Chronic Kidney Disease Flashcards
Definition and stages
Impaired Renal function lasting > 3 months
- with a GFR < 60
1 > 90 2 60 - 89 3A 45-59 3B 30-44 4 15-29 5 <15 or on dialysis
Causes of CKD
- Diabetes (most common)
- HTN
- glomerulonephritis (commonly IgA nephropathy)
- idiopathic
- atherosclerosis
- pyelonephritis
- congenital (PCK)
- Urinary tract obstruction (usually reversible cause)
HPC
symptoms usually begin with urea > 40 mmol/L
- Nocturia, polyuria or oligouria
- loss of apetite, nausea and vomiting, fatigue, weakness
- Paresthesia/tetany (due to hypoclacaemia)
- often asymptomatic if slow progression
Symptoms of Complications:
- SOB, palpitations, pallor (anaemia)
- Bone pain (renal bone disease)
- Pruritis and photosensitivity
- GI sx = pain, reflux, constipation
- confusion, depression, carpal tunnel, restless leg, peripheral neuropathy
- dyspnea and ankle swelling (f. overload)
- Gout
- Dialysis = access problems, infection, pericarditis, peritonitis
Ascertaining aetiology
> glomerulonephritis = Hx of proteinuria, haematuria, oedema, sore throat, immunosuppressive rx
Recurrent UTIs
PCK = FHx, haematuria, HTN
Reflux nephropathy = childhood renal infections, cystoscopy, opoerations
Connective tissue - especially SLE and scleroderma
Trigger for first presentation and previous Ix and Mgt
triggers: NSAIDs, radiocontrast, ACEi, Infection, dehydration, anaemia
Ix: Urinanalysis + Renal biospy
Prev Management:
- Dietary (salt, water and protein restriction)
- Medications = ACEi, EPO, Steroids/immunosuppresion
- Dialysis (haem or perit = how often, relief of symptoms)
- Operations (renal tract, parathyroid-ectomy)
- Transplant workup?
Important PMH, Med, FH, SH?
PMH = previous chemo or multisystem disease (eg SLE) MED = NSAIDs and other analgesia FH = renal disease, diabetes, HTN SH = smoking, employment, support, finances
Examination ?
General
- mental state
- hyperventilation/Kussmaul’s breathing
- Skin - pallor, pigmentation, purpura, yellow (uremic)
Hands
- Nails - terry’s nails (entirely white with small band of brown and tip)
- asterixis
- neuropathy
Arms
- bruising, pigmentation, scratch marks
- High BP + postural drop
- peripheral myopathy
- AV fistula
Face
- anaemia, jaundice
- dry mouth
- fundoscopy - HTN and DM changes
Chest
- heart =pericarditis, failure
- lungs =infection, pulmonary oedema
Abdomen
- scars (dialysis, operations)
- kidneys -usually impalpable unless PKD or tumour
- bladder, liver, lymph nodes
- ascites
- bruit
legs
- oedema
- bruising, pigmentation, scratch marks
- gout
- nephropathy
Neuro
- proximal myopathy
Investigations
Bloods:
- Glomerular function = eGFR, Cr clearance, plasma Cr/urea level
- Tubular function = UEC, albumin
- FBC = normocytic, normochromic anaemia, platelet abnormalities
- Fe studies
- Parathyroid hormone
- Underlying disease = ANA, hepB + hepC
Urine:
- dipstick
- culture and sensitivity
- 24h Urine ACR
Imaging:
- Renal Ultra Sound = size (often small < 8cm) unless other going on (eg. infiltrative disease, PCK, early diabetic nephropathy)
- CT (being wary of contrast)
- Cystoscopy
- Renal artery doppler or CT renal angio
Other:
BIOPSY!! = looking for cause
Complications of CKD
MS CAN BEG
- Metabolic abnormalities
- Gout (urate retention, dont use NSAIDs)
- Insulin (increased requirement)
- lipids (hypercholesterolaemia)
- High K (not excreted and so leads to acidosis) - Skin
- Pruritis, dry skin - Cardiovascular
- risk factors (HTN, DM, smoking, calcium overload)
- pericarditis
- HF due to fluid overload (from a lack of salt and H2O excretion) - Anaemia
- EPO deciciency = SOB - Nervous system
- reduced seizure threshold
- ANS overactivity = HTN
- PNS = carpel tunnel, RLS
- Peripheral neuropathy = common in DM - Bone Disease
- renal osteodystrophy = hyperparathyroid, osteomalacia, osteoporosis, osteosclerosis - Endocrine
- affects prolactin, LH, testosterone, thyroid - GI
- decreased gastric emptying = GORD, acute pancreatitis, constipation
Management
- Treat aggressively the underlying cause - HTN, DM
- Slow progression and manage complication
ELMSA
Education around their disease, the progression and the need for treatment
Lifestyle
- Smoking cessation
- physical activity
- Diet - salt/water balance, reduced fats, restrict dietary phosphate if Renal bone disease
Medication
Manage CVD
- BP control with ACEi or ARB
- Lipids
- Aspirin
Manage Anaemia
- EPO if CKD 3 and Hb <100
- exclude Fe deficiency
- aim for Hb 110-120
Renal Bone disease
- Treat if elevated PTH
- Restrict dietary phosphate
- Phosphate binders - eg. Calcitab
- Calcitriol - increases calcium
RLS
- Clonazepam or gabapentin
Oedema
- high dose loop diuretics
Dialysis/RRT
Indications for acute dialysis A - acidosis E - electrolyte abnormal (hyperkalaemia or acidosis refractory to medical therapy) I - intoxication O - oedema (refractory to diuretics) U – uraemia – pericarditis
Long term A – acute renal failure F – fluid overload despite mx U – uraemic symptoms despite mx C – creatinine > 1000 K – hyperkalaemia despite mx E – electrolyte abn despite charcoal D – drugs eg dabigatran
Peritoneal versus haemodialysis
Peritoneal
- CV safe, large volumes, freedom of diet, preferable in DM
- Peritonitis, protein loss, doesn’t control uraemia
Haem
- 18 hours per week, no protein loss, large volumes
- circulatory access problems, heparin increased risk of bleeding, increased CV instability, dietary compliance needed, anaemia.
