Podcast
Questions and Answers
A 58-year-old female patient with a history of type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia presents with polyuria, polydipsia, and fatigue. Her fasting blood sugar is 140 mg/dL (7.8 mmol/L), and HbA1c is 10.2%. Renal function tests reveal an eGFR of 46 mL/min/1.73 m². Urinalysis shows 2+ protein. Considering her comorbidities and lab results, which underlying pathophysiological mechanism is most likely contributing to her renal dysfunction?
A 58-year-old female patient with a history of type 2 diabetes mellitus (T2DM), hypertension, and hyperlipidemia presents with polyuria, polydipsia, and fatigue. Her fasting blood sugar is 140 mg/dL (7.8 mmol/L), and HbA1c is 10.2%. Renal function tests reveal an eGFR of 46 mL/min/1.73 m². Urinalysis shows 2+ protein. Considering her comorbidities and lab results, which underlying pathophysiological mechanism is most likely contributing to her renal dysfunction?
- Renal artery stenosis causing ischemic nephropathy.
- Acute tubular necrosis due to nephrotoxic medication use.
- Tubulointerstitial nephritis induced by hyperlipidemia.
- Glomerular hyperfiltration secondary to chronic hyperglycemia. (correct)
In the presented case of Mrs. Farah, which combination of laboratory findings most strongly suggests the presence of metabolic acidosis with partial respiratory compensation?
In the presented case of Mrs. Farah, which combination of laboratory findings most strongly suggests the presence of metabolic acidosis with partial respiratory compensation?
- pH 7.30, PaCO2 5.0 kPa, Bicarbonate 20 mmol/L
- pH 7.42, PaCO2 6.2 kPa, Bicarbonate 26 mmol/L
- pH 7.38, PaCO2 5.5 kPa, Bicarbonate 23 mmol/L
- pH 7.28, PaCO2 3.8 kPa, Bicarbonate 18 mmol/L (correct)
Mrs. Farah's renal ultrasound report indicates 'increased cortical echogenicity and poorly defined corticomedullary differentiation'. How do these findings correlate with the diagnosis of chronic kidney disease (CKD)?
Mrs. Farah's renal ultrasound report indicates 'increased cortical echogenicity and poorly defined corticomedullary differentiation'. How do these findings correlate with the diagnosis of chronic kidney disease (CKD)?
- They are consistent with chronic parenchymal disease and renal atrophy seen in CKD. (correct)
- They suggest acute glomerulonephritis with reversible inflammatory changes.
- They point towards polycystic kidney disease as the primary etiology of renal dysfunction.
- They are indicative of acute kidney injury superimposed on normal kidneys.
Considering Mrs. Farah's CKD and associated metabolic acidosis, which of the following long-term consequences is LEAST likely to be directly attributed to uncorrected metabolic acidosis?
Considering Mrs. Farah's CKD and associated metabolic acidosis, which of the following long-term consequences is LEAST likely to be directly attributed to uncorrected metabolic acidosis?
Mrs. Farah's lab results show elevated parathyroid hormone (PTH) and low Vitamin D levels. Which of the following best describes the underlying mechanism of secondary hyperparathyroidism in CKD-Mineral and Bone Disorder (MBD)?
Mrs. Farah's lab results show elevated parathyroid hormone (PTH) and low Vitamin D levels. Which of the following best describes the underlying mechanism of secondary hyperparathyroidism in CKD-Mineral and Bone Disorder (MBD)?
Mrs. Farah is currently prescribed metformin 1000mg twice daily. Considering her eGFR of 46 mL/min/1.73 m², how should her metformin prescription be adjusted based on current guidelines?
Mrs. Farah is currently prescribed metformin 1000mg twice daily. Considering her eGFR of 46 mL/min/1.73 m², how should her metformin prescription be adjusted based on current guidelines?
Which of the following best explains why SGLT-2 inhibitors are increasingly recommended in patients with type 2 diabetes and CKD, like Mrs. Farah, beyond their glucose-lowering effects?
Which of the following best explains why SGLT-2 inhibitors are increasingly recommended in patients with type 2 diabetes and CKD, like Mrs. Farah, beyond their glucose-lowering effects?
In the context of managing Mrs. Farah's hypertension and CKD, which of the following statements accurately reflects the guideline recommendations for blood pressure targets and RAAS blockade?
In the context of managing Mrs. Farah's hypertension and CKD, which of the following statements accurately reflects the guideline recommendations for blood pressure targets and RAAS blockade?
Considering Mrs. Farah's medication list, which combination of drugs is most likely contributing to her risk of hyperkalemia, especially if her renal function were to acutely worsen?
Considering Mrs. Farah's medication list, which combination of drugs is most likely contributing to her risk of hyperkalemia, especially if her renal function were to acutely worsen?
If Mrs. Farah's eGFR were to decline to 25 mL/min/1.73 m² (Stage G4 CKD), which of the following complications related to CKD-MBD would become increasingly important to monitor and manage proactively?
If Mrs. Farah's eGFR were to decline to 25 mL/min/1.73 m² (Stage G4 CKD), which of the following complications related to CKD-MBD would become increasingly important to monitor and manage proactively?
Mrs. Farah's iron studies show low serum iron and low TIBC, but ferritin is within the normal range. How would you interpret these findings in the context of CKD-related anemia?
Mrs. Farah's iron studies show low serum iron and low TIBC, but ferritin is within the normal range. How would you interpret these findings in the context of CKD-related anemia?
Which of the following statements accurately describes the rationale for using sodium bicarbonate supplementation in patients with metabolic acidosis due to CKD?
Which of the following statements accurately describes the rationale for using sodium bicarbonate supplementation in patients with metabolic acidosis due to CKD?
In a patient with advanced CKD (eGFR < 30 mL/min/1.73 m²) and poorly controlled type 2 diabetes, which class of glucose-lowering medication should be used with extreme caution or avoided due to increased risks?
In a patient with advanced CKD (eGFR < 30 mL/min/1.73 m²) and poorly controlled type 2 diabetes, which class of glucose-lowering medication should be used with extreme caution or avoided due to increased risks?
When initiating ACE inhibitor or ARB therapy in Mrs. Farah for hypertension and proteinuria, what is a clinically significant and expected change in serum creatinine that warrants careful monitoring, but not necessarily immediate discontinuation of the medication?
When initiating ACE inhibitor or ARB therapy in Mrs. Farah for hypertension and proteinuria, what is a clinically significant and expected change in serum creatinine that warrants careful monitoring, but not necessarily immediate discontinuation of the medication?
Which of the following is NOT a typical indication for initiating renal replacement therapy (RRT) in a patient with CKD, according to the AEIOU mnemonic and general guidelines?
Which of the following is NOT a typical indication for initiating renal replacement therapy (RRT) in a patient with CKD, according to the AEIOU mnemonic and general guidelines?
Which of the following statements accurately reflects the primary mechanism of action of metformin in managing type 2 diabetes?
Which of the following statements accurately reflects the primary mechanism of action of metformin in managing type 2 diabetes?
In the context of dietary management for Mrs. Farah, who has CKD and diabetes, which of the following is the MOST crucial dietary modification to recommend to slow CKD progression and manage complications?
In the context of dietary management for Mrs. Farah, who has CKD and diabetes, which of the following is the MOST crucial dietary modification to recommend to slow CKD progression and manage complications?
What is the primary advantage of using GLP-1 receptor agonists like semaglutide over sulfonylureas in patients with type 2 diabetes and established cardiovascular disease or CKD?
What is the primary advantage of using GLP-1 receptor agonists like semaglutide over sulfonylureas in patients with type 2 diabetes and established cardiovascular disease or CKD?
Considering Mrs. Farah's past medical history and current presentation, which chronic complication of diabetes mellitus is LEAST likely to be directly assessed or screened for during her routine follow-up appointment?
Considering Mrs. Farah's past medical history and current presentation, which chronic complication of diabetes mellitus is LEAST likely to be directly assessed or screened for during her routine follow-up appointment?
In the context of 'sick day rules' for diabetic patients like Mrs. Farah, what is the most critical advice regarding her oral hypoglycemic medications, particularly metformin and gliclazide, during an acute illness like influenza?
In the context of 'sick day rules' for diabetic patients like Mrs. Farah, what is the most critical advice regarding her oral hypoglycemic medications, particularly metformin and gliclazide, during an acute illness like influenza?
For a patient with CKD stage G3b (eGFR 30-44 mL/min/1.73 m²) and persistent albuminuria, which of the following drug classes is considered first-line for renoprotection, even if blood pressure is within the target range?
For a patient with CKD stage G3b (eGFR 30-44 mL/min/1.73 m²) and persistent albuminuria, which of the following drug classes is considered first-line for renoprotection, even if blood pressure is within the target range?
If Mrs. Farah develops severe hyperkalemia (e.g., serum potassium > 7.0 mmol/L) with ECG changes, what is the most appropriate IMMEDIATE step in acute management?
If Mrs. Farah develops severe hyperkalemia (e.g., serum potassium > 7.0 mmol/L) with ECG changes, what is the most appropriate IMMEDIATE step in acute management?
Which of the following statements best describes the 'uraemic pruritus' experienced by some CKD patients as kidney function declines?
Which of the following statements best describes the 'uraemic pruritus' experienced by some CKD patients as kidney function declines?
In the multidisciplinary management of type 2 diabetes, what is the primary role of a 'Diabetes Educator' in Mrs. Farah's care team?
In the multidisciplinary management of type 2 diabetes, what is the primary role of a 'Diabetes Educator' in Mrs. Farah's care team?
Which of the following statements regarding the use of erythropoiesis-stimulating agents (ESAs) in CKD-related anemia is MOST accurate?
Which of the following statements regarding the use of erythropoiesis-stimulating agents (ESAs) in CKD-related anemia is MOST accurate?
What is the most significant limitation of using serum creatinine alone to assess kidney function in patients with CKD?
What is the most significant limitation of using serum creatinine alone to assess kidney function in patients with CKD?
In the context of renal replacement therapy options, what is a key advantage of peritoneal dialysis (PD) over hemodialysis (HD) for suitable patients like Mrs. Farah?
In the context of renal replacement therapy options, what is a key advantage of peritoneal dialysis (PD) over hemodialysis (HD) for suitable patients like Mrs. Farah?
Which of the following is NOT a recognized mechanism by which chronic hyperglycemia contributes to the development and progression of diabetic nephropathy?
Which of the following is NOT a recognized mechanism by which chronic hyperglycemia contributes to the development and progression of diabetic nephropathy?
During a prescription review for a CKD patient with worsening fatigue and decreased urine output, which of Mrs. Farah's current medications would be MOST concerning given the lab results indicating declining renal function (eGFR 26 mL/min/1.73 m²) and hyperkalemia (Serum Potassium 6.2 mmol/L)?
During a prescription review for a CKD patient with worsening fatigue and decreased urine output, which of Mrs. Farah's current medications would be MOST concerning given the lab results indicating declining renal function (eGFR 26 mL/min/1.73 m²) and hyperkalemia (Serum Potassium 6.2 mmol/L)?
In communicating Mrs. Farah's CKD diagnosis and management plan, adopting a 'patient-centered approach' primarily emphasizes which of the following?
In communicating Mrs. Farah's CKD diagnosis and management plan, adopting a 'patient-centered approach' primarily emphasizes which of the following?
Which of the following statements regarding the use of loop diuretics like furosemide in CKD patients is MOST accurate?
Which of the following statements regarding the use of loop diuretics like furosemide in CKD patients is MOST accurate?
For Mrs. Farah, who has type 2 diabetes, hypertension, hyperlipidemia, and now CKD, what is the most comprehensive initial strategy to manage her multiple comorbidities and slow CKD progression?
For Mrs. Farah, who has type 2 diabetes, hypertension, hyperlipidemia, and now CKD, what is the most comprehensive initial strategy to manage her multiple comorbidities and slow CKD progression?
In reviewing Mrs. Farah's family history, the fact that her father died of a heart attack at age 55 and her mother of a stroke at age 60 is MOST relevant for assessing her risk of:
In reviewing Mrs. Farah's family history, the fact that her father died of a heart attack at age 55 and her mother of a stroke at age 60 is MOST relevant for assessing her risk of:
When considering adding a GLP-1 agonist to Mrs. Farah's regimen, what is a key factor to discuss with her regarding the administration of this medication class?
When considering adding a GLP-1 agonist to Mrs. Farah's regimen, what is a key factor to discuss with her regarding the administration of this medication class?
In the scenario where Mrs. Farah presents one year later with worsening fatigue, decreased urine output, and swelling, and her lab results show eGFR 26 mL/min/1.73 m² and hyperkalemia, which medication from her current list should be immediately reviewed and potentially withheld or adjusted FIRST?
In the scenario where Mrs. Farah presents one year later with worsening fatigue, decreased urine output, and swelling, and her lab results show eGFR 26 mL/min/1.73 m² and hyperkalemia, which medication from her current list should be immediately reviewed and potentially withheld or adjusted FIRST?
What is the primary rationale for recommending annual influenza and pneumococcal vaccinations for patients with CKD like Mrs. Farah?
What is the primary rationale for recommending annual influenza and pneumococcal vaccinations for patients with CKD like Mrs. Farah?
Which of the following best describes the concept of 'adynamic bone disease' in CKD-MBD?
Which of the following best describes the concept of 'adynamic bone disease' in CKD-MBD?
In the context of cardiovascular risk reduction in patients with CKD and diabetes, like Mrs. Farah, which of the following medications is recommended as a cornerstone therapy, irrespective of baseline LDL-cholesterol levels?
In the context of cardiovascular risk reduction in patients with CKD and diabetes, like Mrs. Farah, which of the following medications is recommended as a cornerstone therapy, irrespective of baseline LDL-cholesterol levels?
Considering Mrs. Farah's initial presentation and lab results, which of the following pathophysiological processes is the MOST likely primary driver of her developing chronic kidney disease (CKD)?
Considering Mrs. Farah's initial presentation and lab results, which of the following pathophysiological processes is the MOST likely primary driver of her developing chronic kidney disease (CKD)?
Based on Mrs. Farah's arterial blood gas (ABG) results, which statement BEST describes the acid-base disturbance and the compensatory mechanism at play?
Based on Mrs. Farah's arterial blood gas (ABG) results, which statement BEST describes the acid-base disturbance and the compensatory mechanism at play?
In the context of Mrs. Farah's renal ultrasound findings of 'increased cortical echogenicity and poorly defined corticomedullary differentiation', which of the following pathophysiological changes in the kidney parenchyma BEST explains these findings in CKD?
In the context of Mrs. Farah's renal ultrasound findings of 'increased cortical echogenicity and poorly defined corticomedullary differentiation', which of the following pathophysiological changes in the kidney parenchyma BEST explains these findings in CKD?
Considering the long-term consequences of uncorrected metabolic acidosis in CKD, which of the following clinical manifestations is MOST directly linked to disruptions in bone homeostasis and mineral metabolism?
Considering the long-term consequences of uncorrected metabolic acidosis in CKD, which of the following clinical manifestations is MOST directly linked to disruptions in bone homeostasis and mineral metabolism?
Mrs. Farah's elevated parathyroid hormone (PTH) and low Vitamin D levels are indicative of secondary hyperparathyroidism in CKD-MBD. Which of the following statements BEST describes the sequence of events leading to this condition?
Mrs. Farah's elevated parathyroid hormone (PTH) and low Vitamin D levels are indicative of secondary hyperparathyroidism in CKD-MBD. Which of the following statements BEST describes the sequence of events leading to this condition?
Given Mrs. Farah's eGFR of 46 mL/min/1.73 m² and current metformin prescription of 1000mg twice daily, which of the following is the MOST appropriate adjustment to her metformin dosage according to current guidelines?
Given Mrs. Farah's eGFR of 46 mL/min/1.73 m² and current metformin prescription of 1000mg twice daily, which of the following is the MOST appropriate adjustment to her metformin dosage according to current guidelines?
Beyond glucose lowering, SGLT-2 inhibitors are increasingly favored in patients with type 2 diabetes and CKD like Mrs. Farah primarily due to their demonstrated beneficial effects on which of the following?
Beyond glucose lowering, SGLT-2 inhibitors are increasingly favored in patients with type 2 diabetes and CKD like Mrs. Farah primarily due to their demonstrated beneficial effects on which of the following?
Regarding blood pressure management in Mrs. Farah, who has hypertension and CKD, which of the following statements accurately reflects current guideline recommendations for blood pressure targets and RAAS blockade?
Regarding blood pressure management in Mrs. Farah, who has hypertension and CKD, which of the following statements accurately reflects current guideline recommendations for blood pressure targets and RAAS blockade?
Reviewing Mrs. Farah's medication list (Metformin, Gliclazide, Sitagliptin, Valsartan/HCTZ, Amlodipine, Atorvastatin), which combination of drugs would MOST significantly raise concern for hyperkalemia, particularly if her renal function acutely declines?
Reviewing Mrs. Farah's medication list (Metformin, Gliclazide, Sitagliptin, Valsartan/HCTZ, Amlodipine, Atorvastatin), which combination of drugs would MOST significantly raise concern for hyperkalemia, particularly if her renal function acutely declines?
If Mrs. Farah's eGFR were to further decline to 25 mL/min/1.73 m² (Stage G4 CKD), which of the following CKD-MBD complications would require the MOST proactive and intensive monitoring and management due to its increased prevalence and clinical impact at this stage?
If Mrs. Farah's eGFR were to further decline to 25 mL/min/1.73 m² (Stage G4 CKD), which of the following CKD-MBD complications would require the MOST proactive and intensive monitoring and management due to its increased prevalence and clinical impact at this stage?
Mrs. Farah's iron studies show low serum iron and low TIBC, but ferritin is within the normal range. In the context of CKD-related anemia, how should these findings be INTERPRETED to guide further management?
Mrs. Farah's iron studies show low serum iron and low TIBC, but ferritin is within the normal range. In the context of CKD-related anemia, how should these findings be INTERPRETED to guide further management?
What is the PRIMARY rationale for using sodium bicarbonate supplementation in patients with metabolic acidosis secondary to CKD, considering its impact on CKD progression and complications?
What is the PRIMARY rationale for using sodium bicarbonate supplementation in patients with metabolic acidosis secondary to CKD, considering its impact on CKD progression and complications?
In a patient with advanced CKD (eGFR < 30 mL/min/1.73 m²) and poorly controlled type 2 diabetes, which class of glucose-lowering medications should be used with EXTREME CAUTION or generally avoided due to significantly increased risks of adverse outcomes?
In a patient with advanced CKD (eGFR < 30 mL/min/1.73 m²) and poorly controlled type 2 diabetes, which class of glucose-lowering medications should be used with EXTREME CAUTION or generally avoided due to significantly increased risks of adverse outcomes?
When initiating ACE inhibitor or ARB therapy in Mrs. Farah for hypertension and proteinuria, what magnitude of increase in serum creatinine from baseline is generally considered clinically acceptable and expected, requiring monitoring but NOT necessarily immediate discontinuation?
When initiating ACE inhibitor or ARB therapy in Mrs. Farah for hypertension and proteinuria, what magnitude of increase in serum creatinine from baseline is generally considered clinically acceptable and expected, requiring monitoring but NOT necessarily immediate discontinuation?
According to the AEIOU mnemonic and general guidelines for initiating renal replacement therapy (RRT), which of the following clinical scenarios is NOT typically a primary indication for starting dialysis in a patient with CKD?
According to the AEIOU mnemonic and general guidelines for initiating renal replacement therapy (RRT), which of the following clinical scenarios is NOT typically a primary indication for starting dialysis in a patient with CKD?
Which of the following statements BEST describes the primary mechanism of action of metformin in managing type 2 diabetes mellitus?
Which of the following statements BEST describes the primary mechanism of action of metformin in managing type 2 diabetes mellitus?
In the context of dietary management for Mrs. Farah, who has both CKD and diabetes, which dietary modification is MOST crucial to recommend for slowing CKD progression and managing complications?
In the context of dietary management for Mrs. Farah, who has both CKD and diabetes, which dietary modification is MOST crucial to recommend for slowing CKD progression and managing complications?
What is the PRIMARY advantage of using GLP-1 receptor agonists like semaglutide over sulfonylureas in patients with type 2 diabetes and established cardiovascular disease or CKD, considering their differential effects on cardiovascular and renal outcomes?
What is the PRIMARY advantage of using GLP-1 receptor agonists like semaglutide over sulfonylureas in patients with type 2 diabetes and established cardiovascular disease or CKD, considering their differential effects on cardiovascular and renal outcomes?
Considering Mrs. Farah's past medical history (T2DM, hypertension, hyperlipidemia) and current presentation, which chronic complication of diabetes mellitus is LEAST likely to be the immediate focus of assessment or screening during her routine follow-up appointment focused on CKD?
Considering Mrs. Farah's past medical history (T2DM, hypertension, hyperlipidemia) and current presentation, which chronic complication of diabetes mellitus is LEAST likely to be the immediate focus of assessment or screening during her routine follow-up appointment focused on CKD?
In the context of 'sick day rules' for diabetic patients like Mrs. Farah, what is the MOST critical advice regarding her oral hypoglycemic medications, particularly metformin and gliclazide, during an acute illness such as influenza with reduced oral intake and potential dehydration?
In the context of 'sick day rules' for diabetic patients like Mrs. Farah, what is the MOST critical advice regarding her oral hypoglycemic medications, particularly metformin and gliclazide, during an acute illness such as influenza with reduced oral intake and potential dehydration?
For a patient with CKD stage G3b (eGFR 30-44 mL/min/1.73 m²) and persistent albuminuria, which drug class is considered FIRST-LINE for renoprotection, even if blood pressure is already within the target range?
For a patient with CKD stage G3b (eGFR 30-44 mL/min/1.73 m²) and persistent albuminuria, which drug class is considered FIRST-LINE for renoprotection, even if blood pressure is already within the target range?
If Mrs. Farah develops severe hyperkalemia (e.g., serum potassium > 7.0 mmol/L) with ECG changes (e.g., peaked T waves), what is the MOST appropriate IMMEDIATE step in acute management to prevent life-threatening cardiac arrhythmias?
If Mrs. Farah develops severe hyperkalemia (e.g., serum potassium > 7.0 mmol/L) with ECG changes (e.g., peaked T waves), what is the MOST appropriate IMMEDIATE step in acute management to prevent life-threatening cardiac arrhythmias?
Which of the following statements BEST describes the pathophysiology of 'uraemic pruritus' experienced by some CKD patients as kidney function declines?
Which of the following statements BEST describes the pathophysiology of 'uraemic pruritus' experienced by some CKD patients as kidney function declines?
In the multidisciplinary management of type 2 diabetes, what is the PRIMARY role of a 'Diabetes Educator' in Mrs. Farah's care team, distinct from other healthcare professionals involved?
In the multidisciplinary management of type 2 diabetes, what is the PRIMARY role of a 'Diabetes Educator' in Mrs. Farah's care team, distinct from other healthcare professionals involved?
Which of the following statements regarding the use of erythropoiesis-stimulating agents (ESAs) in CKD-related anemia is MOST accurate and reflects current best practices?
Which of the following statements regarding the use of erythropoiesis-stimulating agents (ESAs) in CKD-related anemia is MOST accurate and reflects current best practices?
What is the MOST significant limitation of using serum creatinine alone to assess kidney function in patients with CKD, particularly in early stages or in certain populations?
What is the MOST significant limitation of using serum creatinine alone to assess kidney function in patients with CKD, particularly in early stages or in certain populations?
Flashcards
Review DM/CKD ALOs
Review DM/CKD ALOs
Review the ALOs (achieved learning outcomes) for DM/CKD from year 2 of medical school.
DM/CKD diagnosis
DM/CKD diagnosis
Explain diagnostic principles for DM/CKD in patients with a suspected diagnosis.
DM/CKD investigations
DM/CKD investigations
Choose the appropriate investigations to diagnose DM/CKD.
DM/CKD management
DM/CKD management
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DM/CKD treatment steps
DM/CKD treatment steps
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DM/CKD history features
DM/CKD history features
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Polyuria/Polydipsia
Polyuria/Polydipsia
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Self-Monitoring Blood Glucose (SMBG)
Self-Monitoring Blood Glucose (SMBG)
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HbA1c
HbA1c
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Chronic Kidney Disease (CKD)
Chronic Kidney Disease (CKD)
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Decreased kidney function
Decreased kidney function
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CKD-Mineral & Bone Disorders (CKD-MBD)
CKD-Mineral & Bone Disorders (CKD-MBD)
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Secondary Hyperparathyroidism
Secondary Hyperparathyroidism
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Normal Acid-Base Balance
Normal Acid-Base Balance
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Renal Replacement Therapy (Dialysis)
Renal Replacement Therapy (Dialysis)
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eGFR
eGFR
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Uraemia in CKD
Uraemia in CKD
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Metformin
Metformin
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Common Metformin Side Effects
Common Metformin Side Effects
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SGLT-2 Inhibitors
SGLT-2 Inhibitors
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GLP-1 receptor agonists
GLP-1 receptor agonists
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Sulfonylureas
Sulfonylureas
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Study Notes
- The lecture is about Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Acute Kidney Injury (AKI), and Acid-Base Disorders for Year 3 THEPII students.
- The lecturer: Dr. Najla Shamsi
Learning Outcomes
- To review the ALOs for DM/CKD from year 2
- To explain the principles of diagnosis in patients with suspected DM/CKD
- To choose appropriate investigations to make a diagnosis of DM/CKD
- To explain the principles of managing patients with DM/CKD
- To outline the steps of management of DM/CKD, including the role of pharmacological agents
- To elicit history features related to the etiology, risk factors, and potential complications of DM/CKD
Farah's Medical History
- Mrs. Farah is a 58-year-old female
- She presented to her GP for a routine follow-up appointment
- She has a history of type 2 diabetes mellitus (T2DM) for 8 years, hypertension, and hyperlipidemia
- She adheres to her medications, has no known drug allergies (NKDA), and has had COVID Pneumonia 3 years ago
- She had two LSCS (Lower Segment Cesarean Section) procedures 20 & 25 years prior
History of Presenting Complaint
- Key questions to ask patients include looking for:
- Current symptoms
- Symptoms of Hyperglycemia: increased thirst, urination, unintentional weight loss, fatigue.
- Current Medication History: recent change in medications/dosage?
- Diet: Change in diet?
- Physical Activity: Change in physical activity?
- Symptoms of Complications: Chest pain, headache, vision changes, numbness, intermittent claudication?
- SMBG: Monitor blood glucose at home?
- Psychological symptoms: History of depression or anxiety?
Farah's Further Medical History
- Polyuria and Polydipsia: Urinates 4-5 times during the day and 2-3 times at night (nocturia)
- Drinks 3 liters of fluids daily
- She experiences mild fatigue without abdominal pain
- She has a sedentary lifestyle
- Breakfast: 2-3 toasts, 2 fried eggs and 8 oz orange juice
- Snack: Tea (with 2 teaspoons of sugar) and 2 biscuits
- Lunch: Half a plate of rice with protein and a can of Coke
- Snack: Piece of cake or another sweet
- Dinner: McDonald's Big Mac (1-2 times a week) and a turkey sandwich with fruits
- She walks 10-15 minutes daily
- She reports no chest pain, shortness of breath, or palpitations, and no visual complaints but it has been several years since she last saw an ophthalmologist
- She experiences mild tingling and numbness in her feet, but no ulcers or calf pain with exertion
- She checks her blood glucose every few days in the morning
- Her FBS (fasting blood sugar) is 140 mg/dL (7.8 mmol/L)
- Mood is stable with no recent changes
- She is a Non-smoker, does not drink alcohol, and has no history of recreational drug use
- She has been married for 35 years; lives in a 2-story house, and works as a substitute teacher
- Father died at age 55, of a heart attack
- Her mother died at age 60, of a stroke
- She has 2 sisters with T2DM and her mother and sisters are Obese
- The patient has no recent travel history and all vaccinations completed
Farah's Physical Examination
- BP: 140/80 mm Hg
- HR: 80 bpm
- RR: 12 breaths/min, Temp: 37°C
- SpO2: 100% on room air
- Weight: 97 Kg, Height: 160 cm
- BMI: 37.9 kg/m² (obese)
- General appearance notes she has obesity but is not in respiratory distress
- She has no rashes, wounds or abnormal discoloration
- She has no signs of pallor or scleral icterus
- Fundoscopy was not performed
- Vesicular breath sounds are normal and there are no adventitious sounds detected
- CVS, there is no elevated JVP
- Precordium palpation reveals no thrills or left heave
- Precordium auscultation reveals no murmurs or other added sounds
- The abdomen is soft, non-tender, no guarding, no rigidity, no organomegaly
- There is not lower limb oedema
- Monofilament Test: normal sensation
- Peripheral pulses are 2+ bilaterally
- (dorsalis pedis/posterior tibial, popliteal, and femoral)
Initial Investigation - Lab Results
- Fingerstick Glucose Result: 12 mmol/L (Reference range: 3.9-5.5 mmol/L)
- Haemoglobin: 11.0 g/dL (Reference range: 13-18 g/dL)
- MCV (mean cell volume): 95 fL (Reference range: 82-100 fL)
- Platelets: 250 * 10^9/L (Reference range: 150-400 * 10^9/L)
- White blood cells: 7.2 * 10^9/L (Reference range: 4.0-11.0 * 10^9/L)
- Neutrophils: 5.0 * 10^9/L (Reference range: 2.0-7.0 * 10^9/L)
- Lymphocytes: 2.1 * 10^9/L (Reference range: 1.0-3.0 * 10^9/L)
- Eosinophils: 0.1 * 10^9/L (Reference range: 0.1-0.4 * 10^9/L)
- She has normocytic anemia
- Urea: 8 mmol/L (Reference range: 2-7 mmol/L)
- Creatinine: 107 µmol/L (Reference range: 55-120 µmol/L)
- eGFR: 46 mL/min/1.73 m² (Reference range: ≥ 90 mL/min/1.73 m²)
- Sodium: 138 mmol/L (Reference range: 135-145 mmol/L)
- Potassium: 4.2 mmol/L (Reference range: 3.5-5.3 mmol/L)
- Chloride: 100 mmol/L (Reference range: 96-106 mmol/L)
- Carbon Dioxide: 20 mmol/L (Reference range: 22-28 mmol/L)
- Glucose: 12.2 mmol/L (Reference range: 3.9-5.5 mmol/L)
- HbA1C: 10.2% (Reference Range: <5.7%)
- Result and Reference ranges:
- Total Protein: 79 g/L (64-82 g/L)
- Albumin: 42 g/L (38-50 g/L)
- Total Bilirubin: 13.7 µmol/L (<18 µmol/L)
- Direct Bilirubin: 4.3 µmol/L (0-5 µmol/L)
- Alkaline Phosphatase: 152 µmol/L (50-135 µmol/L)
- Alanine Transaminase (ALT): 30 µmol/L (16-63 µmol/L)
- Aspartate Aminotransferase (AST): 25 µmol/L (15-41 µmol/L)
- Gamma-glutamyl transferase (GGT): 25 µmol/L (5-55 µmol/L)
- 6.47 mmol/L (3.5-5.2 mmol/L)
- LDL cholesterol: 4.13 mmol/L (1.6-4.7 mmol/L)
- HDL cholesterol: 0.91 mmol/L (0.83-1.86 mmol/L)
- Triglycerides: 2.82 mmol/L (0-1.7 mmol/L)
- Appearance: Clear
- Colour: Yellow
- Specific gravity: 1.025
- pH: 5.0
- Protein: 2+
- Glucose: 2+
- Ketones: Negative
- Nitrates: Negative
- Leukocyte esterase: Negative
- Microalbuminuria: 120mg/g, reference <30mg/g
Initial Iron Studies Results
- Serum Iron: 45 µg/dL (Reference Range: 60-170 µg/dL)
- TIBC: 220 µg/dL (Reference Range: 240-450 µg/dL)
- Transferrin Saturation: 20% (RR: 20-50%)
- Ferritin: 400 ng/mL (Reference Range: 20-300 ng/mL)
- Mild Anemia is common in CKD due to reduced erythropoietin production by the kidneys
- Normocytic Anemia: The MCV of 95 fL indicates normocytic anemia, typical in CKD + the anemia of chronic disease (ACD), normal red blood cells but reduced in numbers
- Functional Iron Deficiency: The low serum iron, low TIBC, and relatively normal or low TSAT suggest that while total iron stores may be adequate or even elevated, the iron is NOT readily available for erythropoiesis due to chronic inflammation and the action of hepcidin
Arterial Blood Gas Results
- pH: 7.32 (Reference Range: 7.35-7.45)
- paO2: 12.0 KPA (Reference Range: 11-13 KPA)
- paCO2: 4.5 KPA (Reference Range: 4.7-6.0 KPA)
- Bicarbonate: 20 mmol/L (Reference Range: 24-40 mmol/L)
- Primary Disorder: The mildly decreased bicarbonate (HCO3¯) and slightly acidic pH indicate mild metabolic acidosis
- Compensatory Response: The slightly lowered PaCO2 (4.5 kPa) shows some respiratory compensation
- Oxygenation: The PaO2 is within the normal range, indicating no hypoxemia
- This ABG result reflects a mild metabolic acidosis with partial respiratory compensation, which is consistent with early to moderate CKD and indicates that the kidneys are struggling but still have a capacity to maintain acid-base balance
Additional Lab Results
- Calcium: 8.6 mg/dL (Reference Range: 8.5-10.2 mg/dL)
- Phosphorous: 4.2 mg/dL (Reference Range: 2.5-4.5 mg/dL)
- Vitamin D: 22 ng/mL (Reference Range: 30-100 ng/mL)
- Parathyroid Hormone (PTH): 85 pg/mL (Reference Range: 10-65 pg/mL)
- Not requested as not clinically indicated - result if performed would be:
- Glucose: 12.2 mmol/L (Reference Range: 3.9-5.5 mmol/L)
- Serum Insulin: 33 µIU/mL (Reference Range: 2.6 to 24.9 µIU/mL)
- C-Peptide: 3.5 ng/mL (Reference Range: >1.8 ng/mL)
Kidney Ultrasound Results
- Right Kidney Size: 8.5 cm in length (normal range: 9-12 cm)
- Left Kidney Size: 8.2 cm in length (normal: 9-12 cm)
- Parenchymal Disease: Increased cortical echogenicity, consistent with chronic parenchymal disease
- Corticomedullary Differentiation: Poorly defined.
- Cysts/Masses: No renal cysts or masses identified.
- Hydronephrosis: None observed.
- Other Findings: No calculi or other abnormalities noted
- Bilateral Renal Atrophy: Both kidneys are smaller than normal, with increased cortical echogenicity, consistent with CKD
- No Obstructive Uropathy: There is no evidence of hydronephrosis or urinary tract obstruction
Further on Kidney Biopsy
- Not requested, as not clinically indicated. Usually done in cases when the diagnosis is not clear and if requested, this is what results would look like in a patient with diabetes:
- Excess glucose in the blood as a result of type 1 or type 2 diabetes causes excess glucose to be excreted in the urine (glycosuria)
- Glucose interacts with proteins in the glomerular basement membrane causing it to thicken
- Hyaline arteriolosclerosis results and causes an increase in glomerular pressure The glomerulus expands and becomes more permeable
- Mesangial cells try to regenerate, developing Kimmelstiel-Wilson nodules
- Damaged, diffusely scarred glomeruli result and the GFR declines
Clinical Assessment from the Results Provided
- Chronic Kidney Disease, likely due to
- Uncontrolled Type 2 Diabetes
- Hypertension
- Hyperlipidemia
Some Causes of CKD
- Diabetes
- Hypertension
- Glomerulonephritis
- Autosomal dominant polycystic kidney disease (ADPKD)
- Alport's syndrome
- Chronic pyelonephritis
- Obstructive uropathy
Management of CKD Includes
- Aiming to slow decline in eGFR with aggressive risk factor management
- Optimizing diabetes control
- Management of Blood pressure
- <140/90mmHg or <130/80mmHg if proteinuria/diabetes
- Using ACE-I or ARB
- Smoking cessation
- Avoiding nephrotoxins (e.g.- NSAIDs)
- Getting annual influenza & pneumococcal vaccines
- Anaemia (when Hb <10.0 g/dL) using; Erythropoiesis-stimulating agents (ESAs)
- Recombinant human EPO + Iron transfusion if applicable
- Vitamin B12/Folate replacement if applicable
- CKD-Mineral & Bone Disorders - include:
- Restricting dietary phosphate
- Calcium supplements with meals
- Vitamin D analogues (i.e.- calcitriol)
- Phosphate Binders
- Restricting salt intake in Fluid Balance
- Potentially using Diuretics (e.g.- Furosemide)
- Metabolic Acidosis
- Bicarbonate
Uremia Symptoms
- Set of symptoms seen in End-Stage Kidney Disease (ESKD) that include
- Gastrointestinal: Anorexia, nausea, vomiting
- Cardiac: Pericarditis
- Neurological: Peripheral neuropathy and CNS issues (such as confusion, seizures, coma)
- Persistent itching (uraemic pruritus)
- Symptom Severity: NOT directly correlated with BUN, creatinine, or GFR levels; varies widely among patients.
- Requires kidney replacement therapy (hemodialysis, peritoneal dialysis, or transplant)
Renal Replacement Therapy (Dialysis) Overview
- It replicates some functions of the kidneys, removing waste, excess fluid, and balancing electrolytes when the kidneys can no longer do so effectively.
- Types of dialysis: Hemodialysis vs. Peritoneal Dialysis
- Decision-Making: Start dialysis the benefits outweigh the risks (pt/Dr decision)
- Indications:
- eGFR >15 mL/min/1.73 m²: Dialysis rarely needed; symptoms usually managed with medication.
- eGFR 5-15 mL/min/1.73 m²: Start dialysis if symptoms (like uremia) don't respond to medical treatment.
- eGFR <5 mL/min/1.73 m²: Dialysis generally recommended due to high risk of complications.
- Special Considerations:
- Indications for RRT mnemonic: AEIOU
- A - Acidosis with a Ph < 7.0 mmol/
- E - Electrolyte imbalance: K+ >7.0 mmol/L OR refractory hyperkalaemia with ECG changes
- I – Intoxication such as Ethylene glycol and lithium
- O - Overload (severe pulmonary oedema)
- U - Uraemia symptoms especially if encephalopathy or pericarditis
- Hemodialysis at home vs peritoneal during the day as less flexible alternatives
Multidisciplinary Team
- Diabetes affects various body systems hence requiring Comprehensive care addresses both physical & psychological needs
- Endocrinologist/GP
- Dietitian
- Diabetes Educator
- Podiatrist
- Ophthalmologist
- Psychologist/Psychiatrist
Treatment Strategies for T2D
- Lifestyle changes: Diet, Exercise, Weight loss, Sleep (OSA management), Mental health/stress-relief
- Oral medications and non-insulin injections
- Insulin
- Weight loss medications and/or Bariatric Surgery
- Blood pressure control Statin
Pharmacological Considerations
- Multiple glucose drugs available with tissue specific action
- Almost all of these drugs/medications are not appropriate in pregnancy or renal impairment
- Except metformin is most commonly first drug of choice and can be combined with multiple classes otherwise
- Metformin: decreases liver (AMPK?) output and intestinal glucosamine/insulin utilization, the only downer is B2 deficiency and GI upset
- Biguanide (metformin): decreases Weight when compared to Sulfonylureas which increase weight, can use GLP-1 agonist and/or SGLT-2 as well
SGLT-2 inhibitors
- Indicated for those with CKD / high proteinuria that reduce kidney failure with the exception of severe renal impariments & dialysis
Common Complications of Diabetes Mellitus
- Acute complications:
- HHS
- DKA
- Chronic Complications:
- Macrovascular: IHD, CVA, PAD
- Microvascular: Nephropathy, Neuropathy, Retinopathy
- Others: Diabetic foot ulcer & Charcot's Osteoarthropathy
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