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REGUB > 15. Chronic Renal Failure > Flashcards

15. Chronic Renal Failure Flashcards

1
Q

What are the functions of the kidney?

7

A
  1. Extracellular fluid volume homeostasis
  2. Osmoregulation
  3. Potassium homeostasis
  4. Acid base balance
  5. Excretion of waste products (inc drugs!!)
  6. Calcium and phosphate homeostasis
  7. Production of hormones
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2
Q

What is glomerular filtration rate (GFR)? How do you measure it?
(4)

What is estimated glomerular filtration rate (eGFR)?

A

GFR

  • Normal approx. 100-120ml/min
  • How do we measure GFR?
    1. Iothalamate clearance
    2. Inulin clearance
    3. 24 hr urine creatinine clearance
    4. Estimated GFR (eGFR)

eGFR
- Calculated from serum creatinine, designed to factor in muscle mass

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3
Q

How do you classify chronic kidney disease?

5

A
  1. Stage 1: GFR normal (>90) or increased & other evidence of kidney damage
  2. Stage 2: Kidney damage & GFR 60-90mls/min
  3. Stage 3: GFR 30-59
  4. Stage 4: GFR 15-29
  5. Stage 5: GFR <15 (5d if on dialysis)
  • If transplanted - becomes 3t, 4t, 5t
  • Stage implies a step or progress
  • CKD 3A (45-60), CKD 3B (30-44)
  • Morbidity and mortality begin to rise at a GFR below 45
  • Anaemia begins to become more common at CKD stage 3b
  • Prevalence of CKD increasing b/c:
    1. Increased obesity and diabetes
    2. Increased longevity
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4
Q

What are the risk factors for CKD?
(7)

What are the causes of CKD?
(7)

A

RISK FACTORS

  1. Hypertension
  2. Diabetes
  3. Atheroma (CVD/IHD/PVD)
  4. Old Age
  5. Asian/Afro-Caribbean
  6. Family history
  7. Prolonged hospital admission

CAUSES

  1. Diabetic nephropathy (most common cause)
  2. Hypertensive nephropathy
  3. Glomerulonephritis
  4. Adult polycystic kidney disease
  5. Tubulo-interstitial nephropathy
  6. Obstructive nephropathy
  7. Chronic pyelonephritis
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5
Q

How do you manage CKD?
(10)

How do you manage CRF?
(9)

What are the drugs used?
(6)

A

CKD

  1. Dietary protein restriction (renal dietician input)
  2. Smoking cessation
  3. Discontinuation of nephrotoxic medications
  4. Limit iodinated contrast administration or adequate pre-hydration & n-acetylcysteine pre-imaging
  5. Hypertension
  6. Anaemia
  7. CKD —> mineral and bone disorder
  8. Fluid balance
  9. Cardiac disease —> mild to moderate degrees of CKD are associated with an adverse cardiovascular prognosis
  10. Preparation for renal replacement therapy

CRF

  1. Threshold 140 / 90 : 130 / 80 if proteinuria
  2. Target < 130 / 80 : 125 / 75 if proteinuria
  3. ACEIs or ARBs
  4. Particularly with proteinuria
  5. Delay progressive renal disease
  6. Creatinine and K+ check before start
  7. Check at 2 weeks, and after any change
  8. Expect fall in eGFR but usually < 25%
  9. Hyperkalaemia >6.0 review drugs

DRUGS

  1. Calcium antagonist (Amlodipine)
  2. Alpha blocker (Doxazosin)
  3. Beta blocker (Bisoprolol)
  4. Combined alpha and beta blocker (Labetolol)
  5. Vasodialtors (Hydralazine)
  6. Loop diuretics (Furosemide): need higher doses in CKD (low salt diet)
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6
Q

What is anaemia of renal disease?

What is the treatment?
2

A
  • Decreased EPO (Erythropoietin) production (when GFR>35)
  • Exacerbated by iron deficiency
    TX
    1. Adequate iron stores
    —> Ferritin >300
    —> Serum iron and transferrin saturation within normal range
  1. Erythropoeitin
    —> Weekly or monthly subcutaneous injection
    —> Aim haemoglobin 11.5-12.5
    —> Watch for hypertension
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7
Q

What mineral and bone disorders do you get in CKD?
(3)

How do you manage secondary hyperparathyrodism?
(3)

A

DISORDERS

  1. Hyperphosphataemia
  2. Hypocalcaemia
  3. Secondary hyperparathyroidism

MANAGEMENT OF SECONDARY HYPERPARATHYROIDISM

  1. Vitamin D replacement (one alfa calcidol 0.5ug)
  2. Phosphate control
    - Diet
    - Binders
    - Adequate dialysis
  3. Calcimimetics
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8
Q

What is the correlation between metabolic acidosis and CKD?

How do you treat it?
1

A
  • Inability of failing kidney to excrete lactic acid in diet
  • Metabolic acidosis may mediate fast progression than CKD

TX
1. Sodium bicarbonate tablets

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9
Q

What is progressive renal disease?

What aren’t options to treat it?
(3)

What are the advantages (5) and disadvantages (3) of PD?

A
  • When eGFR is below 30
  • Worsening kidney function despite removal of initial kidney insult
  • Associated with proteinuria/hypertension/increasing creatinine
  • Patients ultimately progress to dialysis
  • Can be worked up for renal transplantation once eGFR begins to deteriorate (Stage 4-5)

OPTIONS
1. No dialysis (conservative management)

  1. Peritoneal dialysis (PD)
    a. Day time exchanges
    b. Night time automated PD
    - Better if:
    o Residual renal function
    o Independent
    o No abdo operations
    o Space at one to put PD fluid
    o Heart failure
    o Vascular access problem

Advantages of PD

  1. More independence
  2. Constant dialysis and ultrafiltration
  3. No need for vascular access
  4. Travel
  5. Better for diabetics

Disadvantages of PD

  1. Daily activity
  2. Peritonitis
  3. Limited duration due to ultrafiltration failure
  4. Haemodialysis
    a. Hospital based
    b. Home haemodialysis
    - Better if:
    o Elderly and not independent
    o Generally gives better adequacy if sufficient dialysis time
    o Contraindication to PD
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10
Q

What is renal transplantation?

A
  • Treatment of choice for most patients with CKD
  • Improved quality of life
  • Can be either living or deceased donor transplantation
  • Need to balance risks and benefits:
    1. Older patients
    2. Risk of long term immunosuppression
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11
Q

What is urinalysis? What complications does it screen for?
(10)

What is urine dipstick?

What is urinary microscopy? (CASTS)

** see notes for picture charts **

A

COMPLICATIONS

  • Cheap and easily performed test to aid diagnosis and in screening for many complications:
    1. Routine health screening
    2. Suspected urinary tract infection
    3. Hypertension
    4. Abnormal renal function
    5. DM to screen for diabetic nephropathy or DKA
    6. Suspected vasculitis
    7. Haematuria
    8. Suspected Rena calculi
    9. Suspected IE
    10. Pregnancy —> UTIs and pre-eclampsia
URINE DIPSTICK
-	Consist of up to 10 pads which change colour
-	Compared against colour scale 
-	30-120 seconds needed before comparison
-	Most frequently used parameters:
o	Leucocyte esterase
o	Nitrites
o	Protein
o	Blood

URINARY MICROSCOPY

  • Formed in distal convoluted tubule or collecting duct
  • Clumps of cells compressed into shape of tubule
  • Appear cylindrical on microscopy
  • Form through precipitation of Tamm Horsfall mucoprotein
  • Formation of casts increased by low urinary flow rate, high salt concentration, and low pH
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12
Q

What is a renal biopsy?

What are the indications?
(6)

What is the procedure?
(4)

What are the complications?
(4)

A

INDICATIONS

  1. Unexplained significant proteinuria / nephrotic syndrome (>1g/L)
  2. Unexplained AKI + CKD
  3. Renal transplant dysfunction
  4. Non-visible haematuria
  5. Renal dysfunction in systemic disease
  6. Familial renal disease

PROCEDURE

  1. Performed by nephrologist/interventional radiologist
  2. Planned using US or CT guidance
  3. Sterilisation of skin surface w’ injection of local anaesthetic
  4. Biopsy needle guided towards kidney with imaging to obtain sample (pathologist may be a procedure)

COMPLICATIONS

  1. Pain around site
  2. Bleeding: haematuria or perinephric haematoma
  3. Arteriovenous fistula formation: if needle forms connection between artery and vein
  4. Damage to surrounding structures
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13
Q

What is nephrotic syndrome?

What are the causes?
6

A
  • Normal: <150mg/24hrs
  • Microalbuminuria: 30-300mg/24hrs
  • Non-nephrotic proteinuria: <3.5g/24hs
  • Nephrotic proteinuria: >3.5g/24hrs
  • Clinical features: peripheral oedema, foamy urine, weight gain, fatigue & loss of appetite
  • Associated with: hypercholesterolaemia, hypoalbuminaemia, hypercoagulable state & immunosuppression

CAUSES

  1. Diabetic nephropathy
  2. Minimal change disease
  3. Focal segmental glomerulosclerosis
  4. Membranous nephropathy
  5. Systemic lupus erythematosus
  6. Amyloidosis
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14
Q

What is nephritic syndrome?

What are the causes?
(6)

** see picture for comparison between nephrotic and nephritic syndrome **

A
  • Manifestation of glomerular inflammation (glomerulonephritis) and can occur at any age
  • Clinical features: haematuria, oliguria, hypertension, peripheral oedema (not as severe as nephrotic syndrome)
  • Proteinuria present but usually <3g/day

CAUSES

  1. IgA nephropathy
  2. Membranoproliferative glomerulonephritis
  3. Post-streptococcal GN
  4. Goodpasture’s syndrome (Anti-GBM disease)
  5. Granulomatosis with polyangiitis
  6. Henoch-Schönlein purpura
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REGUB (22 decks)

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