Case 22- CKD Flashcards
Causes of proteinuria
CKD
Physical exercise
Fever
Pregnancy
UTI
Hypertensive emergency (renal damage)
Nephritic/ nephrotic syndrome
Urinary protein
NICE recommend using the albumin:creatinine ratio (ACR) in preference to the protein:creatinine ratio (PCR)
Should be a first-pass morning urine specimen
if the initial ACR is between 3 mg/mmol and 70 mg/mmol, this should be confirmed by a subsequent early morning sample. If the initial ACR is 70 mg/mmol or more, a repeat sample need not be tested.
NICE guidelines state ‘regard a confirmed ACR of 3 mg/mmol or more as clinically important proteinuria’
Metabolic complications from CKD
CKD mineral bone disease- hypocalcaemia and hyperparathyroidism (vitamin D analogue)
Renal anaemia (EPO and IV iron- target ferritin over 200 in CKD)
Metabolic acidosis (sodium bicarbonate)
Hyperkalaemia (dietary restriction and consider reduction if ACE-I)
Azotaemia
Elevation of nitrogenous metabolic waste in the blood due to failure of clearance by the kidneys
Uraemia
The clinical syndrome that the progressive azotameia displays (failing kimdeys)
Breathlessness in CKD
Anaemia
Fluid overload (pulmonary oedema)
Metabolic acidosis (lost bicarbonate)
Associated heart failure
Kaussmal respiration
Fast, deep respiration (blowing off extra CO2- compensate for the increased acid that the ketones have produced)
Indications for acute dialysis
AEIOU
Acidosis, Electrolytes (refractory hyperkalaemia), Ingestion of toxins, Overload (fluid), Uraemia
CKD Definition
Kidney damage (marker of kidney damage eg.proteinuria) or a reduction in the glomerular filtration rate to <60 for more than 3 months duration (first 2 stages have to have kidney damage, the next 3 just need eGFR below 60)
CKD Sx
Asymptomatic usually
Fatigue, oedema, SOB (oedema, anaemia, metabolic acidosis), nausea, vomiting, pruritis, anorexia, hyperkalaemia, hyperphosphataemia, hypocalcaemia, metabolic acidosis, CKD MBD
Investigations for CKD
Urinalysis- abnormal urine sediment, haematuria, light chains, protein quantification (albumin:creatinine (ACR))
Bloods- UE (hyperkalaemia, hyperphosphatemia, hypocalcaemia, creatinine, eGFR), PTH, FBC (anaemia)
USS- shrunken kidneys with fibrotic parenchyma
Renal biopsy determine underlying cause
NB- 2 tests required 3 months apart to confirm a diagnosis
Management of CKD
Refer to nephrology if they meet criteria
Optimise diabetic control
Lifestyle advice- dietary advice, exercise, smoking, weight, vaccines, nephrotoxic drug avoidance (NSAID, vancomycin), counselling
ACE (raised A:Cr), ARB, statin (all CKD pts need statin)- BP 130/80 or 125/75 (proteinuria)
NHP Ca channel blocker
Early education about RRT
Iron and exogenous EPO if anaemia
Remedy secondary hyperparathyroidism (vitamin D analogue, phosphate binding drug)
RRT or transplant
Referral to nephrologist
EGFR- less than 30
ACR- above 70
Accelerated progression defines as a decrease in EGFR of 15ml/min or 25% in 1 year
Uncontrolled HTN despite 4 hypertensives
CKD MBD X-ray
Rugger jersey appearance of the spine (striped densities)
ACE and kidney function
EGFR can fall 25% and creatinine can rise 30%
Indications for long term dialysis
End stage renal failure (stage 5 CKD)
Any acute indication continuing long term
Contraindications to a renal transplant
Absolute- metastatic cancer
Temporary- active infection, HIV with viral replication, unstable CVD
Relative- CVD, CCF
Sx of diabetic nephropathy
Initially asymptomatic, HTN, oedema, foamy urine
NB- retinopathy and neuropathy as well (ask about these)
Investigations for diabetic nephropathy
Urine sample for urinalysis (proteinuria), ACR (not detected on a dipstick), glucosuria, finger prick BM
Bloods- FBC (anaemia), UE, blood glucose, HBA1c
Kidney USS- exclude other impairment (large kidneys initially also)
Kidney biopsy- if evidence of another systemic disease (also when no retinopathy- often occur together)
NB- check for retinopathy and neuropathy
NB- ACR should be repeated twice more over 3-6 months to confirm diagnosis
Management of diabetic nephropathy
Conservative- optimise blood sugars, BP (130/80), dietary protein restriction
ACE-I (or ARB, even if BP normal)
Statin- control hyperlipidaemia
Pathognomic feature of DN on a microscopy slide
Kimmelsteil Wilson lesions
Stages of CKD
1- 90+
2- 60+
3a- 45+
3b- 30+
4- 15+
5- below 15
NB- can only diagnose stage 1 and 2 if there is supporting evidence
Management of CKD MBD
Low phosphate diet first, then phosphate binders eg. Sevelamer or calcium carbonate
Vitamin D
Parathyroidectomy
Bisphosphonates if at immediate risk of a fracture
ACE-I and CKD
Can be used in CKD
May cause drop in eGFR of 25% and a rise in creatinine of 30%
Used when a raised albumin:creatinine ratio
ESRD
Stage 5 CKD (eGFR less than 15) requiring RRT
AVF complications
Aneurysm
Infection
Thrombosis
Stenosis
STEAL syndrome
High output heart failure
Failure
Steal syndrome
Distal ischaemia of the AVF limb
Immunosuppressants post renal transplant
Tacrolimus
Mycophenolate
Prednisolone
CKD and hypocalcaemia
Indicates that CKD is chronic and not acute
Water requirements in adult maintenance fluids
25-30ml/kg/day (not child)
Troublesome gynaecomastia on spironolactone
Eplerenone
Raised renin
Can differentiate primary and secondary hyperaldosteronism
If raised, likely secondary eg. Renal artery stenosis
Sevelamer
Non calcium based phosphate binder
Complication of orang transplantation
Squamous cell skin cancer
Hyper acute transplant rejection
No treatment- remove graft
Caused by pre existing antibodies against ABO or HLA
AKI vs CKD
CKD- hypocalcaemia and bilateral small kidneys, and blood tests will reveal a chronic picture (ie. 3 months duration)
Exceptions to small kidneys;
-ADPKD
-diabetic nephropathy
-amyloidosis
-HIV associated nephropathy
Management of ADPKD
Manage complications eg. Anti HTN, avoid NSAIDs, regular monitoring, lifestyle modification (avoid impact sports, fluids, etc.)
Genetic counselling
Tolvaptan (vasopressin receptor antagonist) in some patients
Renal transplant (only cure)
NB- 25% have no FH (recessive is a very rare disease and usually presents in childhood, not adulthood)
Alport syndrome
Inherited in Xlinked dominant pattern
Abnormal GBM
Features;
Microscopic haematuria
Renal failure
Bilateral deafness
Retinitis
Protruding Lens
Split laminate densa/basket weave appearance (renal biopsy)
NB- if their renal transport fails, it could be due to the presence of anti GBM antibodies
Treatment of CKD anaemia
Determine iron status first- may require IV iron before erythropoietin stimulating agent
ESA’s = erythropoietin and darbepoetin
Calcium based phosphate binders
Eg. Calcium carbonate
Problems- hypercalcaemia and vascular calcification
Pathophysiology of CKD MBD
Low vitamin D
High phosphate
Low calcium
Secondary hyperparathyroidism (due to low calcium)
NB- prolonged secondary hyperparathyroidism can cause tertiary hyperparathyroidism
EGFR is based on what variables
CAGE
Creatinine
Age
Gender
Ethnicity
NB- pregnancy, muscle mass (amputee, body building), eating red meat 12 hours prior, can all affect result
CKD HTN management
ACE first line (good for proteinuria)
Furosemide can be added
CKD and proteinuria
NICE recommend using ACR (albumin:creatinine ratio)
3mg/mmol is clinically important proteinuria
Proteinuria and referral to a specialist
ACR of 70+ (unless caused by diabetes and properly treated)
ACR of 30+ with persistent haematuria after exclusion of UTI
ACR of 3-29 with persistent haematuria and other risk factors eg. Declining eGFR, CVD
Management of CKD proteinuria
ACE (or ARB)
If ACR is 70+, give ACE regardless if BP
Common causes of polyuria
Diuretic use
Caffeine and alcohol
Diabetes Mellitus
Lithium
Heart failure
Renal transplant post op problems
ATN graft
Vascular thrombosis
Urine leakage
UTI
Hyper acute rejection (minutes to hours)
Pre existing antibodies to ABO or HLA
Type 2 hypersensitivity
No treatment and remove graft
Acute graft failure (<6 months)
Cell mediated cytotoxic T cells (mismatch of HLA)
Asymptomatic (rising creatinine, pyuria, proteinuria)
Reversible (steroids and immunosuppressants)
NB- CMV is a cause
Chronic graft failure (6 month +)
Antibody and cell mediated mechanism
Fibrosis to transplant
Recurrence of original disease
Immunosuppression post transplant regime
Initial- cyclosporin/tacrolimus + monoclonal antibody
Maintenance- ciclosporin/tacrolimus, + MMF, + sirolimus
Add steroids if acute rejection episodes
Cyclosporin
Calcineurin inhibitor (T cell inactivation)
HTN, hyperlipidaemia, acute rejection
Tacrolimus
Impaired glucose tolerance and diabetes
MMF
B and T cell proliferation
SE- GI and marrow suppression
Sirolimus (rapamycin)
IL-2 receptor
Hyperlipidaemia
Diabetic nephropathy management
Optimise glycaemic control
Dietary protein restriction
BP (less than 130/80)
ACE or ARB
Statin for dyslipidaemia
Side effects of erythropoietin
Accelerated HTN (encephalopathy and seizures)
Bone aches
Flu like symptoms
Skin rashes, urticaria
Pure red cell aplasia
Iron deficiency
Falconi syndrome Sx
Polyuria
Glucosuria
Phosphaturia
Osteomalacia
Causes of Falconi syndrome
Cystinosis
Sjogrens
Multiple myeloma
Nephrotic syndrome
Wilson’s disease
Fibromuscular dysplasia
Renal artery stenosis secondary to atherosclerosis is most common cause of renal VD, but FMD causes the remaining 10%
90% patients are female
HTN, CKD or acute renal failure due to ACE
Flash pulmonary oedema
NB- don’t use ACE or ARB in renal artery stenosis (CCB for HTN)
Caution with 0.9% saline
Large volumes can cause hyperchloraemic metabolic acidosis
Caution with Hartman’s
Contains potassium so shouldn’t be used in hyperkalaemia
Preferred anticoagulants for patients with renal impairment
Apixaban
Kidney size on USS
Large- HIV nephropathy, autosomal dominant polycystic kidney disease, diabetic nephropathy and amyloidosis.
Small- CKD, Glomerulonephritis, hypertension induced nephropathy, renal artery stenosis, chronic pyelonephritis
Vitamin D and CKD
Alfacalcidol is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys
Common electrolyte abnormality ESRD
This combination of hypocalcaemia and hyperkalaemia is often seen in patients undergoing dialysis.
ESRD and pain relief
Oxycodone is a safer opioid to use in patients with moderate to end-stage renal failure
