Chronic kidney disease

Question 1

Causes of chronic kidney disease

Answer 1

Diabetes
Hypertension 
Age-related decline
GN
PCKD
Medications e.g. NSAIDs, PPIs, lithium

Question 2

RFs for CKD

Answer 2

Older age
HTN
Diabetes
Smoking
Use of medications that affect the kidneys

Question 3

Presentation

Answer 3

Usually asymptomatic and diagnosed on routine testing

May have:

• Pruritus (itching)
• Loss of appetite
• Nausea
• Oedema
• Muscle cramps
• Peripheral neuropathy
• Pallor
• Hypertension

Question 4

Investigations in suspected CKD

Answer 4

eGFR - two tests 3m apart to confirm a diagnosis of CKD

Proteinuria - Urine A:C ratio (>3mg/mmol is significant)

Haematuria - on dipstick

Renal ultrasound - can be used to investigate patients with accelerated CKD, haematuria, family history of polycystic kidney disease or evidence of obstruction.

Question 5

Diagnosis of CKD

Answer 5

eGFR score of <60 or proteinuria for a diagnosis of CKD

Question 6

Complications of CKD

Answer 6

Anaemia (normocytic)
Renal bone disease
CV disease
Peripheral neuropathy
Dialysis related problems

Question 7

When does NICE suggest referral to a specialist?

Answer 7

eGFR<30

ACR >70 mg/mmol

Accelerated progression defined as a decrease in eGFR of 15 or 25% or 15 ml/min in 1 year

Uncontrolled hypertension despite ≥ 4 antihypertensives

Question 8

Management of CKD - aims of treatment

Answer 8

Slowing the progression of the disease

Reduce the risk of CV disease and complications

Treating complications

Question 9

Slowing the progression of CKD

Answer 9

Optimise diabetes and HTN control

Treat GN

Question 10

Reducing the risk of complications

Answer 10

Exercise
Maintain healthy weight
Stop smoking

Atorvastatin 20mg for primary prevention of CV disease

Special dietary advice - about phosphate, sodium, potassium and water intake

Question 11

Treating complications of CKD

Answer 11

Metabolic acidosis - give oral sodium bicarbonate

Anaemia - EPO injections (or iron supplementation if it is iron deficiency anaemia instead)

Vitamin D - to treat renal bone disease

Dialysis or renal transplant in end stage renal failure

Question 12

Treating HTN in CKD

Answer 12

ACEi are first line in patients with CKD

Offered to all patients with:

• Diabetes plus ACR > 3mg/mmol
• Hypertension plus ACR > 30mg/mmol
• All patients with ACR > 70mg/mmol

Question 13

What is it important to measure in those on ACEi who also have CKD?

Answer 13

Serum potassium as both CKD and ACEi can cause hyperkalaemia

Question 14

What is anaemia of CKD?

Answer 14

Lack of EPO as kidney cells are damaged. Therefore a drop in RBCs and subsequent anaemia

EPO injections can be given to treat this but treat any iron deficiency first

Question 15

Features of renal bone disease

Answer 15

Osteomalacia
Osteoporosis
Osteosclerosis

Question 16

Pathophysiology of renal bone disease

Answer 16

• High serum phosphate due to reduced renal excretion
• Low active vitamin D as kidney is essential in metabolising vit D to its active form
• Active vit D needed for calcium absorption - so serum calcium also low
• PTH raises (secondary hyperparathyroidism) due to low serum calcium and high phosphate
• This leads to increased osteoclast activity
• Osteoclasts increase the bone breakdown/turnover

Question 17

Management of renal bone disease

Answer 17

Vitamin D supplementation e.g. alfacalcidol and calcitriol

Low phosphate diet

Bisphosphonates can be used to treat Osteoporosis