Chronic kidney disease Flashcards
What is the definition of chronic kidney disease
Reduction in kidney function or structural damage or both, present for more than 3 months with associated health implications
What are some causes of CKD?
Diabetes
Hypertension
PKD
Glomerular disease
AKI
Nephrotoxic drugs
Obstructive uropathy
Multisystem disease
Hereditary kidney disease
CVD
Obesity with metabolic syndrome
What are some examples of potentially nephrotoxic drugs?
Aminoglycosides
ACEi and ARBs
Bisphosphonates
Calcineurin inhibitors
Diuretics
Lithium
Mesalazine
NSAIDs
What are some causes of obstructive neuropathy that can cause CKD?
Calculi
Prostate (BPH, malignancy, etc)
Bladder (Malignancy, chronic cystitis)
Malignancy
Strictures/stenosis
Extrinsic compression
What are the markers of kidney damage - “THE ASS-H”
T - Transplant - Previous transplant Hx
H - Histological abnormality on biopsy
E - Electrolyte abnormalities
A - ACR > 3mg/mmol
S - Sediment absnrmalities in urine (Blood, casts)
S - Structural abnormalities on imaging
H - Hereditary condition on genetic testing
Also an eGFR <60 ml/min/1.73m^2
How many stages of CKD are there?
5 (6 including 3a and 3b)
G1 CKD GFR
eGFR > 90
G2 CKD GFR
eGFR 60-89
G3a CKD GFR
eGFR 45-59
C3b CKD GFR
eGFR 30-44
G4 CKD GFR
eGFR 15-29
G5 CKD GFR
eGFR < 15
How many ACR classifications of CKD are there?
3
A1 CKD ACR
ACR < 3
A2 CKD ACR
ACR 3-30
A3 CKD ACR
ACR > 30
CKD 5D
eGFR < 15 and commenced on dialysis
ERF
Established renal failure (eGFR < 15)
KRT/RRT
Kidney/Renal replacement therapy
ESKD
End-stage kidney disease - eGFR < 15 and on/approaching RRT or conservative management
What is meant by accelerated progression of CKD?
- a persistent decrease in eGFR by 25% or more AND a change in CKD category within 12 months
- OR can also be defined as a persistent decrease in eGFR of 15 mL/min/1.73 m2 within 12 months
How does CKD usually present?
Usually asymptomatic
What are some possible symptoms of CKD?
Pruritus
Loss of appetite
Nausea
Oedema
Muscle cramps
Hypertension
What are some investigations required in CKD?
U+Es
eGFR
Urinalysis (Proteinuria, haematuria)
When may renal USS be used in CKD?
Accelerated CKD
Haematuria
Family history of PKD
Evidence of obstruction
How is CKD managed?
Manage the underlying condition
- Diabetes - HbA1c to target
- Hypertension - ACEi/ARB
- Autoimmune - Immunosuppression
- Obstruction - Relieve obstruction
- Nephrotoxins - Stop drugs
What is the BP target in CKD?
140/90
What is the BP target in CKD + Diabetes or ACR>70mg/mol
130/80
What is the link between CKD and CVD
≥ G3 CKD increases CVD risk by 40% compared to G1 or 2
25mg/mmol increase in urinary ACR leads to 10% increase in stroke risk
What are some CVD risk modification strategies in CKD?
Smoking cessation
Weight loss
Aerobic exercise
Limited salt intake
Lipid-lowering therapy
Aspirin (Possibly)
Describe the link between AKI and CKD
AKI may initiate or accelerate CKD progression
Describe the link between dyslipidaemia and CKD
Secondary causes of dyslipidaemia may include renal causes such as nephrotic syndrome
Describe the use of lipid lowering therapy in CKD
- Offer atorvastatin for the primary or secondary prevention of CDK to people with CKD
- Increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73 m2 or more
What Hb level is classified as renal anaemia?
Hb < 110g/L
How will renal anaemia present?
Tiredness
Shortness of breath
Lethargy
Palpitations
What is the cause of renal anaemia?
Thought to be caused by reduce EPO production by the kidneys, reduced RBC survival and iron deficiency
What is the target Hb in renal anaemia treatment?
100-120g/L
Which CKD stages are more prone to renal anaemia
> G3
What investigations are required in renal anaemia?
Blood tests to rule out B12, folate and other causes of anaemia
Check ferritin stores
Renal anaemia management
Iron therapy:
1st line - Oral iron
2nd line - IV iron (Ferinject, vendor)
If this doesn’t work:
- ESA (Athlete doping drug)
What is renal mineral and bone disorder (MBD)
A complication of CKD in which there is an abnormality in bone turnover and mineralisation
How does CKD MBD present?
Bone pain
Increased bone fragility
Extra-skeletal calcification of skin or blood vessels
What causes CKD MBD?
Impaired regulation of intestinal absorption, renal tubular excretion and vitamin D activation in the kidneys
This disturbs vitamin D, calcium, PTH and phosphate metabolism
This causes abnormalities in bone turnover and mineralisation with vitamin D deficiency, raised serum phosphate, low serum calcium and 2º or 3º hyperparathyroidism
What endocrine conditions can arise from CKD MBD?
2º or 3º hyperparathyroidism
Vitamin D deficiency
What are some dietary changes required in CKD MBD?
Phosphate restriction
Consider salt, potassium and fluid restriction
What are some drugs required in CKD MBD?
Oral sodium bicarbonate - Manage metabolic acidosis
Alfacalcidol (Active vit D)
Phosphate binders (Lanthanum/sevelamer)
What are some other complications of CKD?
Peripheral neuropathy and myopathy
Malnutrition
Malignancy
End-stage renal disease
All cause mortality
