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Urinary Systems > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What is the traditional definition of chronic renal failure?

A

Irreversible and significant loss of renal function

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2
Q

How do we assess for kidney disease?

A

Excretory function
-Glomerular Filtration Rate (eGFR from creatinine blood test)

Filtering function
-Check for presence of blood or protein in urine

Anatomy
-Histology, radiology

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3
Q

What is the problem with the relationship between serum creatinine and GFR (for measuring eGFR)?

A

Creatinine will not be raised above the normal range until 60% of total kidney function is lost

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4
Q

What effects serum creatinine levels?

A

Muscle mass:

  • Age,
  • Ethnicity (African Americans)
  • Gender (Male)
  • Weight
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5
Q

Give some formulae to estimate GFR from serum creatinine

A

Cockcroft Gault

MDRD 4 variable equations

CKD-EPI equation

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6
Q

What crosses the GBM?

A

Water
Electrolytes
Urea
Creatinine

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7
Q

What crosses the GBM but is reabsorbed in the proximal tubule?

A

Glucose

Low molecular weight proteins (a2-microglobulin)

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8
Q

What doesnt cross the GBM?

A

Cells (RBC, WBC)

High molecular weight proteins (albumin, globulins)

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9
Q

How much blood or protein should you be able to measure in a normal kidney?

A

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

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10
Q

How can you test for protein or blood in urine?

A

Urinalysis (“dipstick”)

  • Blood
  • Protein

Protein quantification
-Protein creatinine ratio (PCR)

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11
Q

What is the current chronic kidney disease definition?

A

Chronic kidney disease is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR /= 3 months

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12
Q

What is the prevelence of CKD?

A

Increases with age

About 8-12% in UK

Mostly stage 3

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13
Q

Give some of the complications of chronic kidney disease

A 
Acidosis
Anaemia
Bone disease
Cardiovascular
Death and dialysis
ELectrolytes
Fluid overload
Gout
Hypertension
Iatrogenic issues
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14
Q

How much does CKD cost?

A

About £35,000pa for 1 patient

Around £6,500 drug costs
£20,000 transplant

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15
Q

What is the aetiology of CKD?

A

Polycystic kidney disease

Diabetes

Glomerulonephritis
-And all the causes of that

Hypertension

Renovascular disease

etc

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16
Q

What is the clinical approach to CKD?

A

Detection of the underlying aetiology
-Treatment for specific disease

Slowing the rate of renal decline
-Genetic therapies

Assessment of complications related to reduced GFR
-Prevention and Treatment

Preparation for Renal replacement therapy

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17
Q

What are you looking for in terms of previous evidence of renal disease in a CKD history

A

Raised urea/ creatinine

Proteinuria/ haematuria

Hypertension

LUTS

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18
Q

What systemic diseases do you need to keep an eye out for in a CKD history?

A

Diabetes Mellitus

Collagen vascular diseases:
-SLE, Scleroderma, Vasculitis

Malignancy:
-Myeloma, Breast, lung, lymphoma

Hypertension

Sickle cell disease

Amyloidosis

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19
Q

What drugs are you keeping an eye out for in CKD history?

A

NSAIDs

Penicillins/ aminoglycosides

Chemotherapeutic drugs

Narcotic abuse

ACE inhibitor/ ARBs

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20
Q

What uraemic symptoms may you be looking for in a CKD history?

A

Nausea, anorexia, vomiting

Pruritus

Weight loss

Weakness, fatigue, drowsiness

21
Q

What are some of the clinical signs of depleted volume status?

A

Orthostatic BP

Skin turgor/ temperature

22
Q

What are some of the clinical signs of fluid overload?

A

Raised JVP

Crepitations

Ascites

Oedema

23
Q

What chemistry investigations may you want to carry out to look for CKD aetiology?

A

U&E (Na, K, Cl)

Creatinine

Bicarbonate

Total protein, albumin

Calcium, phosphate

Liver function tests

Creatine Kinase

Immunoglobulins, serum protein electrophoresis

24
Q

What haematology investigations may you want to carry out to look for CKD aetiology?

A

FBC

  • Hb
  • MCV
  • MCH
  • WBC
  • Platelets
  • % hypochromic RBCs
25
Q

What will be included in a coagulation screen you may want to carry out?

A

PT

APPT

+/- Fibrinogen

26
Q

What imaging may you want to carry out to find the aetiology of CKD?

A

Ultrasound
Plain radiology
CT Nuclear medicine
MRI

27
Q

When can pathology be useful for finding the aetiology in CKD?

A

Unexplained renal failure and Normal sizes kidneys

28
Q

How can you slow the rate of renal decline?

A

BP control

Control Proteinuria

Reverse other contributing factors - treat causes

Others:

  • Allopurinol
  • Dietary proetin restriction
  • Fish oils
  • Lipid lowering
  • Control acidosis
29
Q

What investigations can you carry out to assess complications related to reduced GFR?

A

Blood count and Film
- ?Anaemic

Calcium Phospate Albumin PTH
- ?Renal bone disease

Creatine Urea
- ?GFR

Bicarbonate
- ?Acidosis

Electrolytes
- ?Hyperkalaemia

Urine Protein excretion (Pr:Cr)
- ?Degree of proteinuria

30
Q

When does anaemia usually manifest in CKD?

A

When GFR

31
Q

Describe the anaemia resulting from CKD?

A

Normochronic Normocytic

Reduced erythropoietin production

Reduced red cell survival

Increased blood loss

32
Q

How do you treat anaemia due to CKD?

A

Usually treat if

33
Q

When is metabolic acidosis usually seen in CKD?

When is metabolic acidosis most marked?

A

Nor usually seen until GFR

34
Q

What are the symptoms of metabolic acidosis due to CKD?

A

General symptoms

Worsens hyperkalaemia

Exacerbates renal bone disease

35
Q

How do you treat metabolic acidosis in CKD?

A

Treat with oral Na Bicarbonate

-Care with volume overload

36
Q

How does CKD result in bone disease?

A

Reduced GFR leads to hyperphosphataemia

Loss of renal tissue leads to lack of vitamin D
-(indirect reduction in Ca absorption)

Low Calcium and raised phosphate

Secondary hyperparathyroidism (elevtaed PTH)

May progress to tertiary hyperparathyroidism

37
Q

How does CKD effect activation of vitamin D?

A

Vitamin D, derived from sunlight or diet, requires to be hydroxylated to be active - 1,25 (OH) 2 D

The 1a hydroxylation is catalysed by 1a hydroxylase in the kidney

CKD -> low 1a hydroxylase, so low activation of vitamin D

38
Q

How does low vitamin D lead to low calcium?

A

Reduced intestinal absorption

Reduced tubular reabsorption

Resulting stimulation of PTH secretion (i.e. secondary hyperparathyroidism)

39
Q

What does high phosphate levels cause?

A

Reduced 1a hydroxylase therefore low vitamin D

Stimulates PTH production

Associated with vascular and cardiac calcification

40
Q

How do you manage renal bone disease?

A

Control phosphate
-Diet

  • Phosphate binders
  • –CaCO3, Ca Acetate, Sevelamer, lanthanum

Normalise Calcium and PTH
-Active Vit D analogues (Calcitriol)

  • Tertiary disease
  • –Parathyroidectomy and Calcimetics (Cinacalcet)
41
Q

Why does CKD result in Hyperkalaemia?

A

Normally excreted by exchange with Na+ in distal tubule

Reduced delivary of Na+ to distal tubule as GFR falls

Other factors include underlying disease, drgs and diet

42
Q

How do you treat acute hyperkalaemia?

A

Stabilise cardiac membrane
-Calcium Gluconate

Shift K+ into cells

  • Salbutamol
  • Insulin-Dextrose

Remove calcium from body:

  • Dialysis
  • Calcium resonium
43
Q

How do you treat chronic hyperkalaemia?

A

Diet

Drug modifications

44
Q

When does fluid/ volume overload become problomatic in CKD?

A

When GFR

45
Q

How does CKD lead to fluid/ volume overload?

A

Unable to excrete an excess Na+ load

Na+ and water retention

Oedema and hypertension

46
Q

How do you treat fluid overload in CKD?

A

Na+ restriction

Fluid restriction

Loop diuretics

47
Q

How do you tackle hypertension in CKD?

A

Treatment as per slowing rate of progression

Most imporatnt in proteinuric renal disease

ACEI may offer additional advantage

Otherwise tailored therapy

Aim

48
Q

What drugs should by be weary of in CKD?

A

The main effect of kidney disease is reduced excretion of drugs and their toxins
-Beware antibiotics, morphine, digoxin, metformin amongst others

In those with CKD certain drugs and agents can cause acute kidney injury on top of CKD:
-Contrast agents, antibiotics

49
Q

What is associated with worse outcomes in CKD?

A

Worse kidney function (GFR)

More proteinuria

Urinary Systems (26 decks)

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