephrotoxicmedicationandavoidNSAIDs Statintherapy, e.g.atorvastatin20mgOD, andlow-dose aspirin(75mgOD) inall patientswith CKD Offer annual influenza and 23-valent polysaccharide pneumococcal vaccination with a booster
every5years
1
GiveavitaminDsupplement(cholecalciferol)ifdeficient.
Bloodpressurecontrol
UseanACEinhibitor,ARB,ordirectrenininhibitortocontrolbloodpressureinpatientswithany ofthefollowing:
CKD,hypertension,andACR≥30mg/mmol CKD,diabetes,andACR≥3mg/mmol CKDandACR≥70mg/mmol
Bloodpressuretargets:
<140mmHgsystolic,<90mmHgdiastolic
IfdiabeticORACR≥70mg/mmol,usetarget<130mmHgsystolic,<80mmHgdiastolic If patientsdo notfallintoanyof thesecategories, followstandard hypertensionguidelines (see
Chapter6)
Monitor eGFR and potassium before starting, 1–2 weeks after starting, and after each dose increase Donotusethesemedicationsifpre-treatmentpotassium>5mmol/L Stopmedicationsifpotassium>6mmol/L.
Electrolyteimbalances
Hyperphosphataemia in patients with GFR category G4–5 should be managed with phosphate binderssuchascalciumacetate,1tabletwitheverymeal ConsidersodiumbicarbonateifGFRcategoryG4–5andserumbicarbonate<20mmol/L.
SGLT2inhibitors
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StartanSGLT2inhibitor,e.g.dapagliflozin10mg,ifACR≥25 Ifcommenced,patientsshouldbemonitoredforhypovolemiaandworseningofeGFR Advisethatthemedicationshouldbeheldifthepatientfeelsunwell,becomesdehydrated,orhas reducedfoodintake.ThisisduetotheriskofeuglycaemicDKA.
Psychosocialconsiderations
Anxiety,depression,andfatiguearecommon.
Complications
Acute-on-chronickidneydisease Cardiovasculardisease:
↑mortality associatedwithworsening renalfunctionis largelysecondarytocardiovascular
disease Anaemia:
If eGFRis <60mL/min/1.73m2, CKD maybethe cause but othercauses of anaemia should
alsobeconsidered
Treat iron deficiency; oral iron supplements are usually sufficient if the patient is not on
dialysis
Offererythropoietinstimulatingagentsifthepatientislikelytobenefitintermsofqualityof
lifeandphysicalfunction
Avoidbloodtransfusion,particularlyiftransplantationisatreatmentoption,duetotheriskof
allosensitization Renalmineralandbonedisorder:
Disturbance in vitamin D, calcium, PTH, and phosphate metabolism due to dysregulated
homeostasis Peripheralneuropathyandmyopathy(duetouraemia) Malignancy:
The exact cause is unknown, but end-stage kidney disease patients may have an ↑ risk of
malignancy,particularlyrenalandthyroid Renalreplacementtherapy:
Dialysisortransplantation.
Monitoringandfollow-up
MonitorCKDwitheGFRandACRatleastannually:
Monitormultipletimesayearifhighriskorveryhighrisk(Fig.47.1) ScreenforanaemiaatleastannuallyinpatientswithGFRcategoryG3and atleastbiannuallyin patientswithGFRcategoryG4–5notondialysis
Monitor serum potassium 2–4 times a year.2 Also check before starting an ACE inhibitor, 1–2 weekslaterandaftereverydosechange Monitorcalcium,phosphate,ALP,PTH,and25-hydroxyvitaminD(calcidiol)levelsifGFRG4–5.
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Specialistrenalreferral
ReferifCKDwith:
eGFRreduction≥25%causingachangeineGFRcategoryinthelastyear eGFRfalling≥15mL/min/1.73m2peryear
ACR≥70mg/mmol(unlesssecondarytodiabetes) ACR≥30mg/mmolwithhaematuria Resistanthypertension(poorlycontrolledonatleastfourantihypertensivemedications) Rareorgeneticcause Suspectedrenalarterystenosis.
Specialisturologyreferral
ReferifCKDwith:
Renaloutflowobstruction
Specialconsiderations
Pregnancyandbreastfeeding
Many drugs may not be suitable for use in pregnancy and breastfeeding, while others requiredoseadjustment.SeeTable47.2.
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Table47.2SummaryofsafetyofdrugsusedinCKDinpregnancyandbreastfeeding
Drug Safeinpregnancy? Safeinbreastfeeding?
Angiotensin-2receptor antagonistsandACE inhibitors
Avoidinpregnancyunlessessential Informationislimited;notrecommendedin
breastfeeding
SGLT2inhibitors Avoid Avoid
Statins Avoidinpregnancy(discontinue3
monthspriortoattemptingto conceive)
Manufactureradvisestoavoid;noinformation available
Antiplateletmedication (aspirin)
Usedoseswithcautionduringthird trimester Avoidanalgesicdosesifpossiblein lastfewweeks
Avoid;possibleriskofReye’ssyndrome
VitaminDsupplement (cholecalciferol)
Highdosesteratogenicinanimalsbut therapeuticdosesunlikelytobe harmful
Cautionwithhighdoses;maycause hypercalcaemiaininfant—monitorserum calciumconcentration
Vaccinations Inactivatedvaccinesnotknowntobe
harmful
Inactivatedvaccinesnotknowntobeharmful
Hepaticandrenalimpairment
Be aware thatmost drugs willneed dose adjustmentinaccordancewiththe severityof impairment.TheRenalDrugHandbook/Databaseisakeyresourceforsafeprescribingin CKD;mosthospitalswillhavethis,usuallyviathepharmacyortherenalteam.
Furtherreading
1. NICE Clinical Knowledge Summaries (2021). Chronic kidney disease: background. Available at:
https://cks.nice.org.uk/chronic-kidney-disease#!background
2.TheRenalDrugDatabase.Availableat:https://renaldrugdatabase.com
3.KDIGO(2012).2012ClinicalPracticeGuidelinefortheevaluationandmanagementofchronickidney disease.Availableat:https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf
1NICEClinicalKnowledgeSummaries.Immunizations– pneumococcal:summary. 2016.Available at:
https://cks.nice.org.uk/immunizations-pneumococcal#!topicSummary
2UKKidneyAssociation.Clinicalpracticeguidelines:treatmentofacutehyperkalaemiainadults.2020.
https://t.me/med1917
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