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Urinary System > Chronic Kidney Disease > Flashcards

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
Q

What is the clinical approach to CKD?

A

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

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26
Q

What are the most important features of a patient’s history when investigating CKD?

A 
Previous evidence of renal disease
FH 
Systemic diseases 
Drug exposure 
Pre/post-renal factors e.g. congestive cardiac failure, cirrhosis 
Uraemic symptoms
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27
Q

What features of examination are important when investigating CKD?

A

Vital signs
Volume status
Systemic illness
Obstruction

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28
Q

What investigations might be used in detection of the underlying aetiology of CKD?

A

Bloods - U&Es, FBC
Histology, renal biopsy
Urine tests - urine dip, urine PCR or ACR, 24 hour collection
Radiology

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29
Q

What biochemistry tests might be used when investigating CKD?

A 
Urea, creatinine, electrolytes
Bicarbonate
Total protein, albumin 
Calcium, phosphate 
LFTs
Creatine kinase
Immunoglobulins, serum protein electrophoresis
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30
Q

What haematology tests might be used when investigating CKD?

A 
FBC
Hb
MCV
MCH
WBC
Platelets
% hypo chromic RBCs
31
Q

What features of coagulation might be tested when investigating CKD?

A

PT
APPT
Fibrinogen

32
Q

What imaging tests might be done when investigating CKD?

A 
Ultrasound 
Plain radiography 
CT 
Nuclear medicine
MRI
33
Q

What is the general management of CKD?

A 
BP control
Control proteinuria 
Reverse other contributing factors, treat causes 
Allopurinol
Dietary protein restriction 
Fish oils
Lipid lowering 
Control acidosis
34
Q

When is metabolic acidosis seen?

A

Not usually seen until GFR < 20ml/min

Most marked in tubular-interstitial disease

35
Q

What are the symptoms of metabolic acidosis?

A

General symptoms
Worsens hyperkalaemia
Exacerbates renal bone disease
Treated with oral sodium bicarbonate

36
Q

When does anaemia usually manifest in CKD?

A

When GFR < 20 ml/min

37
Q

What are the features of anaemia in CKD?

A

Reduced erythropoietin production
Reduced red cell survival
Increased blood loss

38
Q

How is anaemia in CKD treated?

A

Usually treat is < 10 gl/dl or symptomatic
Iron replacement
ESA therapy

39
Q

How does CKD result in bone disease?

A

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
Q

How is vitamin D activated?

A

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
Q

What effect does high phosphate have on alpha-1 hydroxylase and vitamin D?

A

High phosphate -> reduced alpha 1 hydroxylase -> low vitamin D

42
Q

What effect does high phosphate have on PTH production?

A

High phosphate stimulates PTH production

43
Q

What vascular and cardiac pathologies is high phosphate associated with?

A

Vascular and cardiac calcification

44
Q

What effect does increased PTH have on osteoclasts and osteoblasts?

A

Increased PTH leads to increased number and activity of osteoclasts and osteoblasts so there is more bone turnover

45
Q

How is phosphate controlled?

A

Dietary management

Phosphate binders

46
Q

How are calcium and PTH normalised?

A

Active vitamin D analogues e.g. calcitriol

Manage tertiary disease e.g. parathryoidectomy

47
Q

What are the CVS risks for renal disease?

A 
Hypertension
Hyperlipidaemia 
Smoking 
Underlying disease 
Renal bone disease 
Endothelial dysfunction 
Lifestyle
48
Q

How does CKD lead to hyperkalaemia?

A

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
Q

What factors might influence hyperkalaemia in CKD?

A

Underlying disease
Drugs
Diet

50
Q

How can hyperkalaemia be treated?

A

Stabilise - calcium gluconate
Shift - salbutamol, insulin dextrose
Remove - dialysis, calcium resonium
Chronic - diet and drug modification

51
Q

What might hyperkalaemia induce?

A

Fatal cardiac arrhythmia

52
Q

When is fluid overload usually problematic?

A

When GFR < 20/min

53
Q

What are the features of fluid overload?

A

Unable to excrete excess sodium load
Sodium and water retention
Oedema and hypertension

54
Q

How is fluid overload treated?

A

Sodium restriction
Fluid restriction
Loop diuretics

55
Q

What will treatment of hypertension slow in CKD?

A

Rate of progression

56
Q

What is hypertension in CKD often associated with?

A

Volume overload

57
Q

When is hypertension in CKD most important?

A

In renal disease with proteinuria

58
Q

What is the BP aim in CKD patients?

A

< 125/75 in CKD with significant proteinuria

120/80 in CKD with no proteinuria

59
Q

What does build up of urea toxin cause?

A

Uraemic pericarditis

60
Q

What is the main effect of kidney disease?

A

Reduced excretion of drugs and their toxins

61
Q

What drugs/agents can cause acute kidney injury on top of CKD?

A

Contrast agents

Antibiotics

62
Q

How is acidosis managed in CKD?

A

Bicarbonate

63
Q

How is anaemia managed in CKD?

A

EPO and iron

64
Q

How is bone disease managed in CKD?

A

Diet and phosphate binders

65
Q

How is CV risk managed in CKD?

A 
BP management
Aspirin
Cholesterol management 
Exercise
Weight management
66
Q

How are electrolytes managed in CKD?

A

Diet

Consider drugs

67
Q

How is fluid overload managed in CKD?

A

Salt and fluid restriction

Diuretics

68
Q

How is gout managed in CKD?

A

Optimise overall health and medication

69
Q

What is involved in preparation for end-stage renal disease and renal replacement therapy?

A

Education and information
Selection of modality - haemodialysis, peritoneal dialysis, transplant, conservative
Plan access
Decide when to start RRT

70
Q

When is creatinine raised above the normal range?

A

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
Q

What are the advantages and disadvantages of serum creatinine testing?

A

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
Q

What can be used to estimate GFR from serum creatinine?

A

Isotope GFR
Inulin clearance
24-hour urine collection

73
Q

What calculations can be used to estimate GFR from serum creatinine?

A

Cockcroft Gaullt
MDRD 4 variable equation
CKD-EPI equation

Urinary System (22 decks)

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