Chronic kidney disease

Question 1

what are different functions of the kidneys?

Answer 1

Question 2

what three aspects are assessed to assess kidney disease?

Answer 2

Filtration (excretory) function - remove

Filtration (barrier) function - retain

Anatomy - abnormality

Question 3

how is excretory renal function measured?

Answer 3

Inulin clearance
Isotope GFR
24 hour urine collection plus blood test
GFR estimating equations

Question 4

describe the relationship between creatinine and GFR?

Answer 4

Question 5

what is the problem against a clear relationship between creatinine and GFR?

Answer 5

Problem
Creatinine is generated from breakdown of muscle
Not everyone has the same muscle mass

Depends on:
Age
Ethnicity
Gender
Weight
Other issues eg liver disease

Question 6

what are formulae to estimate GFR from serum creatinine?

Answer 6

Cockcroft Gault
= ([140-age] x weight x 1.23) / SCr x (0.85 if female)

MDRD 4 variable equation
= 175 x [SCr/88.4] -1.154 x [age] -0.203 x (0.742 if female) x (1.212 if black)

CKD-EPI equation

Question 7

how is CKD classified?

Answer 7

Question 8

how should permeability of the GBM be?

Answer 8

Crosses GBM
Water
Electrolytes
Urea
Creatinine

Crosses GBM but reabsorbed in proximal tubule
Glucose
Low molecular weight proteins (α2 microglobulin)

Does not cross GBM
Cells (RBC, WBC)
High molecular weight proteins (albumin, globulins)

Question 9

how is urine analysed to assess kidney filtering function?

Answer 9

Should be no blood or protein measurable in urine if filtering properly

Urinalysis (“dipstick”)
Blood
Protein

Protein quantification
Protein creatinine ratio (PCR)

Question 10

what is the definition of CDK?

Answer 10

Chronic kidney disease (CKD) is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR<60 ml/min/1.73m2 that is present for ≥3 months

Question 11

what is the prevalence of CDK?

Answer 11

Question 12

what is renal replacement therapy?

Answer 12

Renal replacement therapy comprises either transplantation or dialysis

Question 13

what are aetiological factors for CDK?

Answer 13

Question 14

what should the clinical approach be towards CDK?

Answer 14

Detection of the underlying aetiology
Treatment for specific disease
Slowing the rate of renal decline
Generic therapies
Assessment of complications related to reduced GFR
Prevention and Treatment
Preparation for Renal Replacement Therapy

Question 15

describe symptoms and signs of CKD

Answer 15

Question 16

how is underlying aetiology of CKD detected?

Answer 16

Question 17

what is done to detect underlying aetiology following history and thorough examination?

Answer 17

Question 17

what investigations are done in chemistry to detect aetiology of CKD?

Answer 17

Urea, creatinine, electrolytes (Na, K, Cl)
Bicarbonate
Total protein, albumin
Calcium, phosphate
Liver function tests
Creatine kinase
Immunoglobulins, serum protein electrophoresis

Question 17

what investigations are done in haematology to detect aetiology of CKD?

Answer 17

Full blood count
Hb
MCV
MCH
WBC
Platelets
% hypochromic RBCs

Question 18

what investigations are done in coagulation screen to detect aetiology of CKD?

Answer 18

PT
APPT
+/- Fibrinogen

Question 18

what urine investigations are done for CKD?

Answer 18

Urinalysis (“dipstick”)
Blood
Protein

Protein quantification
Protein creatinine ratio (PCR)
Albumin creatinine ratio

Question 18

what imaging is done to detect aetiology of CKD?

Answer 18

US
Non-invasive
No ionising radiation
May provide information about chronicity of renal disease

Question 18

how can you pathological confirm aetiology?

Answer 18

kidney biopsy

Question 18

how can the rate of renal decline be slowed?

Answer 18

BP control *most important

Control proteinuria (particularly ACE inhibitors / ARBs)

Treat underlying cause

Others

Question 18

what complications are associated with reduced GFR?

Answer 18

Acidosis
Anaemia
Bone disease
CV risk
Death & Dialysis
Electrolytes
Fluid overload
Gout
Hypertension
Iatrogenic issues

Question 18

how are complications rekated to GFR managed?

Answer 18

Acidosis - bicarb
Anaemia – EPO and iron
Bone disease – diet and phosphate binders
CV risk – BP, aspirin, cholesterol, exercise, weight
Death & Dialysis – counsel and prepare
Electrolytes – diet and consider drugs
Fluid overload – salt and fluid restriction, diuretics
Gout – optimise +/- meds
Hypertension – weight, diet, fluid balance, drugs
Iatrogenic issues – BE AWARE

Question 18

what preparation for end stage renal disease and renal replacement therapy should be done?

Answer 18

Education & information
Selection of modality
HD / PD ?transplant ??conservative care
Planning access
Deciding when to start RRT

Multidisciplinary team