22. CKD case overview Flashcards
what is orthostatic proteinuria
benign condition caused by Changs in renal haemodynamic and present in minority of otherwise normal individuals and is caused by prolonged standing
proteinuria can occur in other situations which do not indicate CKD, name them
after physical exercise fever pregnancy UTI abnormally high BP nephrotic/nephritic syndrome
if there is dipstick proteinuria what might this suggest
glomerular or tubulointerstitial disease
urine sediment with RBC and RBC casts may indicate what
proliferative glomerulonephritis
what does Red blood cell casts mean
there is microscopic bleeding from the kidney
what does pyuria/ white cell casts suggest
interstitial nephritis (especially if eosinophils are present in the urine)
what is the most reliable prognostic factor in CKD
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
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
ACR
what does ACR stand for
albumin creatinine ratio
what does PCR stand for
protein creatinine ratio
what things are carried out at an annual diabetic review
- 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
if a dipstick shows 1+ protein what result will sending it off to the labs give
ACR levels
what glycoprotein is secreted by the renal tubules
uromodulin (tamm-horsfall glycoprotein THP)
how much uromodulin is produced by the renal tubules in one day and why is this significant when measuring protein in urine
150ml/day
- Proteinuria more than 150mg/day is abnormal and is an important feature of increased glomerular permeability and therefore of early renal disease
Microalbuminuria (30-300mg/day) is an early feature of of what
several renal diseases including diabetic nephropathy and other forms of glomerular or tubular diseases
Staging of kidney disease requires which two test results
Albumin creatinine ratio (ACR) A1-A3
GFR G1-G5
what proteins are filtered by the glomeruli and then mostly reabsorbed
LMW proteins
define CKD (NICE)
- 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
how do ACEi reduce proteinuria/albuminuria
- 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
what are the main counselling points for starting an ACEi ie ramipril
- 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
which of the following medication should be avoided if eGFR is less than 30
- ramipril
- amlodipine
- metformin
- atorvastatin
metformin
which statin its there an increased risk of myopathy and rhabdomyolysis if the patient takes amlodipine and more than 20mg of this statin
simvastatin therefore would need to be changed over to atorvastatin instead
should this issue be referred as routine, urgent or immediate referral;
malignant hypertension and hyperkalaemia
immediate
should this issue be referred as routine, urgent or immediate referral;
proteinuria with odema and low serum albumin (nephrotic syndrome)
urgent
should this issue be referred as routine, urgent or immediate referral;
dipstick proteinuria and urrine PCR greater than 100 or proteinuria with microscopic haematuria
routine
what is the normal size of a kidney
10-12cm
what are the main blood test abnormalities in someone with CKD
mineral bone disease - hypocalcaemia and hyperparathyroidism
renal anaemia
metabolic acidosis
hyperkalaemia
in association with CKD how would you treat mineral bone disease
calcitriol/alphacalcidol (vitamin D analogue)
in association with CKD how would you treat renal anaemia
erythropoietin and IV iron, target ferritin more than 200 in CKD
in association with CKD how would you treat metabolic acidosis
oral alkali eg sodium bicarbonate
in association with CKD how would you treat hyperkalaemia
dietary restriction and if fails consider reduction of ACE-
what are some of the symptoms in someone with worsening CKD that needs consideration of RRT
nausea, poor appetite and feelings of breathlessness
