22. CKD case overview

Question 1

what is orthostatic proteinuria

Answer 1

benign condition caused by Changs in renal haemodynamic and present in minority of otherwise normal individuals and is caused by prolonged standing

Question 2

proteinuria can occur in other situations which do not indicate CKD, name them

Answer 2

after physical exercise 
fever 
pregnancy 
UTI abnormally high BP 
nephrotic/nephritic syndrome

Question 3

if there is dipstick proteinuria what might this suggest

Answer 3

glomerular or tubulointerstitial disease

Question 4

urine sediment with RBC and RBC casts may indicate what

Answer 4

proliferative glomerulonephritis

Question 5

what does Red blood cell casts mean

Answer 5

there is microscopic bleeding from the kidney

Question 6

what does pyuria/ white cell casts suggest

Answer 6

interstitial nephritis (especially if eosinophils are present in the urine)

Question 7

what is the most reliable prognostic factor in CKD

Answer 7

spot urine collection for total protein:creatinine ration

• can estimate total 24 hour urinary protein excretion
• degree of proteinuria correlates with the rate of progression of the underlying kidney disease

Question 8

in 24 hour urine collection for total protein and creatinine clearance, which has the greater sensitivity and is recommended for people with diabetes
ACR
PCR

Answer 8

ACR

Question 9

what does ACR stand for

Answer 9

albumin creatinine ratio

Question 10

what does PCR stand for

Answer 10

protein creatinine ratio

Question 11

what things are carried out at an annual diabetic review

Answer 11

• BP, urine collection, BMI and examination of feet
• also blood test to check for HbA1c levels and renal function (creatinine and eGFR)
• cholesterol level and also lifestyle issue. eg smoking, sexual dysfunction

Question 12

if a dipstick shows 1+ protein what result will sending it off to the labs give

Answer 12

ACR levels

Question 13

what glycoprotein is secreted by the renal tubules

Answer 13

uromodulin (tamm-horsfall glycoprotein THP)

Question 14

how much uromodulin is produced by the renal tubules in one day and why is this significant when measuring protein in urine

Answer 14

150ml/day
- Proteinuria more than 150mg/day is abnormal and is an important feature of increased glomerular permeability and therefore of early renal disease

Question 15

Microalbuminuria (30-300mg/day) is an early feature of of what

Answer 15

several renal diseases including diabetic nephropathy and other forms of glomerular or tubular diseases

Question 16

Staging of kidney disease requires which two test results

Answer 16

Albumin creatinine ratio (ACR) A1-A3

GFR G1-G5

Question 17

what proteins are filtered by the glomeruli and then mostly reabsorbed

Answer 17

LMW proteins

Question 18

define CKD (NICE)

Answer 18

• abnormalities of kidney function or structure present for more than 3 months
• this includes all people with markers of kidney damage and those with GRF less than 60 on at least 2 occasions with the tests separated by period of at least 90 days

Question 19

how do ACEi reduce proteinuria/albuminuria

Answer 19

• angiotensin II preferentially acts of the efferent arterioles to maintain the hydrostatic pressure at the glomeruli
• RAS over activation is damaging and so reducing the action of angiotensin II can reduce glomerular hydrostatic pressure reducing damage

Question 20

what are the main counselling points for starting an ACEi ie ramipril

Answer 20

• main side effects are dry cough
• angioodema is also common
• hyperkalamia and hypotension
• need to stop if AKI is diagnosed
• contraindicated in pregnancy
• check K and Cr 2 weeks after starting/dose change/diuretics
• if eGFR less than 30 need to stop diuretics before starting ACEi/ARB

Question 21

which of the following medication should be avoided if eGFR is less than 30

• ramipril
• amlodipine
• metformin
• atorvastatin

Answer 21

metformin

Question 22

which statin its there an increased risk of myopathy and rhabdomyolysis if the patient takes amlodipine and more than 20mg of this statin

Answer 22

simvastatin therefore would need to be changed over to atorvastatin instead

Question 23

should this issue be referred as routine, urgent or immediate referral;
malignant hypertension and hyperkalaemia

Answer 23

immediate

Question 24

should this issue be referred as routine, urgent or immediate referral;
proteinuria with odema and low serum albumin (nephrotic syndrome)

Answer 24

urgent

Question 25

should this issue be referred as routine, urgent or immediate referral;
dipstick proteinuria and urrine PCR greater than 100 or proteinuria with microscopic haematuria

Answer 25

routine

Question 26

what is the normal size of a kidney

Answer 26

10-12cm

Question 27

what are the main blood test abnormalities in someone with CKD

Answer 27

mineral bone disease - hypocalcaemia and hyperparathyroidism
renal anaemia
metabolic acidosis
hyperkalaemia

Question 28

in association with CKD how would you treat mineral bone disease

Answer 28

calcitriol/alphacalcidol (vitamin D analogue)

Question 29

in association with CKD how would you treat renal anaemia

Answer 29

erythropoietin and IV iron, target ferritin more than 200 in CKD

Question 30

in association with CKD how would you treat metabolic acidosis

Answer 30

oral alkali eg sodium bicarbonate

Question 31

in association with CKD how would you treat hyperkalaemia

Answer 31

dietary restriction and if fails consider reduction of ACE-

Question 32

what are some of the symptoms in someone with worsening CKD that needs consideration of RRT

Answer 32

nausea, poor appetite and feelings of breathlessness