Case 2 - CKD Flashcards
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Define CKD
- Presence of kidney damage
- Abnormal albumin excretion or decreased kidney function
- Quantified or measured by eGFR that persists for more than three months
How is CKD staged?
eGFR with associated albumin (ACR) score
eGFR CKD stage G1
- eGFR 90 or more but signs of kidney damage
- Normal and high
eGFR stage G2
- 60-89 with markers of kidney damage
- Mild reduction related to normal range for young adult
eGFR stage G3a
- 45-59
- Mild-moderate reduction
eGFR stage 3b
- 30-44
- Moderate to severe reduction
eGFR stage 4
- 15-29
- Severe reduction
eGFR stage 5
- eGFR <15
- Kidney failure
ACR score A1
- Less than 3 mg/mmol
- Normal to mildly increased
ACR score A2
- 3-30mg/mmol
- Moderately increased
ACR score A3
- More than 30mg/mmol
- Severely increased
Causes of CKD
- Diabetes
- HTN
- Glomerulonephritis
- Renovascular disease
- PCKD
- Obstructive nephropathy - urological problems
- Chronic/recurrent pyelonephritis
Complications of CKD
- Anaemia of chronic disease
- CKD mineral and bone disease
- Secondary and tertiary hyperparathyroidism
- HTN
- Cardiovascular disease - no1 cause of death
- Malnutrition/sarcopenia
- Dyslipidaemia
Complications of CKD as it progressess
- Electrolyte distubances
- Fluid overload
- Metabolic acidosis
- Uraemic pericarditis
- Uraemic encephalopathy
Who is involved in renal management?
MDT eg renal physicians, GPs, renal specialist nurse, dieticians, pharmacists, vascular surgeons
Management of CKD - general
- Treat underlying disease
- Reduce CV risk
- Reduce progression of CKD
- Prevent complications
- Plan for future - RRT?
How do we treat underlying disease in CKD?
- Treat and monitor diabetic control
- Treat HTN
- Treat infections promptly
- Tolvaptan if meeds criteria for PCKD
- Immunosupression for glomerulonephritis if needed
How do we reduce CV risk to patients with CKD?
- Statin
- BP control -<130/80
- Improve diabetes control
- Weight loss
- Exercise
- Stop smoking
How do we reduce progression of CKD
- Reduce proteinuria - ACEi/ARBs
- Monitor bloods
- Control BP
How do we prevent/treat complications in management of CKD?
- Dietary advice re low phosphate and low K+ diet
- Phosphate binders
- IV iron/folate/Vit B12 replacement
- EPO
- Replace Vitamin D deficiency
- Calcimimetics for tertiery hyperparathyroidism
- Dietician help
What do we discuss in plan for future for management of CKD?
- Options if reach end stage renal failure
- Home care team input
- Discuss advantages and disadvantages of types of RRT
Depending on choice:
* Fistula referal - venous mapping?
* Refer for PD tube insertion?
* Work up for transplant? - tests and transplant clinic
Which diabetes causes diabetic nephropathy?
Type 1 DM or long duration of Type 2
What is diabetic nephropathy often associated with?
Other microvascular diabetes complications eg
* Retinopathy
* Peripheral neuropathy
How is diabetic nephropathy often diagnosed?
- Screening for it if have diabetes
- Raised urine albumin:creatinine ratio/PCR raised
- Evidence of long standing/poorly controlled DM
- Evidence of other microvascular disease
Treatment of diabetic nephropathy
- ACEi/ARB - reduce proteinuria
- Anti-hypertensives for BP control
- CV risk modification
- Continue screens for microvascular complications eg eye and foot checks
What is hypertensive nephropathy?
- Chronic raised BP causes nephrosclerosis
- Difficult to tell at advanced presentation whether HTN caused renal problems or the other way around
Investigations to identify primary or secondary HTN
- 24hr metanephrines (Phaechromocytoma)
- Aldosterone:renin ratio (primary aldosteronism)
- Cortisol and dexamethasone supression test (Cushing syndrome)
- TSH (hyperthyroidism)
- MRA (renal artery stenosis)
Treatment for hypertensive nephropathy
Anti-hypertensives
What is polycystic kidney disease?
Autosomal dominant condition resulting in cysts within kidney which can rupture and/or become infected
Two types of PCKD
- Type 1 - PDK1 mutation on chromosome 16 (85%)
- Type 2 - PDK2 mutation on chromosome 4 (15%)
Symptoms of PCKD
Related to size/infection of cysts eg
* Flank pain
* Haematuria
* Fever
* Or can be asymptomatic
Diagnosis for PCKD
USS
Family history is KEY
Treatment for PCKD
- Control BP
- Tolvaptan (vasopressin receptor 2 antagonist) available if slow progression of CKD
- Genetic counselling and testing
2 common complications of CKD
- Anaemia of chronic disease
- Mineral bone disease
What factors contribute to cause anaemia of chronic disease in CKD?
- Decreased EPO production
- Absolute iron deficiency - poor absorption/malnutrition
- Functional iron deficiency - inflammation/infection
- Blood loss
- Shortened RBC survival
- Bone marrow supression - uraemia
- Medication induced
- VitB12/folate deficiency
Managment of anaemia of CKD
- Measure haematinics - Vitamin B12, folate, folate, ferritin, iron, transferrin saturation, CHr
- If deficient - replace first
- IV iron may be better tolerated than PO
- Discuss with renal team re starting ESA (erythropoesis stimulating agent)
- Aim for Hb 100-120
How can CKD mineral bone disease be diagnosed - criteria?
- Abnormalities of calcium, phosphate, alkaline phosphatase, PTH or Vit D metabolism
- Vascular +/- soft tissue calcification
- Abnormal bone turnover, metabolism, volume, linear growth/strength
Low turnover bone states in CKD
- Adynamic bone disease
- Osteomalacia - low Vit D usually
High bone turnover states CKD
Osteitis Fibrosa - usually due to high PTH
What does CKD lead to in terms of causing mineral bone disease?
- Increased fibroblast GF23
- Increased alkaline phosphatase and PTH
- Increased phosphate
- Decreased serum calcium
- Decreased 1,25 Vitamin D
What is tertiary hyperparathyroidism?
PTH is released despite raised Ca2+ levels (independently)
As a result of PT gland nodular hyperplasia
Consequence of advanced CKD
Management of CKD mineral bone disease
- Reduce occurance and or severity of bone disease
- Reduce CV morbidity and mortality caused by elevated PTH and high phosphate and calcium overload
Signs of CKD
- Jaundice
- Raised JVP
- Pallor
- Excoriation of pruiritis
- Bruising
- AV fistula for dialysis
- Brown line pigmentation of nails
- Central venous catheter for dialysis access
- Scar of kidney transplant
- Tenckoff catheter for peritoneal dialysis
- Crackles lung bases - pulmonary oedema
Tests to confirm cause of CKD
- Urine ACR
- Urine dipstick - haematuria
- BP
- Serum HbA1C
- Renal USS - PCKD? Obstruction?
- Renal angiogram - renal artery stenosis?
- Autoimmune screen - ANA/anti-dsDNA, C3, C4 (SLE), anti-GBM (goodpastures) ANCA (vasculitis)
- CV disease - echo? lipids?
