Block 4: CKD and glomerulonephritis Flashcards
CKD: monitoring ACEi and ARB’s
- Measure serum potassium concentration and calculate eGFR before starting after 1-2 weeks and with each dose increase. Do not modify the dose if either
- the GFR decrease from pre-treatment baseline is less than 25% or
- the serum creatinine increase from baseline is less than 30%.
CKD complications: A WET
- A: Metabolic acidosis, managed with oral bicarbonate or dialysis
- W: water removal, avoid excessive water and sodium intake. Treatment with diuretics and dialysis
- Erythropoiesis: anaemia of chronic kidney disease, can be treated with erythropoietin stimulating agents (erythropoietin) and iron supplements
- Toxin removal: uraemic encephalopathy, treat with dialysis
CKD complications: BED
- Blood pressure control: cardiovascular disease due to a combination of water and salt overload, hypertension and atherosclerosis
- Electrolyte balance: Hyperkalaemia, treatment includes restriction of dietary potassium, med review, use oral potassium binders, dialysis
- Vitamin D activation: due to increased secretion of PTH, impaired renal hydroxylation of vitamin D and renal phosphate retention. Management includes giving hydroxylated vitamin D (calcitriol), restrict dietary phosphate and administer phosphate binders (sevelamer)
CKD: refer to a nephrologist is
- a urinary albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
- a urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out of three dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection
- consider referral to a nephrologist for people with an ACR between 3-29 mg/mmol who have persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease
Creatinine
- Creatine is an energy store for twitch muscles this is then broken down into creatinine.
- It is excreted at a constant rate from the kidneys.
- Blood concentration of creatinine is specific for determining kidney injury, if it goes up suggests kidney damage.
- Creatinine depends on muscle mass. If high creatinine and eGFR then normal but if eGFR is low then damage
- Affects creatinine levels: pregnancy, muscle mass, limb amputation, pregnant, elderly
Urea
- Ammonia is converted to urea in the liver, its then transported to the kidneys where it is excreted.
- Not specific for kidney injury
- High levels: dehydration, Gi bleed, increased protein breakdown
- Low levels: malnutrition, liver disease, pregnancy
Sodium
- Main component of extra-cellular fluid
- Sodium content is monitored by aortic / carotid bodies and reflects fluid status by cardiac stretch
- Juxtaglomerular apparatus monitors sodium and causes renin release
Potassium
- Main intracellular electrolyte component
- Controlled by aldosteron in the DCT acting to increase K+ excretion
- Levels vary with hydrogen ion concentration as they compete for the transporter in the kidney
Indications for kidney biopsy
- Unexplained renal impairement
- Unexplained proteinuria
- Unexplained glomerular haematuria
- Renal masses (urology)
- Renal transplant: rejection, dysfunction
- Connective tissue diseases
- Treatment monitoring/Research
Kidney biopsy
- Invasive procedure: uses anaesthetics
- Patient lies on stomach: tends to go for left kidney
- Must lie on back for 6 hours after with 15 minute observations
- Sample is hand delivered to lab
- Ultrasound guided- uses biopsy gun
- Need 2 cores of tissue and 10 glomeruli
- Can show: inflammation, scarring, infection and deposition
- Risks: bleeding (visible haematuria), pain
Autosomal dominant Polycystic Kidney disease (ADPKD) multisystem disease which can cause
- Berry aneurysms: intracranial haemorrhage
- Valvular heart disease
- Dilatation of aorta
- Diverticulosis
- Pancreas, spleen, liver cysts
- Epididymal cysts
ADPKD: genetics
- PKD1 (Chr16p) polycystin-1
- PKD2 (Chr4q) polycystin-2
- (subfamily of transient receptor potential (TRP) channels)
- Genes are involved in calcium ion transport and have a role in the primary cilia
- Genetically unresolved cases (7-10%) - GANAB
ADPKD: definition and presentation
Definition: most commonly inherited disorder of the kidneys. Characterised by the formation of renal cysts and extrarenal manifestations like hepatic cysts, intracranial aneurysms and aortic root dilation
Presentation: normally between 30 and 60 causes haematuria, loin pain and hypertension. 50% will develop end stage renal disease. Accounts for 10% of patients with renal failure
ADPKD types
- Type 1 ADPKD:85% of cases. Caused by a mutation in PKD1 on chromosome 16. Symptoms tend to be more severe in this type
- Type 2 ADPKD:15% of cases. Caused by a mutation in PKD2 on chromosome 4. Symptoms tend to be less severe in this type
ADPKD: signs on examination
- Palpable kidneys/abdominal mass
- Hepatomegaly due to hepatic cysts
- Abdominal wall hernias: These are more common in ADPKD, affecting 45% of patients
- Cardiac murmur: This is due to an increased incidence of mitral valve prolapse, mitral regurgitation, aortic regurgitation and dilated aortic root in patients with ADPKD.
- Symptoms: haematuria, chronic loin pain, hypertension, recurrent UTI’s, kidney stone, headaches
Management and investigations of ADPKD
Management: control symptoms. Should refer to a nephrologist, control blood pressure and manage renal pain. In end stage renal disease may need transplant or dialysis.
Tolvaptan can slow cyst formation
Investigations: if positive family history ultrasound to look for cysts
Alport syndrome
X linked inheritance: females carry the disease and men get the symptoms. Men cant give it to men.
A gene which encodes collagen in the basement membranes of the kidney, inner ear and eye. Defect in type IV collagen
Glomerular disease with haematuria and proteinuria. With early onset sensorineural deafness and blindness
Causes mutations in COL4A3, COL4A4 and COL4A5
Glomerulonephritis definition
Refers to several renal diseases which affect both kidneys. Causes inflammation of either the glomeruli or the small blood vessels in the kidneys. Causes proteinuria and haematuria
Glomerulus
- A collection of capillaries surrounded by the Bowmans capsule
- Capillaries are supported by cells and connective tissue known as the mesangium
- Fluid and other substances pass from the capillaries to the urinary space which pass into the PCT
- The endothelium, basement membrane and podocytes make up the filtration barrier.
- Damage to the glomerulus causes blood and protein to leak
Glomerulonephritis: classification
- Primary: glomerular injury due to primary renal pathology. For example, IgA nephropathy, minimal change disease, focal segmental glomerulosclerosis
- Secondary: glomerular injury occurring as part of a systemic process. For example, Vasculitis (ANCA associated vasculitis), amyloidosis, diabetes mellitus
- Focal versus diffuse: a glomerulopathy can be focal (only some glomeruli are involved) or diffuse (all glomeruli are affected)- 50% cut off
- Global versus segmental: global affects all parts of the glomeruli and segmental only part of the glomeruli is affected- 50% cut off