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Medicine year 3 ANNA > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What are the 8 functions of the Kidneys?

A
  1. Regulation of inorganic ions (Na+, K+, Ca2+, Cl-, Pi, Mg2+)
  2. Regulation of water balance and osmolality
  3. Excretion of nitrogenous wastes (urea, creatinine)
  4. Excretion of foreign chemicals (drugs, pollutants etc.)
  5. Regulation of pH and HCO3-
  6. Synthesis of renin
  7. Synthesis of erythropoietin + activation of Vitamin D3
  8. Gluconeogenesis (liver much more important for this)
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2
Q

What is RRT (Renal Replacement Therapy) and what does it involve?

A

RRT = therapy that replaces blood filtering function of the kidneys

Used in AKI and Chronic Kidney Disease

It involves:

  1. Hemodialysis
  2. Peritoneal dialysis
  3. Renal transplant
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3
Q

What is Orthostatic Proteinuria?

A
  • It is a benign condition caused by changes in renal hemodynamics
  • Present in 2-5% of otherwise normal pts
  • Caused by prolonged period of standing
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4
Q

Proteinuria can occur in other situtations, which do not indicate CKD, name 6?

A
  1. After physical exercise
  2. Fever
  3. Pregnancy
  4. UTI
  5. Abnormally high BP
  6. Nephrotic / nephritic syndrome
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5
Q

What are the 4 main features of Nephrotic Syndrome?

A
  1. Proteinuria ( >3.5g in 24hrs, ++++ Protein Dipstick, urine looks frothy)
  2. Hypoalbuminaemia (Albumin lost in urine due to gaps in podocytes of glomerulus)
  3. Oedema (Albumin lost in urine –> ↓ intravascular oncotic pressure –> fluid moves into into surrounding tissues)
  4. Hyperlipidemia (Liver compensates for hypoalbuminaemia by ↑ production, but side effect is ↑ lipid production)
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6
Q

What are the 4 main features of Nephritic Syndrome?

A
  1. Haematuria (+++ Blood dipstick - microscopic or macroscopic)
    • Possible ‘red cell casts’ = microscopic cylindrical structure, present in urine, produced in nephrons in diseased states
    • Haematuria occurs due to gaps in podocytes of glomerulus
  2. Proteinuria (++ Protein dipstick = small amount)
  3. Hypertension (usually mild)
  4. Low Urine Volume (i.e. oliguria, < 300 ml/day) - due to ↓ renal function
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7
Q

Urine dipstick detects proteinuria, in which 2 areas of the Kidney’s can the problem be?

A
  1. Glomerulus pathology
  2. Tubulointersitial pathology
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8
Q

What 2 things can Pyuria (pus in urine) and/or white cell casts (microscopic cylindrical white cell structures which form in nephrons in pathological states) in urine indicate?

A
  1. Intersitial Nephritis (most commonly caused by reaction to medication e.g. β-lactam Abx and NSAIDs, but can also be casued by infection)
  2. UTI
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9
Q

What can Spot Urine Collection for total protein : creatinine ratio be used as an estimate of?

A

24hr Urinary Protein Excretion

  • Degree of proteinuria correlates with progression of kidney disease
  • Degree of proteinuria is most reliable prognostic factor in CKD
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10
Q

Which has greater sensitivity for low levels of proteinuria;

Protein:creatinine ratio

OR

Albumin:creatine ratio

A

Albumin:creatinine Ratio

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11
Q

Which method of monitoring proteinuria is recommended for diabetics;

Protein:creatinine ratio

OR

Albumin:creatine ratio

A

Albumin:creatine ratio

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12
Q

What should a patient with urinalysis indicating non-visible haematuria have done?

A

Urine Culture (to exclude UTI)

  • If UTI is excluded –> repeat urinalysis TWICE to confirm PERSISTENT non-visible haematuria –> refer for urological review
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13
Q

Which is the most important factor to address to ↓ risk of future cardiovascular disease?

Cholesterol

Blood Pressure

Diabetes

Weight

Smoking

A

Blood Pressure

  • Several multi-national trials suggest that although all factors are important, blood pressure control has the MOST impact on CV events in future
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14
Q

How can you assess a patients riks of developing Cardiovascular Disease?

A

QRISK

  • Estimate the risk of developing cardiovascular disease over the next 10-years
  • Influential Factors:
    • Age
    • Gender
    • Ethnicity
    • Smoking status
    • Comorbidities: Diabetes status, SLE, Migraine, RA, AF
    • Medications e.g. BP meds, steroids, antipsychotics
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15
Q

What are normal values for:

  1. PCR (Protein : Creatinine ratio)
  2. ACR (Albumin : Creatinine ratio)
A

PCR < 15 mg/mmol

ACR < 3 mg/mmol

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16
Q

What 2 factors are used to Stage Chronic Kidney Disease?

A

eGFR and ACR (albumin:creatine ratio)

  • Patient is classified as G1, G2, G3a, G3b, G4 or G5 based on eGFR
  • Patient is classified as A1 - A3 based on ACR
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17
Q

What ranges for 24hr urine collection, spot urine albumin, and spot ACR indicated microalbuminuria (moderate ↑ urine albumin)?

A
  • 24hr urine collection = 30-300 mg/24hr
  • Spot urine albumin = 30-300 mg/L
  • ACR = 3.5-35 mg/mmol
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18
Q

Which protein is secreted by renal tubules up to 150 mg/day

and forms the boundary for the normal level of protein in urine

(<150 mg/day)?

A

Tamm-Horsfall Glycoprotein (THP) also called Uromodulin

  • > 150 mg/day = proteinuria –> suggests ↑ glomerular permeability
  • This protein is not tested for by urine dipstick (which usually tests for albumin)
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19
Q

What classes of drugs are considered ‘Renoprotective’ and are used to; mangage progression of CKD, lower BP and manage nephropathy in diabetics?

A

ACE-I and ARBs (Angiotensin II receptor blockers)

  • Progression of CKD can be slowed using ACE-I or ARBs independent of their effect on BP
  • In Type 1 DM:
    • ACE-I –> ↓ albuminuria + reduce diabetic nephropathy
    • ARBs –> ↓ proteinuria
  • In Type 2 DM:
    • ACE-I –> ↓ abuminuria + reduce diabetic nephropathy + reduce CDK progression
    • ARB –> ↓ abuminuria + reduce CDK progression
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20
Q

Via what 3 mechanisms does Diabetes cause Nephropathy?

A
  1. ↑ Glomerular Pressure
    • Hyperglycaemia –> ↑ RAAS system –> ↑ angiotensin II –> vasocontriction of efferent arteriole + ↑ peripheral resistance –> heart responds by ↑ BP
  2. Barotrauma of mesangium (Cells surrounded by cappilary lumen - see pic)
    • ↑ BP in glomerulus –> mesangial cells secrete cytokines (inflammation) + undergo mesangial expansion - which causes:
      • ↑ pressure applied to glomerular cappilaries –> ↓ surface area for filtration
      • Podocytes to move apart –> allowing larger molecules to be filtered
  3. Nephron Ischaemia
    • The vasculature suuplying the nephrons comes off the efferent arteriole - hence vasoconstriction of this vessel ↓ blood supply to nephrons –> atrophy + destruction
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21
Q

What clinical finding is indicative of the first stage of Diabetic Nephropathy?

A

↑ eGFR

  • This is due to ↑ glomerular BP caused by RASS activation and the heart working against ↑ vasocontriction
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22
Q

Are the Kidneys intraperitoneal or retroperitoneal?

A

Retroperitoneal

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23
Q

At what Spinal level are the Kidneys?

A

T12 - L3

24
Q

What is included in the definition of Chronic Kidney Disease?

A
  1. Presence of Kidney damage for ≥ 3 months and/or …
    • Kidney damage defined as pathological abnormalities in;
      • Blood
      • Urine
      • Imaging - renal structure or renal tract abnormalities
      • Renal biopsy evidence
  2. eGFR < 60 ml/min/1.73m2 on at least 2 seperate occasions seperated by at least 90 days (with or without markers of kidney damage)
25
Q

Is it common or not for patients with non-advanced CKD to have overt symtpoms?

A

Uncommon

  • Overt symptoms from CKD are restricted to those with advanced CKD
26
Q

Is CKD as a whole more common in the eldery or the young?

What are the 3 most common causes of CKD?

A

Elderly

  1. Diabetes
  2. Hypertension
  3. Glomerulonephritis
27
Q

Is advanced CKD more common in the elderly or the young?

A

Young

  • In later stages of CKD (4 or 5) there is ↑ prevalence of young patients with glomerulonephritis and genetic causes of CKD
  • Elderly patients tend not to have advanced CKD as they often have other co-morbidities which result in death before development of advanced CKD
  • There is concern that elderly patients are given a higher CKD classification as a pathology when it may be due to natural decline in kidney function with age
28
Q

Is End-Stage Kidney Disease rare or common?

A

Rare

  • Incidence (2009) was 109 per million population
29
Q

What nitrogenous waste product is used to calculate eGFR?

A

Creatinine

30
Q

What are common side effects of ACE-I?

A
  • Dry Cough (~10% suffer from this) - often requires cessation
  • Angioedema (1-2 per 1000 white population) i.e. swelling of lower layer of skin in face, tongue, larynx, abdomen, arms or legs
  • Hypotension
  • Hyperkalemia
  • ↓ eGFR (up to 15% is acceptable, >15% stop medication and review)
31
Q

How might plasma creatinine change due to ACE-I / ARBs?

A

↑ plasma creatinine

  • 25-30% increase is considered acceptable
  • Plasma [Creatinine] must be checked after starting ACE-I / ARB and after every dose change (same with plasma K+)
  • If creatinine does ↑ then blood needs to be checked regularly as a more significant ↑ could indicated –> renovascular disease / renal artery stenosis
32
Q

In which patients are ACE-I contraindicated?

A

Pregnant or mothers desiring pregnancy

  • Avoid unless essential
  • Affect fetal BP and renal function
  • ↑ risk of congenital malformations
33
Q

In what situtations should a patient be referred to Nephrology?

A

According to eGFR (ml/min/1.73m2):

  • < 15 (CKD 5) - Immediate referral/discussion
  • 15-29 (CKD 4) - Urgent referral/discussion (routine if pt is stable)
  • 30-59 (CKD 3) - Routine referral if:
    • Sustained ↓ in eGFR of ≥25% AND a change in GFR category within 12 months
    • OR
    • Sustained ↓ in GFR of ≥15 ml/min/1.73m2 within 12 months
    • Unexplained microscopic haematuria
    • Proteinuria PCR > 45 mg/mmol
    • Unexplained anaemia (i.e. Hb <110 g/L), abnormal K+, Ca2+ or phosphate
    • Systemic illness e.g. SLE, RA
    • Uncontrolled BP (>150/90 on 4 agents)
  • 60+ (CKD 1/2) - referral not required unless other evidence of kidney disease

Referral Irrespective of eGFR:

  • Malignant HTN
  • Life threatening Hyperkalaemia ( K+ > 7.0 mmol/L)
  • Nephrotic Syndrome
  • Macroscopic haematuria + negative urological tests
  • Proteinuria + microscopic proteinuria
  • Dipstick proteinuria + PCR > 100 mg/mmol
34
Q

What is the target Ferritin for Renal Anaemia due to CKD?

A

> 200 ug/L

35
Q

What is the mechanism of Renal Anemia in CKD?

A

CKD causes damage to the Kidney peritubular cells –> ↓ erythropoietin production

↓ erythropoietin production –> ↓ RBC / Haemoglobin = Anaemia

36
Q

What are the 4 main effects of CKD on the body?

A
  1. Anaemia (renal)
  2. Metabolic Acidosis
  3. Secondary Hyperparathyroidism / Hypocalcaemia
  4. Hypertension

Analyse this diagram on management of CKD + Complications

37
Q

What is the normal size of a Kidney?

Size of Kidney in the following;

Atrophy

Hypertrophic

Polycystic

A
  • 11 cm = normal
  • 7.5 cm = atrophy
  • 13.5 cm = hypertrophy
  • 18.4 cm = polycystic

Note - besides the normal size, these are example measurements (not cutoffs)

38
Q

What is Azotemia?

A

Raised nitrogenous waste compounds (urea and creatinine) in the blood often due to insufficient filtering of blood by Kidneys

39
Q

What is Uraemia?

A

Clinical syndrome that results from failing Kidneys and progressive azotaemia - High blood urea levels

40
Q

What is the normal range of eGFR?

A

100-130 ml/min/1.73m2

41
Q

What are 6 indications for dialysis?

A
  1. pH < 7.2 (acidaemia due to metabolic acidosis, where sodium bicarb may cause fluid overload)
  2. K+ > 7 mmol
  3. Fluid overload (unresponsive to diuretics)
  4. Toxins SLIME = salicylic acid, lithium, isopropanol (antiseptics, disinfectant and detergent), magnesium and ethylene glycol (antifreeze)
  5. Creatinine > 400
  6. Uraemia complications e.g. encephalopathy or uraemic pericarditis (urea enters pericardial sac and fluid follows)
42
Q

What are the 4 types of Diuretics?

A
  1. Osmotic diuretics e.g. mannitol or urea (IV), glycerin or isosorbide (oral)
    • Osmotic diuretics limit reabsorbtion of H2O in nephron via increasing osmolality in renal tubule –> results in ↑ excretion of Na+, K+, Ca2+, Mg2+, Cl-, HCO3-, phosphate and H2O
  2. Loop diuretics - e.g. furosemide, bumetanide
    • NKCC2 antagonists –> inhibiting Na+, K+ and Cl- reabsorption –> ↑ H2O loss
  3. Thiazide diuretics e.g. hydrochlorothiazide and chlorothiazide
    • Na+/ Cl- symporter antagonist (distal convoluted tubule) –> results in ↑ excretion of Na+, K+, Cl-, and Ca2+ but ↓ excretion of Mg2+
  4. K+ sparing diuretics - 2 types:
    • ENaC (epithelial sodium channel) blockers e.g. amiloride or triamterene
    • Aldosterone antagonists e.g. Spironolactone or eplerenone
43
Q

Hemodialysis has 1 absolute contraindication and 5 relative contraindications - what are they?

A

Absolute = Inability to achieve suitable vascular access

Realtive:

  1. severe dementia
  2. severe HF
  3. bleeding disorder
  4. low BP
  5. severe active psychotic disorder
44
Q

What are the 5 absolute contraindications for peritoneal dialysis?

Peritoneal dialysis has many relative contraindications, list some

A

Absolute Contraindications:

  1. IBD
  2. Ichaemic bowel
  3. Acute diverticulitis
  4. Abdominal abscess
  5. Pregnancy 3rd trimester

Relative Contraindications: Stomas, VP shunt, abdo hernias, blind, obesity, severe obstructive airway disease, severe active psychotic disorder

45
Q

Describe Hemodialysis

A
  • Involves filtering your blood via a dialysis machine
  • 4 hour sessions 3 times per week
  • Involves patient going to a clinic or hospital for appointments
  • Done via an IV line inserted into neck or a fistula (which is created in your arm and can take ~3 months before it’s ready for use)
46
Q

Describe Peritoneal Dialysis

A
  • Catheter is inserted through abdomen into peritoneum (tummy cavity)
  • Dialysate solution is inserted into your peritoneum
  • Toxins filter into peritoneum from blood
  • Requires emptying every 4-6 hours, and takes 30 mins
  • Peritoneal dialysis is portable but requires patient training
  • CAPD (continous ambulatory peritoneal dialysis) - patient does themselves and can move about between 30 min fluid exchange (toxin filled fluid out and new fluid in)
  • APD (automated peritoneal dialysis) - done by machine over 7-10 hours every night whilst you sleep
47
Q

What is the target BP for a proteinuric CKD patient?

A

< 130/80

48
Q

Name 9 risk factors for CKD!

A
  • Diabetes
  • HTN
  • Age > 50 yrs
  • Male
  • Black or Hispanic
  • FHx
  • Smoking
  • Obesity
  • Autoimmune disorders
49
Q

What are 6 signs/symptoms of CKD?

A
  1. Fatigue - CKD is associated with renal anaemia due to ↓ erythropoietin production once GFR < 50
  2. Pruritis - due to accumulation of toxic waste products e.g. urea
  3. Hypertension
  4. Oedema - periorbital / peripheraly oedema develops due to salt and H2O retention due to low GFR
  5. Nausea with/without vomiting - accumulation of toxic waste products (urea)
  6. Reduced urine output - low GFR
50
Q

Which of the following is a contraindication to renal transplant?

Active Malignancy

HIV

Age > 80

Concurrent or recurrent infections

Diabetes

A

Active Malignancy

Concurrent or recurrent infections

51
Q

What are the 2 most common causes of ESRD (End Stage Renal Disease) in the UK?

A
  1. Diabetes
  2. Hypertension
52
Q

What is the drug Cinacalcet used for and how does it work?

A
  • Cinacalcet = calcimimetic (mimics Ca2+)
  • It binds to and activates the calcium-sensing receptors on the parathyroid glands –> ↑ negative feedback and inhibiting the gland from further PTH production and section
  • ↓ PTH
53
Q

What is IgA Nephropathy (Berger’s Disease)?

How does it present?

How is it Managed?

A
  • IgA nephropathy = mesangioproliferative glomerulonephritis
  • Commonest cause of glomerulonephritis
  • Pathologenesis = mesangial deposition of IgA immune complexes

Presentation:

  • Young (20-30), Male : Female (2:1)
  • More common in; asian and caucasian
  • Recurrent haematuria - often painless, sometimes loin pain
    • 50% with visible haematuria post URTI or gastroenteritis
    • 33% with asymptomatic micoscopic haematuria
  • Proteinuria - norm <2/3 g/day (often less than nephrotic syndrome range i.e. >3.5g/day)

Management:

  • If HTN and/or proteinuria –> ACE-I or ARBs
  • Steroids/immunosuppressant not shown to be useful

Prognosis:

  • 25% develop ESRF
54
Q

How is IgA Nephropathy different to Henoch–Schönlein purpura (HSP)?

A
  1. IgA Nephropathy is more common in young adults vs HSP is more common in children
  2. IgA Nephropathy typically affects only the kidneys vs HSP is a systemic disease

HSP Summary:

  • Henoch-Schonlein purpura = an IgA mediated small vessel vasculitis
  • Primarily seen in children
  • Features:
    • Palpable purpuric rash - buttocks, extensor surfaces of arms and legs
    • Abdo pain
    • Polyarthritis
    • Features of IgA nephropathy can occur: haematuria + renal failure
  • HSP is self-limiting with excellent prognosis (especially without renal involvement) - 1/3rd have relapses of symptoms
55
Q

What drugs are commonly used for immunosuppression in Renal Transplant?

A
  1. Ciclosporin - inhibits calcineurin (a phosphatase involved in T-cell activation)
  2. Tacrolimus - inhibits calcineurin (a phosphatase involved in T-cell activation)
    • Less HTN or hyperlipidaemia compared to ciclosporin
    • Higher incidience of diabetes
  3. Monoclonal antibodies e.g. Daclizumab or Basilximab - IL-2 receptor inhibitors on T-cells
56
Q

What 3 factors can affect the result of a patient estimate GFR?

A
  1. Pregnancy
  2. Muscle mass (e.g. amputees, body-builders)
  3. Eating red meat 12 hours prior to sample being taken

Medicine year 3 ANNA (30 decks)

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