Chronic Kidney Disease

Question 1

Name the functional unit of the kidney

Answer 1

Nephron

Question 2

What is GFR?

Answer 2

It Is the amount of filtrate formed within the nephrons of both kidneys each minute.

Question 3

What happens when GFR is too high or too low?

Answer 3

GFR too high:
Excessive loss of needed substances
GFR too low:
Inadequate excretion of waste products from the blood.

Question 4

What affects GFR?

Answer 4

Changes in arterial blood pressure affect GFR

Question 5

Describe the direct roles of the kidneys

Answer 5

• Regulation of: blood ionic composition, ph, volume, pressure, osmolarity and glucose levels
• Production of hormones (renin prosoglandin bradykinin)
• Excretion of wastes and foreign substances

Question 6

What is CKD?

Answer 6

The gradual loss of kidney function over time.

Question 7

Criteria for CKD:

Answer 7

• Damage for ≥3 months, (structural or functional abnormalities) Manifested by either: Pathological abnormalities or Markers of damage
• GFR

Question 8

Treatment:

Answer 8

Prevent or slow further damage to the kidneys.
Stage 1-2
Reduce risk factors, treatment of co-morbidities
Stages 3-4
Slow progression, reduce CVD risk factors and treat co-morbidities
Stage 5
Transplant
Dialysis

Question 9

Drugs used for treatment:

Answer 9

§ Diuretics
§ Statins
§ Beta-blockers
§ Calcium channel blockers
§ ACE inhibitors
§ Antidepressants
§ Thyroid hormones
§ Narcotic pain meds
§ Insulin
§ Angiotensin II receptor blockers
§ Antiplatelet drugs

Question 10

What is Haemodialysis?

Answer 10

Blood is pumped through a haemodialyzer (artificial kidney)

Question 11

Describe the pros and cons of Haemodialysis

Answer 11

Pros:
Filters the blood
Excretes wastes and adds nutrients
Cons:
Expensive, time consuming, risk of complications, can not produce hormones

Question 12

What is Peritoneal Dialysis?

Answer 12

Peritoneum acts as the filter.

Dialysate fluid flows by gravity or is pumped into and drained from the peritoneal cavity 4 – 5 x per day

Question 13

Describe the pros and cons of Peritoneal Dialysis

Answer 13

Pros:
Cheaper, don’t have to go clinic, can keep working, can be done at night and blood doesn’t leave the body
Cons:
Takes a lot of time, can be seen by people, can cause breathing difficulties, risk of infection at catheter site

Question 14

Demographics:

Answer 14

Common in Maori and PI
Affects ~10% of NZ population
If Maori and have diabetes - then you are 3x more likely to have renal failure

Question 15

Aetiology of Renal Failure:

Answer 15

§ Diabetes
§ Glomerulonephritis
§ High blood pressure
§ Reflux nephropathy
§ Polycystic kidney disease

Question 16

Risk Factors of Renal Failure:

Answer 16

• High BP
• Low HDL
• High triglycerides
• High fasting blood
glucose
• Abdominal obesity

Question 17

What is the leading cause of death in both non-end stage and end stage CKD.

Answer 17

CVD

Question 18

Signs and Symptoms of CKD:

Answer 18

Anemia
Muscle wasting
Metabolic Bone Disease
Oedema 
Fatigue
Nausea
Cramps 
Peripheral Neuropathy

Question 19

Benefits of exercise in CKD:

Answer 19

§ Improve exercise capacity and physical functioning
§ Improve strength
§ Improve quality of life – functional, psychological and the burden of symptoms
§ Blood pressure control
§ Control of diabetes
§ Reduction / prevention of CVD risk factors
§ Survival

Question 20

Exercise recommendations in CKD:

Answer 20

ACSM recommends 20-60 mins continuous moderate exercise 3-5 days per week.

Question 21

What tests would you do in an initial assessment for patients with CKD?

Answer 21

§ SF-36 quality of life measure
§ Microalbuminuria urine test
§ Fasting blood glucose and lipids
§ Body composition – BMI, waist and hip circumference, triceps skin fold and mid arm
circumference
§ ECG monitored sub-max treadmill or cycle test (modified Balke or ramp protocol)
§ 5-rep sit to stand
§ Hand grip strength
§ Berg Balance if deemed necessary
§ Establish goals.

Question 22

Exercise prescription for CKD

Answer 22

• 2-3 sessions / week.
  § Start conservatively!
  § Ensure adequate warm up and cool down.
  § Increase duration before intensity.
  § May need to start with short bouts interspersed with rest.
  § Monitor:
  § Heart rate
  § Blood pressure
  § RPE
  § Weight
  § Glucose
  § Start resistance training after week 2.
  § Make sure it is enjoyable.
  § Educate on the benefits of exercise and a healthy lifestyle – increase adherence.
  Exercise needs to be individualised to each patient’s tolerance, function and preference.

Question 23

Considerations for exercise in CKD patients:

Answer 23

• Medical clearance
• BP taken on arm without catheter
• Exercise on a non-dialysis day
• Use RPE
• AV fistulas need to be fully healed before upper limb exercises are done
• Make sure warm down is done so they leave clinic with baseline measures

Question 24

Contraindication to exercise in CKD:

Answer 24

§ Electrolyte abnormalities, particularly hypokalemia and hyperkalemia
§ Recent changes to the ECG, especially symptomatic tachy-arrhythmias or bradyarrhythmias.
§ Excess inter-dialytic weight gain of >4kg since last dialysis or exercise session
§ Unstable on dialysis treatment and changing medication regimen
§ Pulmonary congestion
§ Peripheral oedema