Chronic Kidney Disease Flashcards
What is the definition of CKD?
Abnormal kidney function/structure for > 3 months. Eg, eGFR <60 or markers of kidney dmanage if eGFR > 60
What are the different stages of CKD?
Stage 1 - eGFR > 90, with evidence of impaired renal function.
Stage 2 - eGFR: 60-89, with evidence of impaired renal function.
Stage 3a - eGFR: 45-59
Stage 3b - eGFR: 30-44
Stage 4 - eGFR: 15-29
Stage 5 - eGFR < 15 or need for renal replacement therapy
The divided further based on albumin creatinine ration A1 (<3mg/mmol), A2(3-30mg/mmol) and A3 (>30mg/mmol)
What are the causes of CKD?
Diabetic nephropathy,
Hypertension,
Adult polycystic kidney disease
Chronic glomerulonephritis,
Chronic pyelonephritis,
Myeloma,
Vasculitis
What are the investigations for CKD
Bloods: FBC, U&Es, LFTs, HbA1c, bone profile.
Urine: Dipstick, uPCR
Renal ultrasound.
eGFR can be affected by pregnancy (better), muscle mass and eating red meat 12h before sample.
What are the symptoms of CKD?
Pruritus,
Nausea, anorexia and weight loss,
Fatigue,
Leg swelling (due to loss of water and salt control)
Breathlessness,
Nocturia,
Joint/bone pain,
Confusion
What are the signs of advanced CKD?
Peripheral and pulmonary oedema,
Pericardial rub (due to accumulation of toxins in pericardium),
Rash/excoriation,
Hypertension,
Tachypnoea,
Cachexia,
Pallor or lemon yellow tinge
What are the complications of CKD?
CRF HEALS
Cardiovascular disease,
Renal osteodystrophy,
Fluid,
Hypertension,
Electrolyte disturbence,
Anaemia,
Leg restlessness (uraemia),
Sensory neuropathy (uraemia)
What is the management of hypertension in CKD?
ACE inhibitors are first line - very good for proteinuric renal disease. Small rise in creatinine can be expected.
Furosemide
What are the targets in blood pressure treatment in CKD?
Bp < 140/90 (patients with PCR < 100)
BP <130/80 (patients with PCR >100 or diabetics)
How do you manage proteinuria?
ACE inhibitors are offered to all patients with:
Diabetes plus a urine ACR above 3 mg/mmol
Hypertension plus a urine ACR above 30 mg/mmol
All patients with a urine ACR above 70 mg/mmolACEi or ARBs
Dapagliflozin is the SGLT-2 inhibitor licensed for CKD. It is offered to patients with:
Diabetes plus a urine ACR above 30 mg/mmol
What patient’s with CKD should be referred to nephrology?
5 year risk of needing RRT > 5%
uACR > 70 (unless diabetes)
eGFR < 30
Uncontrolled HTN on 4+ agents
Suspected renal artery stenosis
Why do you get bone disease in CKD?
Low vitamin D (enzyme needed to activate vit D is in kidneys)
High phosphate (kidneys excrete phosphate),
Low calcium (due to high phosphate and low vit D.
Secondary hyperparathyroidismW
What are the clinical presentations of renal bone disease?
Osteitis fibrosa cystica,
Adynamic,
Osteomalacia,
Osteosclerosis,
Osteoporosis
What is the management of renal bone disease?
1st line - reduce dietary phosphate.
2nd line - Phosphate binders, alfacalcidol, parathyroidectomy (sometimes)
What are some phosphate binders?
- Sevelamer (non calcium based and used more frequently. Binds to dietary phosphates and reduced absorption. Also lowers uric acid)
- Calcium based binders (problems include hypercalcaemia and vascular calcification)
What is an X ray finding of renal bone disease?
Rugger jersey spine - sclerosis of both ends of each vertebrae
What is the management of proteinuria?
ACEi
SGLT2 inhibitors
When are ACEi indicated?
Indicated if diabetic and uACR > 3.
If hypertensive and uACR > 30
All patients with ACR > 70.
When are SGLT2 inhibitors indicated?
All - Diabetes and uACR > 30
Consider in patients with diabetes and uACR 3-30. and non diabetics with uACR > 22.6.
What are the causes of anaemia in CKD?
- Reduced erythropoietin levels,
- Reduced iron absorption as hepcidin is an acute phase reactant and therefore often increased in CKD.
- Reduced erythropoeisis and anorexia due to toxicity of uraemia,
- reduced RBC survival
What is the management of anaemia in CKD?
Target Hb = 100-110.
Target TSAT = >20%
1st line - Optimisation of iron status (look at transferrin saturation). Oral iron if not on ESA or dialysis.
2nd line - ESA eg, erythropoietin but must exclude other causes of anaemia first.
Caution around blood because
What is the management of hyperkalaemia?
If K+ is between 5.5 and 6.5 then give calcium resonium.
If K+ is >6.5 and/or ECG changes then five calcium gluconate and insulin/dextrose infusion or nebulised salbutamol.
What drug can be used in the treatment of kyperkalaemia in patients with CKD 3b-5?
Lokelma (Sodium Zirconium cyclosilicate) - can be used acutely and in as maintenance to stop people coming off ACEi/ARBs
What are the different types of renal replacement therapy?
Haemodialysis,
Peritoneal dialysis
Renal transplant
Describe features of haemodialysis
Involves regular filtration of the blood through dialysis machine. Most regimes are 3x per week for 3-5 hours.
Need good access - ideally AV fistula but can use AV graft or tunneled line (TCVC)
Requires anticoagulation.
Cleaning is via solute diffusion
Fluid is removed via hydrostatic ultrafiltration
What are the complications of haemodilaysis?
Site infection, endocarditits, stenosis at site, hypotension, cardiac arrhythmias, air embolus, anaphylaxis, disequilibrium syndrome
What are the principles of peritonealdialysis?
Need of a PD catheter. No anticoagulation needed. Can do daily or night treatments (automatic PD or continuous ambulatory PD).
Solute removal via diffusion through peritoneal membrane. Fluid removal via osmosis
What are the complications of peritoneal dialysis?
Peritonitits,
Sclerosing peritonits,
Catheter infection/blockage,
Constipation,
Hyperglycaemia,
Fluid retention,
Hernia
Back pain
What are the principles of renal transplantation?
Either living donor or cadavor.
Replaces all the functions of the kidneys and better quality of life.
Improves fertility and cheaper than long term dialysis
What are the complications of renal transplant?
Surgical: pain, bleeding, infection, dishiscence, leak.
Immunosuppression: rejection, infection, diabetes, hypertension, malignancy,
Psychologcal: rejection guilt, return to dialysis,
