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Year 3 > Case 22 - CKD > Flashcards

Case 22 - CKD Flashcards

1
Q

What is the definition of CKD?

A

Abnormalities of kidney structure/function over a period of 3 months with implications for health
Usually progressive and irreversible and leads to ESRD over time

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2
Q

What is azotaemia?

A

The build up of nitrogenous waste in the blood due to lack of excretion by the kidneys

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3
Q

What is uraemia?

A

A result of azotaemia due to failing kidneys

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4
Q

RFs for CKD

A 
Age
Smoking
Increased CV risk
Black/hispanic
Male
HTN
Genetics
Autoimmune Hx
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5
Q

Symptoms of CKD

A 
Pruritus
Lethargy
Oedema
N and V
Anorexia
Arthalgia
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6
Q

What are the main causes of CKD?

A 
DM and HTN
Can also be caused by:
-Glomerulonephritis
-Congenital abnormalities
-Recurrent UTIs
-PKD
-Lupus
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7
Q

What is the Pathophysiology of diabetic nephropathy?

A

HTN resulting from diabetes affects afferent arteriole
RAAS is activated by hyperglycaemia > HTN
The high pressures through the glomerulus cause mesangial expansion - there is fibrosis and collagen deposition
GBM becomes thickened as mesangium pushes on it
There is a reduction in glomerular SA to filter the urine through
There is effacement of the podocytes and the gaps between the podocytes become larger to allow larger molecules through them
Nephron ischaemia as they lead from afferent arteriole

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8
Q

How can diabetic nephropathy be staged/classed?

A

Stage 1 - Increased GFR due to HTN
Stage 2 - Preoteinuria
Stage 3 - Microhaematuria due to nephron death
Stage 4 - Oligouria

Class 1 = GBM thickening
Class 2 = mesangial expansion
Class 3 = nodular sclerosis
Class 4 = diabetic glomerulosclerosis

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9
Q

What can you pick up on a MSU?

A 
Proteinuria
Haematuria
Brown muddy casts = tubular necrosis/renal ischaemia
WBC casts = infection
RBC casts = urothelial injury
Glycosuria
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10
Q

What causes proteinuria?

A 
Can be normal after a period of standing 
Can also be present:
-After exercise
-During infection
-In pregnancy
-HTN
-Fever
-Nephrotic/nephritic syndrome

When proteinuria has been found, can do ACR to quantify as it is more sensitive
>150mg is abnormal
Then, can use PCR, or 24 hour urinary collection to monitor the levels of protein in the urine

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11
Q

How can GFR help in CKD diagnosis?

A

Used in part of the definition of CKD as a measure of kidney function
Should consider those with different ethnicities and builds - will have varying amounts of creatinine naturally
Can use to monitor the kidney function rather than relying on a set value
Multiply creatinine x1.2 for those from Afro-Carribean origin due to increased muscle mass

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12
Q

How can USS help in CKD diagnosis?

A

Can visualise any obstruction e.g. ureteric stones
Can also see PKD - well differentiated round cysts

Indicated in:
Persistent haematuria
FHx PKD and aged 20+
GFR<30
Need to have a biopsy
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13
Q

How can biopsy help in CKD diagnosis?

A

To confirm a suspected diagnosis of glomerulonephritis
Can see glomerular sclerosis in DM
Interstitial nephritis

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14
Q

What are the stages of CKD?

A 
Stage 1 GFR >90 - but with signs of kidney injury
Stage 2 GFR 60-89
Stage 3a GFR 45 -59
Stage 3b GFR 30-44
Stage 4 GFR 15-29
Stage 5 GFR <15

Can treat 1 and 2 in primary care
4 and 5 need referral
3 needs referral if rapid decline in GFR, anaemia etc.

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15
Q

How can you stage CKD with ACR?

A 
Using the GFR stage 1-5
ACR 1 = <30mg
ACR 2 = 30-300mg
ACR 3 = >300mg
Can then have a combined G and A staging
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16
Q

Who do you screen for CKD?

A

Anyone who is likely to be vulnerable:
FHx
Older
Low kidney mass

Anyone with direct kidney damage:
HTN
DM
Autoimmune
Sepsis
Obstruction
Long courses of nephrotoxic drugs
17
Q

How do you initially treat CKD?

A

Treat the underlying cause e.g. HTN/Diabetes
Ensure good nutrition and hydration
Treat complications

18
Q

How can you treat hypertension in CKD?

A

ACE-i/ARB can still be used, but are only first line in diabetic nephropathy, high proteinuria or proteinuria and HTN
AIm for 140/90mmHg or 130/80mmHg in DM

19
Q

Which diuretics can be used in CKD?

A

Loop diuretics e.g. furosemide

Osmotic diuretics e.g. mannitol

Thiazide-like diuretics e.g. bendroflumethiazide

Potassium sparing diuretics:
Aldosterone antagonists e.g. spironalactone
Amiloride

Carbonic anhydrase inhibitors

20
Q

How do you alter CV risk in CKD?

A

Lifetsyle and dietary factors
Consider statins, aspirin etc. depending on QRISK
Biggest cause of mortality in CKD patients - due to HTN caused by CKD

21
Q

Pros and cons of haemodialysis

A

Can be done in a clinic or at home
Need fistula inserting 3 months before - should prepare for this
3x a week for 4 hours at a time

Pros
In a clinic you will get to know other CKD pts
Delivered by trained professionals
Can be done at home at your own convenience
Can have more control over your care
Fewer ups and downs between treatment if at home

Cons
Ups and downs between treatments
Not flexible to yourmschedule if in a clinic
Having family treating you can be stressful
Less flexibility to travel
Strict diet

22
Q

Pros and cons of peritoneal dialysis

A

Catheter needs to be inserted into eh abdomen prior to starting the treatment
Can be CAPD, or APD
CAPD - bag exchanges 4x a day
APD - overnight the machine cycles through about 3-5

Pros 
More control over your treatment
Easier to travel
Can be done anywhere
May not need to exchange during the day with APD
Cons
Risk of peritonitis
Continuous treatment - needed 7 days a week
Disruption of daily routine
Restricted movement at night
23
Q

Pros and cons of renal transplant

A 
Pros 
Better quality of life, with easy travel
More time, less spent on dialysis
No special diet
High graft survival
Cheaper to the NHS
Cons
Anti-rejection meds and immunosuppressants means very vulnerable to infection
Extensive testing
Can have a kidney rejected
Wait for an average of 3 years
Last for an average of 15y
24
Q

What are some of the common immunosuppression drugs for CKD?

A 
Tacrolimus
Prednisolone
Azothioprine
Cyclosporin
Sirolimus
25
Q

What are complications of CKD?

A 
Kidney rejection after transplant
Infections in immunocompromised
CKD bone mineral disease
Anaemia
Acidosis
26
Q

How do you treat transplant rejection?

A

Diagnose on biopsy
Will see either lymphocytic infiltration of tubules or vessels
IV steroids to dampen down the immune system’s reaction

27
Q

How are infections different post-transplanted kidney?

A

Most common is UTI or chest
Should be aware of more unusual infections in transplanted patients
Normal infections have a higher mortality rate

28
Q

What is CKD bone mineral disease?

A

Kidney activates vitamin D (1st hydroxylation is done by the liver)
If this activation is not done, there will be a reduction in the absorption of calcium
Alongside the lack of excretion of phosphate from the kidney, this leads to low serum calcium
PTH is made and breaks down bone by activating osteoclasts to release calcium
This is secondary hyperparathyroidism
Tertiary hyperparathyroidism is when the gland has become so used to low calcium, that it stops becoming reactive to negative feedback and a solitary nodule keeps kicking out PTH despite high calcium and phosphorus

29
Q

How does CKD cause anaemia?

A

Kidneys make EPO
When EPO cannot be made, there is not enough RBC made
Normocytic, normochromic anaemia
Need to give ferritin (aim for >200 levels) - higher than in normal patients
Can give weekly EPO injections to patients that need it

30
Q

How can CKD cause acidosis?

A

With the reduction in excretory function of the kidney, fewer hydrogen and potassium ions are lost in the urine and are therefore reabsorbed into the blood
Can give bicarbonate to counteract this
May be respiratory compensation
Urgent dialysis if this gets seevre i.e. hyperkalaemic above 7, pH<7.25

Year 3 (23 decks)

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