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Chronic Kidney Disease Flashcards

1
Q

What is chronic kidney disease?

A

The irreversible and significant loss of renal function

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2
Q

What are the symptoms and signs of uraemia?

A 
Nausea
Vomiting
Fatigue
Anorexia
Weight loss
Muscle cramps 
Pruritis 
Mental status changes
Visual disturbances
Increased thirst
Anaemia
Acidaemia 
Electrolyte abnormalities
Hypertension
Exacerbation of CVS conditions 
Fluid retention 
Muscle wasting 
Arrhythmias
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3
Q

When can uraemia occur?

A

Once creatinine clearance is below 10-20ml/min

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4
Q

How is kidney disease assessed for?

A

Using excretory function, filtering function and anatomy

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5
Q

How is excretory function assessed?

A

Using estimates of GFR (eGFR) from creatinine blood tests

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6
Q

What substances cross the glomerular basement membrane?

A

Water
Electrolytes
Urea
Creatinine

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7
Q

What substances cross the glomerular basement membrane but are reabsorbed in the proximal tubule?

A

Glucose

Low molecular weight proteins

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8
Q

What substances do not cross the glomerular basement membrane?

A

Cells - RBC, WBC

High molecular weight proteins e.g. albumin and globulins

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9
Q

If the kidneys are filtering properly, what should not be measurable in the urine?

A

Blood or protein

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10
Q

How can filtering function be assessed?

A

Using urinalysis to detect blood and protein, and protein quantification to determine the protein-creatinine ratio

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11
Q

How can urinary system anatomy be assessed?

A

Using histology and radiology

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12
Q

What does eGFR estimate?

A

The volume of blood that is filtered by the kidneys over a given period of time

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13
Q

What can eGFR be used for?

A

Can be used to screen for and detect early kidney damage and to monitor kidney function

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14
Q

According to the NKF-K/DOQI classification system, what is stage 1 kidney disease?

A

Kidney damage/normal or high GFR

GFR > 90

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15
Q

According to the NKF-K/DOQI classification system, what is stage 2 kidney disease?

A

Kidney damage/mild reduction in GFR

GFR 60-89

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16
Q

According to the NKF-K/DOQI classification system, what is stage 3 kidney disease?

A

Moderately impaired
3a - GFR 45-59
3b - GFR 30-44

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17
Q

According to the NKF-K/DOQI classification system, what is stage 4 kidney disease?

A

Severely impaired

GFR 15-29

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18
Q

According to the NKF-K/DOQI classification system, what is stage 5 kidney disease?

A

Advanced or on dialysis

GFR < 15

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19
Q

How is chronic kidney disease defined?

A

Defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR < 60ml/min/1.73m^2 that is present for 3 months or more

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20
Q

What percentage of the UK population are affected by CKD?

A

8-12%

most present with stage 3

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21
Q

What can screening for CKD reduce?

A

The number of people presenting with later stage disease and requiring dialysis and transplant

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22
Q

What are the complications of CKD?

A 
Acidosis
Anaemia
Bone disease
Cardiovascular problems
Death
Dialysis 
Electrolyte abnormalities
Fluid overload
Gout 
Hypertension 
Iatrogenic issues

Complications are more likely with a worsening eGFR

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23
Q

What does mortality from CKD increase with?

A

Worsening renal function

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24
Q

CKD describes a number of different conditions, what are some of these?

A 
Diabetes
Glomerulonephritis
Hypertension 
Renovascular disease
Polycystic kidney disease
Myeloma
IgA nephropathy
Sarcoidosis
Chronic exposure to nephrotoxins 
Reflux nephropathy 
Chronic obstructive nephropathy
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25
What is the clinical approach to CKD?
Detection of underlying aetiology - treatment for specific disease Slow rate of renal decline - generic therapies Assessment of complications related to reduced GFR - prevention and treatment Preparation for renal replacement therapy
26
What are the most important features of a patient's history when investigating CKD?
``` Previous evidence of renal disease FH Systemic diseases Drug exposure Pre/post-renal factors e.g. congestive cardiac failure, cirrhosis Uraemic symptoms ```
27
What features of examination are important when investigating CKD?
Vital signs Volume status Systemic illness Obstruction
28
What investigations might be used in detection of the underlying aetiology of CKD?
Bloods - U&Es, FBC Histology, renal biopsy Urine tests - urine dip, urine PCR or ACR, 24 hour collection Radiology
29
What biochemistry tests might be used when investigating CKD?
``` Urea, creatinine, electrolytes Bicarbonate Total protein, albumin Calcium, phosphate LFTs Creatine kinase Immunoglobulins, serum protein electrophoresis ```
30
What haematology tests might be used when investigating CKD?
``` FBC Hb MCV MCH WBC Platelets % hypo chromic RBCs ```
31
What features of coagulation might be tested when investigating CKD?
PT APPT Fibrinogen
32
What imaging tests might be done when investigating CKD?
``` Ultrasound Plain radiography CT Nuclear medicine MRI ```
33
What is the general management of CKD?
``` BP control Control proteinuria Reverse other contributing factors, treat causes Allopurinol Dietary protein restriction Fish oils Lipid lowering Control acidosis ```
34
When is metabolic acidosis seen?
Not usually seen until GFR < 20ml/min | Most marked in tubular-interstitial disease
35
What are the symptoms of metabolic acidosis?
General symptoms Worsens hyperkalaemia Exacerbates renal bone disease Treated with oral sodium bicarbonate
36
When does anaemia usually manifest in CKD?
When GFR < 20 ml/min
37
What are the features of anaemia in CKD?
Reduced erythropoietin production Reduced red cell survival Increased blood loss
38
How is anaemia in CKD treated?
Usually treat is < 10 gl/dl or symptomatic Iron replacement ESA therapy
39
How does CKD result in bone disease?
Reduced GFR leads to hyperphosphataemia Loss of renal tissue leads to lack of activated vitamin D Low calcium and raised phosphate (Secondary hyperparathyroidism, may progress to early tertiary hyperparathyroidism)
40
How is vitamin D activated?
Vitamin D derived from sunlight or diet Needs to be hydroxylated to be active Hydroxylation is catalysed by alpha-1 hydroxylase in the kidney In CKD, alpha-1 hydroxylase is low so low activation of vitamin D Low vitamin D -> low calcium Reduced intestinal reabsorption, reduced tubular reabsorption Resulting stimulation of PTH secretion
41
What effect does high phosphate have on alpha-1 hydroxylase and vitamin D?
High phosphate -> reduced alpha 1 hydroxylase -> low vitamin D
42
What effect does high phosphate have on PTH production?
High phosphate stimulates PTH production
43
What vascular and cardiac pathologies is high phosphate associated with?
Vascular and cardiac calcification
44
What effect does increased PTH have on osteoclasts and osteoblasts?
Increased PTH leads to increased number and activity of osteoclasts and osteoblasts so there is more bone turnover
45
How is phosphate controlled?
Dietary management | Phosphate binders
46
How are calcium and PTH normalised?
Active vitamin D analogues e.g. calcitriol | Manage tertiary disease e.g. parathryoidectomy
47
What are the CVS risks for renal disease?
``` Hypertension Hyperlipidaemia Smoking Underlying disease Renal bone disease Endothelial dysfunction Lifestyle ```
48
How does CKD lead to hyperkalaemia?
Potassium is usually excreted by exchange with sodium in the distal tubule Reduced delivery of sodium to distal tubule as GFR falls so reduced exchange
49
What factors might influence hyperkalaemia in CKD?
Underlying disease Drugs Diet
50
How can hyperkalaemia be treated?
Stabilise - calcium gluconate Shift - salbutamol, insulin dextrose Remove - dialysis, calcium resonium Chronic - diet and drug modification
51
What might hyperkalaemia induce?
Fatal cardiac arrhythmia
52
When is fluid overload usually problematic?
When GFR < 20/min
53
What are the features of fluid overload?
Unable to excrete excess sodium load Sodium and water retention Oedema and hypertension
54
How is fluid overload treated?
Sodium restriction Fluid restriction Loop diuretics
55
What will treatment of hypertension slow in CKD?
Rate of progression
56
What is hypertension in CKD often associated with?
Volume overload
57
When is hypertension in CKD most important?
In renal disease with proteinuria
58
What is the BP aim in CKD patients?
< 125/75 in CKD with significant proteinuria | 120/80 in CKD with no proteinuria
59
What does build up of urea toxin cause?
Uraemic pericarditis
60
What is the main effect of kidney disease?
Reduced excretion of drugs and their toxins
61
What drugs/agents can cause acute kidney injury on top of CKD?
Contrast agents | Antibiotics
62
How is acidosis managed in CKD?
Bicarbonate
63
How is anaemia managed in CKD?
EPO and iron
64
How is bone disease managed in CKD?
Diet and phosphate binders
65
How is CV risk managed in CKD?
``` BP management Aspirin Cholesterol management Exercise Weight management ```
66
How are electrolytes managed in CKD?
Diet | Consider drugs
67
How is fluid overload managed in CKD?
Salt and fluid restriction | Diuretics
68
How is gout managed in CKD?
Optimise overall health and medication
69
What is involved in preparation for end-stage renal disease and renal replacement therapy?
Education and information Selection of modality - haemodialysis, peritoneal dialysis, transplant, conservative Plan access Decide when to start RRT
70
When is creatinine raised above the normal range?
Will not be raised above the normal range until 60% of total kidney function is lost Serum creatinine levels are higher with higher muscle mass
71
What are the advantages and disadvantages of serum creatinine testing?
Cheap and easy test to do to indicate function | But not very sensitive - GFR can drop significantly before there is any effect on creatinine
72
What can be used to estimate GFR from serum creatinine?
Isotope GFR Inulin clearance 24-hour urine collection
73
What calculations can be used to estimate GFR from serum creatinine?
Cockcroft Gaullt MDRD 4 variable equation CKD-EPI equation

Urinary System (22 decks)

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