Flashcards in Renal Health maintenance Deck (24)
In renal failure pts preventive strategies usually focus on renal disease related issues of? Other general health issues?
- mineral metabolism
- vascular access for dialysis
- other general health issues:
vaccinations, cancer screening, control of DM, lipid management
What acute issues take priority over general health issues?
- volume overload
- vascular thrombosis
- unstable BP
- with abnorm of immune fxn, pts with kidney disease are more susceptible to infection and malignancies
Preventive strategies include?
- infection screening
- lipid management
- DM control
- HTN management
- cancer screening
- smoking cessation
Who should be screened for kidney disease according to the National Kidney Foundation?
family hx of kidney disease
older than 60
ethinic minorities: african americans, native americans, asians
- recommended that minimal screening include assessment of GFR (serum creatinine included) and proteinuria
- Microalbuminuria is now an essential component
Who should be tested for urinary protein?
- as part of the initial assessment: new HTN, hematuria, or decreased GFR, DM
- as part of annual monitoring: bx proven GN, reflux nephropathy
-as part of routine monitoring for pts receiving nephrotoxic agents
What are the general signs you are looking for in a pt with suspected renal disease?
- blood in urine
Why is there such a high infection risk in renal pts? Where do this infections occur?
- renal failure pts have immune insufficiency
- hospitalization for infection are 3-4x worse in pts with CKD
- other risks: bacterial infection - lungs, intestines, peritoneum, urinary tract, and skin, infections secondary to skin excoriations from pruritus, xerosis, and atrophy of sweat glands
- common microorganisms are staph and E. coli
- klebseilla is not uncommon in pts with CKD who are hosp for pulm infections
Morbidity/mortality in renal failure pts because of infection?
- sepsis in ESRD has mortality that is 100-300 fold higher than general pop
- infective endocarditis can be fatal
- UTI's in anuria pts: pyocystitis can lead to sepsis
- pulmonary infections: have 14-16 fold higher mortality rate
Screening and prophylaxis for bacterial infections in renal failure pts?
- examin skin
- placement of AV fistulas before initiation of hemodialysis
- screen for staph nasal colonization
- consider use of mupirocin or gentamicin ointment to catheter exits
- educate on dental evals
- endocarditis prophylaxis (2 g amoxicillin or 600 mg clindamycin) 1 hr before invasive dental procedures
What immunizations should renal failure pts have?
- influenza: decrease chance of hospitalizations
- pneumococcus: given to elderly and immunocompromised
revaccination 5 years after initial vaccination
can give titers every 2 years in ESRD when titers decrease below 200 micrograms/L
- complication of arthrus-type reaction with frequency
- hep A (0, 1, 6 months)
- hep B (need surface Ag testing for HBV, and testing done before intiation of dialysis, seroconversion rates worsen as renal disease progresses, series of 3 injections 0,1-2, and 4-6 months
- hep C: not a vaccine, still good to screen, increase seroconversion with pts on dialysis
ESRD pts with Hep C must be tx before transplant d/t rejection
Why is lipid management so impt in renal disease? What should be checked and how often?
- risk of CVD is high
- fasting LDL, HDL, TG and total cholesterol levels should be checked once a year for pts with CKD
- should be set up with renal dietician
- meds: statins (simvastatin 20 mg qday)
Good glucose control?
- progression of CV complications with poor glycemic control
- HbA1C level should be controlled to belwo 7
- HbA1C should be checked every 6 months, unless change in tx, then every 3 months until goal is reached
- metformin should be avoided with creatinine above 1.5 in men nad 1.4 in women because of lactic acidosis
Blood pressure control?
- strict pressure control high priority
- ACEI or ARBs are commonly used as initial meds
- BP goal is less than 130/80, the NKF suggest BP be less than 125/75
- tight BP control can halt progression of renal failure
Why is tobacco cessation so impt? meds?
- cigarette smoking is assoc with more rapid decline in renal failure
- pt should be encouraged to stop cause of CV risk
nicotine patch (21 mg, 14 mg, 7 mg), wellbutrin/bupropion, chantix (BBW: risk of suicide)
Cancer screening in renal failure pts?
- tumors of GU tract develop 4-5x more frequently than lung, colon, or breast
- prostate cancer: 50 years and older with life expectancy of 10 yyears get annual DRE and PSA
- pts at high risk at 40 with DRE and PSA (only if on transplant list) get screened
- colorectal screening: colonoscopy at age 50 and repeat every 10 years if initial was negative, annual fecal occult blood test, flexible sigmoidoscopy every 5 years
- breast cancer: high risk pts whose life expectancy is 5 years
screening mammograms for women older than 50, and women older than 40 that are on the transplant list
both groups do SBEs
- cervical cancer: high risk pts with life expectancy of 5 years or more, screening pap smears at age 21, HPV DNA testing and HPV vaccine in transplant pts, yearly pap test for those on transplant list
What should an screening for anemia include?
- retic count
- serum ferritin
- transferrin saturation (TSAT)
- hemoglobin target should be 11-12 g/L
What should a workup of bone metabolism include?
- intact PTH
should limit dietary phosphorus to 800-1000 mg a day, use phosphate binders (inhibit absorbtion in GI tract)
When should screening for urinary protein be done in an initial assessment?
- in new HTN, hematuria, or decreased GFR
- unexplained edema
- suspected multi-system disease (SLE, vasculitis), DM
Urinary protein should be a part of annual monitoring in pts with?
- bx proven GN
- reflux nephropathy
- urological unexplained hematuria or proteinuri
What is microalbuminuria a sign of and what is it assoc with?
- first sign of diabetic nephropathy and assoc with poor glycemic control and elevated BP
What meds should you avoid or be cautious with in renal disease?
- avoid NSAIDs
- abx be careful:
levoquin, cipro, gemifloxacin
- magnesium containing meds: laxatives and antacids (tums)
At what GFR should you refer to nephro?
- under 15: immediate referral
- 15-29: urgent referral (routine if known to be stable)
- 30-59: routine referral
- 60-89: referral not reqd unless high risk issues present
Good pt information to know?
- complete medical hx
- urinary sxs (obstructed)
- meds: NSAIDs, nephrotoxic meds
- exam findings
- labs: UA,CBC, CMP, phosphorus, lipids, HgA1C, SCr
- renal U/S