265 - CKD

Question 1

what are the leading causes of chronic kidney disease (CKD)?

Answer 1

diabetes and hypertension

Question 2

what is another name for diabetic kidney disease (DKD)?

Answer 2

diabetic nephropathy

Question 3

what are the microvascular complications associated with DM?

Answer 3

DKD
diabetic neuropathy
retinopathy
sexual dysfunction
cerebrovascular complications

Question 4

pathophysiology of DKD?

Answer 4

prolonged hyperglycaemia causes capillaries in glomeruli to malfunction → less able to filter waste and remove fluid from the body → albumin leaks into urine

as DKD progresses kidney tissue becomes scarred →decreased GFR → compensatory HTN → more glomerular damage → vicious cycle

Question 5

early clinical indicator of DKD?

Answer 5

elevated albumin in urine

Question 6

later clinical indicator of DKD?

Answer 6

decreased GFR

Question 7

non-modifiable risk factors for DKD?

Answer 7

age
ethnicity
genetic predisposition

Question 8

modifiable risk factors for DKD?

Answer 8

sub-optimal glycaemic control
hypertension
hyperlipidaemia
smoking

Question 9

progression of DKD?

Answer 9

normoalbuminuria → microalbuminuria (incipient DKD) → proteinuria (overt DKD) → chronic renal failure

Question 10

what is prevention/management of DKD dependent on?

Answer 10

good control of BGL and BP

Question 11

what is the IDF recommended target for BP for someone with DM?

Answer 11

< 130/80mmHg

Question 12

normal GFR?

Answer 12

> 90

Question 13

“severely decreased” GFR?

Answer 13

> 30

Question 14

GFR indicating renal failure?

Answer 14

> 15

Question 15

when would a urine sample for ACR ideally be taken?

Answer 15

early morning

Question 16

what factors may increase albuminuria?

Answer 16

exercise
infections
menstruation
pregnancy

Question 17

what percentage of people with type 2 DM had evidence of microvascular complications related to diabetes at the time of diagnosis?

Answer 17

about 50%

Question 18

which diabetes meds are excreted via the renal route and should therefore be used with caution in pts with DKD?

Answer 18

sulfonylureas
alpha-glucosidase inhibitors
SGLT2-inhibitors
DPP4-inhibitors
GLP-1 analogues
insulin

Question 19

why should diabetes meds excreted via the renal route be used with caution in pts with DKD?

Answer 19

renal excretion may lead to enhanced action when kidneys are impaired

Question 20

why should metformin be discontinued if GFR < 30?

Answer 20

risk of lactic acidosis

Question 21

what is the treatment for microalbuminuria?

why?

Answer 21

ACE inhibitor or ARB, regardless of blood pressure, as they help protect renal function

Question 22

chain of meds for CKD? (via NICE)

Answer 22

ACE-inhibitor or ARB (but not both)* → if BP still suboptimal, add CCB → if BP still suboptimal, add thiazide-type diuretic → if BP still suboptimal, consider a further diuretic or alpha-blocker or beta-blocker

*if pt > 55 years, consider starting with CCB

Question 23

when do clinical features of CKD begin to show?

Answer 23

usually not until late in the disease (GFR < 15ml/min)

Question 24

what are the two main types of dialysis?

Answer 24

peritoneal dialysis (PD) 
haemodialysis (HD).

Question 25

when should people with type 2 diabetes be screened for DKD?

Answer 25

from diagnosis

Question 26

how is GFR calculated?

Answer 26

serum creatinine and ethnicity, body surface area and age

Question 27

what confirms a diagnosis of microalbuminuria?

Answer 27

2 separate elevated ACR above 3mg/mmol

Question 28

first line medication for microalbuminuria in afro-Caribbean patients should be what?

Answer 28

CCB

Question 29

dialysis is indicated for people with GFR of what?

Answer 29

< 15 mls/min