1b Chronic Kidney Disease and Renal Failure

Question 1

What are the important aspects of homeostatic function of the kidney?

Answer 1

Electrolyte balance
Acid base balance
Volume homeostasis

Question 2

What are the important aspects of excretory function of the kidneys?

Answer 2

nitrogenous waste
hormones
peptides
middle sized molecules
salt and water

Question 3

What is the endocrine function of the kidneys?

Answer 3

EPO production and 1-alpha hydroxylase vitamin D

Question 4

What are the important aspects of glucose metabolism in the kidneys?

Answer 4

Gluconeogenesis and insulin clearance

Question 5

What type of anaemia does loss of EPO production result in?

Answer 5

Normocytic and normochromic

Question 6

What happens to potassium levels in a patient with kidney failure?

Answer 6

increase

Question 7

What happens to bicarbonate levels in a patient with CKD?

Answer 7

decrease

Question 8

What happens to phosphate levels in a patient with CKD?

Answer 8

increase

Question 9

What happens to the pH of the blood in a patient with CKD?

Answer 9

lowers

Question 10

What does a reduction in 1 alpha hydroxylase vitamin D lead to?

Answer 10

reduce calcium and increased parathyroid hormone,

Question 11

What happens to urea and creatinine in a CKD patient?

Answer 11

Both increased

Question 12

What is the key condition which patients with CKD will die from due to an increased risk?

Answer 12

Cardiovascular risk

Question 13

What are some clinical signs of CKD?

Answer 13

• high creatinine
• feeling weak, too weak to move
• pale
• hand cold and decreased capillary refill
• hypotensive
• tachypnoeic despite 100% O2 sats and clear lungs

Question 14

What is the volume assessment of a CKD patient?

Answer 14

volume depleted, hypovolemic = dry volume status

Question 15

What type of breathing might CKD patients present with?

Answer 15

Kussmaul respiration

Question 16

Why does the respiratory rate increase for patients with CKD despite clear lungs and 100% O2 sats?

Answer 16

excess hydrogen ions which is converted into carbon dioxide - this stimulates breathing to remove the excess H+ = results in KUSSMAUL breathin

Question 17

What is Kussmaul respiration a key sign of?

Answer 17

Acidosis

Question 18

What is the common acid base status of a patient with CKD?

Answer 18

metabolic acidosis with respiratory compensation

Question 19

Why does respiratory compensation occur in CKD?

Answer 19

Low pH = acidosis, bicarbonate low so metabolic acidosis, Carbon dioxide also low so has been some respiratory compensation = breathing out carbon dioxide to try and reduce CO2

Question 20

What happens to the size of the kidneys in CKD?

Answer 20

Shrinking of the kidneys - on an ultrasound

Question 21

What happens to the kidney size on AKI?

Answer 21

Preserved

Question 22

What symptoms might someone experience with CKD?

Answer 22

Symptoms of extreme lethargy, weakness and anorexia.
Clinically volume depleted resulting in severe hypotension.
Elevated plasma urea and creatinine make diagnosis of renal failure.

Question 23

What is the acid base status in AKI?

Answer 23

Mild metabolic acidosis with respiratory compensation

Question 24

Kidney failure tends to REDUCE secretion of salt and water leading to:

Answer 24

Hypertension
Oedema
Pulmonary oedema

Due to water and salt retention

Question 25

In which situation might salt and water loss be seen?

Answer 25

tubulointerstitial disorders due to the concentrating mechanism results in hypovolemia = due to loss of fluid through vomiting

Question 26

What is meant by oedema?

Answer 26

Oedema = excess extracellular fluid

Question 27

What is the main extracellular ion?

Answer 27

sodium

Question 28

Describe the acidosis mechanism in kidney failure?

Answer 28

reduce excretion of H+ ions, results in increased H+ ions They enter into the cells and as a result the H+ ions swap for potassium, which leave the cells This results in a rise of potassium

Question 29

What symptoms does acidosis due to kidney failure result in?

Answer 29

Anorexia Muscle Catabolism

Question 30

What are the causes of hyperkalaemia due to kidney failure?

Answer 30

↓ Distal tubule potassium secretion Acidosis

Question 31

What are the symptoms which result from hyperkalaemia due to kidney failure?

Answer 31

Cardiac arrhythmias Neural and muscular activity Vomiting

Question 32

What are the ECG changes which are seen due to hyperkalaemia?

Answer 32

Peaked T waves P wave - broadens - reduced amplitude - - disappears QRS widening Heart block Asystole VT/VF

Question 33

What does reduced EPO as a result of kidney failure lead to?

Answer 33

Anaemia

Question 34

What does reduced vitamin D as a result of kidney failure lead to?

Answer 34

Reduced intestinal calcium absorption Hypocalaemia Hyperparathyroidism

Question 35

Why does CKD lead to phosphate retention?

Answer 35

Kidneys not working-> GFR drops -> less phosphate excreted

Question 36

What impact does phosphate retention have?

Answer 36

Calcium levels go down (also as a result of low levels of vitamin D), which leads to hyperparathyroidism

Question 37

Describe the effect of vitamin D on PTH?

Answer 37

Vitamin D suppresses PTH production so low vit D will increase PTH production

Question 38

Which type of hyperparathyroidism occurs?

Answer 38

Secondary, which can eventually change into tertiary

Question 39

What is the major outcome for a patient with CKD?

Answer 39

Cardiovascular disease

Question 40

What are the three components of a standard cardiovascular risk?

Answer 40

Hypertension Diabetes Lipid Problems

Question 41

What are the additional CVD risks due to CKD?

Answer 41

Inflammation Oxidative stress Mineral / Bone metabolism disorders

Question 42

What medication is used to drive K+ back into cells?

Answer 42

Sodium bicarbonate

Question 43

How is the fluid balance restored?

Answer 43

If hypo = give IV fluids If Hyper = use dialysis

Question 44

What are the treatments for hyperkalaemia

Answer 44

Sodium bicarbonate to drive K+ into the cells Diuretics to drive K+ into the cells gut absorption - use potassium binders to bind the excess potassium in the gut

Question 45

what are the conservative treatment methods for long term management?

Answer 45

- erythropoietin injections to correct anaemia - diuretics to correct salt-water overload - phosphate binders to reduce phosphate to prevent bone disease - 1.25 vit d supplements - symptom management

Question 46

What is the best treatment for CKD?

Answer 46

Kidney transplant

Question 47

What is the equation used to work out the chance of the patient reaching end stage renal failure in the next five years?

Answer 47

Kidney Failure Risk Equation

Question 48

Which patients is the KFRE not used in?

Answer 48

patients with a rapidly changing eGFR

Question 49

Why should transfusions be avoided?

Answer 49

transfusion -> sensitisation -> transplant failure

Question 50

Why is UREA a poor method of measuring GFR?

Answer 50

Confounded by diet, catabolic state, GI bleeding (bacterial breakdown of blood in gut), drugs, liver function etc.

Question 51

what are the problems associated with using creatinine clearance?

Answer 51

Overestimates GFR at low GFR (as a small amount of creatinine is also secreted into urine) Difficult for elderly patients to collect an accurate sample

Question 52

why is creatinine not effective of assess GFR?

Answer 52

Affected by muscle mass, age, race, sex etc. Need to look at the patient when interpreting the result. TREND helpful.

Question 53

What happens to GFR and ACR as risk of CKD increases?

Answer 53

GFR goes down ACR increases

Question 54

What are the home therapies for kidney failure?

Answer 54

Haemodialysis peritoneal dialysis