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MD2 Renal > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

52 year old male school teacher, fit and well, undergoes a blood test for an insurance medical

Serum creatinine 150umol/L, estimated GFR 45ml/min/1.73m^2, urinary protein 0.5 g/day

What are the normal parameters for these tests?

A

Normal creatinine in men: 70-120umol/L

Normal creatinine in women: 50-97umol/L

GFR <60mL/min/1.73m^2 is considered abnormal

Normal urinary protein: <0.2 g/day

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2
Q

52 year old male school teacher, fit and well, undergoes a blood test for an insurance medical

Serum creatinine 150umol/L, estimated GFR 45ml/min/1.73m^2

The pathology report says “eGFR 30-60mL/min/1.73m^2 indicates moderate decrease in GFR - 2 or more results in this range indicates stage 3 CKD and monitoring for rapid progression may be indicated; assessment and Mx of CV RFs indicated in CKD”

He is very worried, his father died from kidney failure and he wants to know if he will too

PHx: HTN (well-treated)

How do you define CKD?

A

GFR <60mL/min/1.73m^2 for >3/12 with or without evidence of kidney damage

OR

Evidence of kidney damage (with or without decreased GFR) for >3/12 months: microalbuminuria, proteinuria, glomerular haematuria, pathological abnormalities (e.g. on renal biopsy), anatomical abnormalities (e.g. cysts on U/S)

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3
Q

What are the 4 main functions of the kidney and how are they disturbed with kidney disease?

A

Excretion of solutes and waste products: accumulation of solutes and waste products

Acid/base homeostasis: accumulation of acids

Na+/water balance: Na+/water imbalance (causing HTN)

Endocrine functions (EPO, vit D): anaemia, Ca2+/PO4-/PTH imbalance (causing MBD)

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4
Q

What ONE marker is accepted as the measure of kidney function? How is this usually measured? What is one caveat to its use?

A

Ability or efficiency of kidneys to filter solutes and waste products from the blood at the glomerular, i.e. the glomerular filtration rate (GFR)

To measure GFR, you need to measure a substance that is freely filtered, but not secreted or reabsorbed by the tubules; typically creatinine is used

eGFR should ONLY be used with a steady state serum Cr (i.e. not in AKI)

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5
Q

Outline 3 options for measuring GFR

A

IV inulin: measure serum and urine clearance rates

Radioisotope renography: inject radiolabelled substance (e.g. DTPA, MAG3) and measure serum clearance rates in the kidney with nuclear scans

Use an endogenous substance that is largely freely filtered and not resaborbed or secreted that much (e.g. creatinine, cystatin C)

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6
Q

Why is serum creatinine alone not recommended when testing for kidney disease?

A

Can be normal, leading to under-recognition (39% of those aged >65 wll have CKD with a normal serum Cr)

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7
Q

What is the limitation of using creatinine clearance (24 hr urine measures) to assess GFR?

A

Tends to exceed true GFR by 10-20% (because of the urinary creatinine derived from tubular secretion)

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8
Q

What methods can be used to estimate GFR using creatinine measures?

A

Serum Cr

Creatinine clearance (24 hr urine measures)

Estimated GFR equations

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9
Q

How are estimated GFR equations developed and what are they based on?

A

Developed from large patient cohorts, validated with true measures of GFR (nuclear scans) to allow estimation of GFR based on serum Cr, age and gender

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10
Q

What equations are used to calculate eGFR?

A

Cockcroft-Fault equation

MDRD equation

CKD-EPI equation (currently recommended in Aus)

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11
Q

What is the CKD-EPI?

A

Two equations in one for estimating eGFR; recognises the different relationship of eGFR for high and low serum Cr

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12
Q

Describe the relationship between eGFR and age

A

In healthy adults eGFR falls by up to 10mL/min/1.73m^2 per decade beyond the age of 40

In people aged >70, stable eGFR values between 45-59mL/min/1.73m^2 may be consistent with normal GFR for this age, if no other signs of kidney damage (proteinuria, haematuria) are present

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13
Q

Describe how CKD is divided into stages based on level of decline of GFR

A

CKD 1-2: 60-120 mL/min/1.73m^2

CKD 3a: 45-60 mL/min/1.73m^2

CKD 3b: 30-45 mL/min/1.73m^2

CKD 4: 15-30 mL/min/1.73m^2

CKD 5: 0-15 mL/min/1.73m^2

(From stage 3 onwards, subtract 15)

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14
Q

When do signs and symptoms of CKD commonly present?

A

Severe CKD (eGFR <15 mL/min)

On the whole, this is a silent condition with few clues of underlying damage

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15
Q

Describe the epidemiology of CKD in Aus

A

1 in 3 adults at risk of developing CKD

1 in 9 adults has CKD

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16
Q

Describe the system of further staging of CKD based on presence or absence of urinary protein/albumin

A
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17
Q

What is the definition of microalbuminaemia?

A

Urine albumin-creatinine ratio (ACR) for males: 2.5-25 mg/mmol

ACR for females: 3.5-35 mg/mmol

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18
Q

What is the definition of macroalbuminaemia?

A

Urine albumin-creatinine ratio (ACR) for males: >25 mg/mmol

ACR for females: >35 mg/mmol

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19
Q

What is normal ACR for males and females? When might a patient with a normal ACR and normal GFR be diagnosed with CKD?

A

Normal ACR for males: <2.5

Normal ACR for females: <3.5

Not CKD unless haematuria, structural or pathological abnormalities are present

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20
Q

How can albumin be measured in the urine?

A

Urinalysis: dipstick shows 1+, 2+, etc and this method is poorly sensitive/specific

Urine ACR

Urine protein:creatinine ratio (PCR)

24 hr urine collection

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21
Q

List 6 causes of FPs when measuring proteinuria

A

UTI

Sepsis

CCF

Strenuous exercise

Heavy protein intake

Menses

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22
Q

What is the relationship between PCR and 24 hr urine protein?

A

PCR x 10 (mg/mmol) ~= 24 hr urine protein (mg/d)

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23
Q

What PCR and ACR is equivalent to proteinuria of 1g/24 hrs?

A

PCR 100 ~= proteinuria 1g/24 hrs

ACR 70 ~= proteinuria 1g/24 hrs

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24
Q

What is the aim of staging in CKD?

A

Identify risk of progression of kidney disease

Identify risk of CV complications

25
Q

List 6 RFs for CKD

A

Older age (>55)

HTN

DM

Smoker

Obese

First degree family relative with CKD

26
Q

How should patients with RFs for CKD be managed?

A

Serum Cr, urine AC and BP as part of early detection and management

27
Q

Describe the natural Hx of CKD

A

1/3 maintain stable kidney function or have mild decline in eGFR: 0-1 mL/min/year

1/3 moderate progression: 1-4 mL/min/year

1/3 severe progression: >4 mL/min/year

Greater risk of decline with increasing levels of proteinuria

28
Q

52 year old male school teacher, fit and well, undergoes a blood test for an insurance medical

Serum creatinine 150umol/L, estimated GFR 45ml/min/1.73m^2, urinary protein 0.5 g/day

Phil feels very well, though clearly has impaired kidney function, which comes with the risk of progressive decline in kidney function AND elevated CV risk

Do you need to find out why Phil has kidney disease? Why?

A

Yes!

Knowing the underlying cause of CKD helps to identify if any treatments are available, helps with overall prognosis and indicates likelihood of progression

29
Q

Ix of patient with CKD

A

Bloods: FBE, CMP, PTH, HbA1c, LFTs, uric acid, iron studies, B12/folate, consider other tests for systemic disease depending on clinical scenario

Urine: urinalysis with microscopy, spot urine for ACR/PCR, consider 24 hr urine collection for protein and creatinine clearance

Imaging: renal tract U/S

30
Q

What imaging can be considered in CKD?

A

Renal U/S

CT +/- contrast

Nuclear isotope scans (DMSA, MAG3, DTPA)

31
Q

Renal U/S of patient with CKD

Describe the abnormalities. Dx?

A

Multiple cysts are seen in the kidney which is enlarged in size (cysts were also seen in the liver)

Dx: APCKD

32
Q

How is APCKD inherited?

What does a FHx of early death from renal failure suggest about type of APCKD?

A

AD inheritance pattern

If FHx of early death from renal failure, it is likely the patient has type 1 variant for which there is no effective method of preventing decline to end-stage kidney disease (ESKD), although there have been some promising early trials with vasopression 2 antagonists

33
Q

Basic underlying principles of Mx for all patients with CKD

A

Identify and treat underlying cause of kidney disease

Reduce further progression of kidney disease (lifestyle measures + BP, lipids and glucose control)

Reduce CV risk (lifestyle measures + BP, lipids and glucose control)

Early detection and Mx of metabolic complications (anaemia, Ca2+/PO4-/PTH, acidosis)

Medication adjustment/avoidance of renally excreted and nephrotoxic medications

34
Q

Virginia, 52 year old sales executive with blood test showing serum Cr 150 umol/L

She is asymptomatic

PHx: HTN

Is her eGFR expected to be better, worse or the same as a man in the same context?

A

eGFR will be lower, as women have less lean muscle mass and produce less creatinine than men

35
Q

Virginia, 52 year old sales executive with blood test showing serum Cr 150 umol/L, eGFR 34 mL/min/1.72m^2 and 1.5 g/day proteinuria; there is glomerular haematuria on urine microscopy

She is asymptomatic

PHx: HTN

What are the possible causes of her haematuria?

How can glomerular causes of bleeding be identified from other sources?

A

Can be due to glomerular pathology, malignancy, ureteric stones, or more “benign” causes (e.g. menstrual periods, UTI)

Urine microscopy can look at the morphology of the red cells and identify the presence of red cell casts to determine if there is a glomerular lesion

36
Q

Virginia, 52 year old sales executive with blood test showing serum Cr 150 umol/L, eGFR 34 mL/min/1.72m^2 and 1.5 g/day proteinuria; there is glomerular haematuria on urine microscopy

She is asymptomatic

PHx: HTN

A renal tract U/S is performed. Describe the findings.

Following this a renal biopsy is performed. Describe the findings.

What is the cause of her kidney disease?

A

Renal tract U/S shows bilateral small kidneys with an echogenic appearance

Renal biopsy shows glomeruli with mesangial expansion and mesangial cell proliferation; immunofluorescence is positive for IgA deposits in the mesangium

These findings are consistent with a diagnosis of IgA nephropathy

37
Q

What is the effect of lifestyle changes on CKD?

A

Addressing SNAP factors results in at least 50% reduction in risk of DM, with cessation of smoking expected to reduce risk of progressive CKD by at least 50%

Lifestyle changes mostly aim to reduce SBP

38
Q

What lifestyle changes are recommended for CKD management?

A

Weight reduction: aim for >5% weight loss if obese or overweight

Healthy diet: fruit and veg, low fat, low cholesterol, high fibre (biggest effect on SBP!)

Dietary salt restriction: less than 100 mmol/day

Physical activity: 30 mins/5 days each week

Moderate alcohol consumption: less than 1-2 STD/day

39
Q

What are the two most important modifiable RFs for reducing progression of CKD? What are the targets for these?

A

HTN and proteinuria

Target BP for CKD should be less than 130/80mmHg, or 125/75mmHg in proteinuria/DM

40
Q

What is the leading cause of death in CKD patients? What is the relationship between this and CKD?

A

CVD

Multifactorial relationship: LVH can be a RF, atherosclerosis and arteriosclerosis contribute

41
Q

What metabolic complications of CKD should be monitored for and managed?

A

Anaemia

Metabolic acidosis

CMP/PTH Mx

Dyslipidaemia

Malnutrition

42
Q

What level of correction for anaemia should be aimed for in CKD?

A

Hb 100-120 g/L

43
Q

What is the effect of anaemia on dialysis patients?

A

Increased rates of hospital admission and IHD/LVH, and reduced quality of life

44
Q

What problems can metabolic acidosis cause in CKD patients?

A

Muscle catabolism

Metabolic bone disease

Reduced immune function

45
Q

How is metabolic acidosis treated? What precautions should be taken? Does treatment have any effect on CKD progression?

A

Sodium bicarbonate: maintain >20mmol/L

Watch for sodium loading: volume expansion, HTN

Treatment with bicarbonate may slow down renal progression

46
Q

What is CKD-MBD?

A

Chronic Kidney Disease Mineral and Bone Disorder

A systemic disorder defined by laboratory Ix, bone abnormalities and calcification of soft tissues

47
Q

How is CKD-MBD treated?

A

Phosphate binders

Control of hyperPTH with 1,25-OH vit D and cinacalcet

48
Q

Diane, 63 year old retired medical secretary with 12 year Hx of T2DM, HTN and CKD with macroalbuminaemia

3 years ago: serum Cr 150 umol/L, eGFR 32 mL/min/1.72m^2

Since then her renal function has gradually declined: serum Cr 250 umol/L, eGFR 17 mL/min/1.72m^2

What stage CKD does Diane have? What is her risk of CVD/ESKD?

A

Stage 4

Rate at which her kidney function has declined allows a rough prediction that she will have CKD stage 5 within a year (eGFR <15 mL/min/1.72m^2) and ESKD (eGFR <10 mL/min/1.72m^2) within 2 years

49
Q

Diane, 63 year old retired medical secretary with 12 year Hx of T2DM, HTN and CKD with macroalbuminaemia

3 years ago: serum Cr 150 umol/L, eGFR 32 mL/min/1.72m^2

Since then her renal function has gradually declined: serum Cr 250 umol/L, eGFR 17 mL/min/1.72m^2

What are the signs and symptoms of CKD stage 4-5?

A

General: lethargy and malaise, fluid overload, nocturia

Skin: pruritis

CV: HTN, HF, pericarditis, IHD

Neurological: peripheral neuropathy, seiures, restless legs

GI: anorexia, N+V, dysgeusia/metallic taste in mouth

Opthalmologic: changes of HTN mayy be present

50
Q

What are the targets for glycaemic control in CKD?

A

Pre-prandial BSL: 4.4-6.7 mmol/L

HbA1c: <7.0%

51
Q

What is the importance of good glycaemic control in CKD?

A

Intensive blood glucose control significantly reduces the risk of developing microalbuminaemia, macroalbuminaemia and/or overt nephropathy in people with T1DM and T2DM

Manage with lifestyle modification, oral hypoglycaemic agents or insulin

52
Q

How does CKD 4-5 Mx differ from Mx of CKD 3?

A

Basic underlying principles remain the same (treat cause, reduce progression, reduce CV risk, Mx of metabolic complications, Rx adjustment)

PLUS pressing need to plan for treatment when solute clearance (i.e. waste products and toxins) and fluid balance declines to a level at which life is endangered

53
Q

What is renal replacement therapy (RRT)?

A

Dialysis and transplantation

54
Q

When should dialysis be started?

A

No difference in death, CV events, complications of dialysis or infectious events seen in studies comparing early (eGFR 10-14 mL/min/1.72m^2) and late (eGFR 5-7 mL/min/1.72m^2) dialysis

Most patients start dialysis at eGFR less than 10 mL/min/1.72m^2 or when symptoms dictate

55
Q

Which of the main physiological roles of the kidney does dialysis aim to replace?

A

Fluid balance: preserves UO and ensures optimal fluid removal

Solute removal: removal of waste products and solutes, electrolytes and excess acid (most easily measured solutes are creatinine and urea, but there are several thousand substances identified that accumulates in progressive CKD)

56
Q

Explain the principles of haemodialysis

A

Blood circulates at high volume (300 mL/min) through a dialyer composed of many capillary width tubes of semi-permeable membrane

Solutes move by osmosis, fluid by ultrafiltration

Efficiency can be modulated by changing dialyser (surface area, permeability) blood flow and total time

57
Q

Describe the principles of peritoneal dialysis

A

Dialysate is infused into peritoneal cavity, left to dwell for equilibration of solutes and fluids, then the used dialysate is discarded

Semi-permeable membrane is the visceral capillary wall lining the peritoneal cavity; solutes leave the blood by diffusion, fluids move from blood to dialysate by a mix of osmotic and hydrostatic pressures (glucose is the osmotically active agent)

58
Q

Diane, 63 year old retired medical secretary with 12 year Hx of T2DM, HTN and CKD with macroalbuminaemia

Current renal function: serum Cr 250 umol/L, eGFR 17 mL/min/1.72m^2

Patient elects to commence dialysis with peritoneal dialysis her first option; she undergoes surgical insertion of her PD catheter when her eGFR is 12, commencing training for self-care with eGFR 10, as symptoms of nausea and anorexia appear
What else should the treating team advise on?

A

Treating team should also highlight the importance of transplantation, as well as the likelihood of haemodialysis in the future

MD2 Renal (6 decks)

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