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Chronic Kidney Disease Flashcards

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1
Q

what are the 6 main functions of the kidneys

A
  1. body fluid homeostasis - urine production
  2. regulation of vascular tone - BP
  3. excretory function - urea, creatinine, drugs
  4. electrolyte homeostasis - Na, K, Cl, Ca Phos
  5. acid base homeostasis - H+, bicarbonate
  6. endocrine function - vit D, erythropoeitin, renin
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2
Q

what (in simple terms) is chronic renal failure

A

Irreversible and significant loss of renal function - all main functions can be affected

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3
Q

what are the three ways we can assess for kidney disease

A
  1. filtration (excrete out) function
  2. filtration (keep in) function
  3. look at anatomy
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4
Q

how is the excretory filtration function of the kidneys assessed

A

use estimates of glomerular filtration rate (eGFR) from creatinine blood test

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5
Q

what are the normal levels for GFR

A

90-120 ml/min/1.73m2

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6
Q

what are the GFR levels for stage 1 kidney disease

A

> 90

- kidney damage/normal or high GFR

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7
Q

what are the GFR levels for stage 2 kidney disease

A

60-89

- kidney damage/mild reduction in GFR

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8
Q

what are the GFR levels for stage 3a/b kidney disease

A

a) 45-59
b) 30-44
- moderately impaired

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9
Q

what are the GFR levels for stage 4 kidney disease

A

15-29

- severely impaired

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10
Q

what are the GFR levels for stage 5 kidney disease

A

<15

- advanced or on dialysis

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11
Q

what is the relationship between serum creatinine and GFR

A

as % normal GFR decreases, serum creatinine rises
BUT
creatinine will not be raised above normal until 60% of total kidney function lost

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12
Q

why do african americans have a higher serum creatinine level at any level of creatinine clearance

A

they have a naturally higher muscle mass

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13
Q

what can affect muscle mass and therefore serum creatinine results

A

age, ethnicity, gender, weight

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14
Q

what are other ways of assessing GFR

A

inulin clearance, isotope GFR, 24 hour urine collection+blood tests, GFR estimating equations

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15
Q

how is the reabsorbtive filtration function of the kidneys assessed

A

check for presence of blood or protein in urine

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16
Q

what molecules can cross the glomerular bowmans membrane

A

water, electrolytes, urea, creatinine

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17
Q

what molecules can cross the glomerular bowmans membrane BUT are reabsorbed in the proximal tubule

A

glucose, low molecular weight proteins (a2 micro globulin)

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18
Q

what molecules do NOT cross the glomerular bowmans membrane

A

cells (RBC, WBC), high molecular weight proteins (albumin, globulins)

THEREFORE
should be NO blood or protein measurable in urine if filtering properly

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19
Q

what are the two ways of checking for blood and protein in the urine

A

urinalysis (dipstick) - shows if blood and protein present

protein quantification - shows protein creatinine ratio

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20
Q

how is the anatomy of the kidneys assessed

A

look at histology and radiography

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21
Q

what is the current definition of chronic kidney disease (CKD)

A

either:
1. the presence of kidney damage (abnormal blood, urine or x-ray findings)
OR
2. GFR <60 ml/min/1.73m2 that is present for >or equal to 3 months

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22
Q

what sees prevalence of CKD increase

A

increases with age

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23
Q

what percentage of the UK has CKD

Study These Flashcards
A

~8-12%

mostly stage 3

24
Q

List some the complications CKD

Study These Flashcards
A 
Acidosis
Anaemia
Bone disease
Cardiovascular 
Death &amp; Dialysis
Electrolytes
Fluid overload
Gout
Hypertension
Iatrogenic issues
25
when are complications more likely to arrive
as eGFR get worse - more likely to suffer from complications
26
how much does renal replacement therapy cost per patient per year
~£35,000/patient/annum
27
what is the relationship between mortality and renal function
mortality increases with worsening renal function
28
what are common causes of CKD
1. diabetes 2. glomerulonephritis (and all that cause that) 3. hypertension 4. renovascular disease 5. polycystic kidney disease other include: myeloma, IgA nephropathy, nephrocalcinosis, sarcoidosis, chronic obstructive nephropathy
29
what are the 4 parts of the clinical approach to CKD
1. detection of the underlying aetiology (treatment for specific diseases) 2. slowing rate of renal decline (generic therapies) 3. assessment of complications related to reduced GFR (prevention and treatment) 4. preparation for renal replacement therapy
30
what are the areas to cover in taking a history to diagnose CKD
Previous evidence of renal disease Family history Systemic diseases Drug exposure Pre/post renal factors Uraemic symptoms
31
HISTORY: what would you look for in previous evidence of renal disease
Raised urea/creatinine Proteinuria/haematuria Hypertension Lower urinary tract symptoms
32
HISTORY: what would you look for in family history
(PKD/Alports)
33
HISTORY: what would you look for in systemic diseases
Diabetes mellitus Collagen vascular diseases - SLE, scleroderma, vasculitis Malignancy - Myeloma, breast, lung, lymphoma Hypertension Sickle cell disease
34
HISTORY: what would you look for in drug exposure
``` NSAIDs Penicillins/aminoglycosides Chemotherapeutic drugs Narcotic abuse ACE inhibitor / ARBs ```
35
HISTORY: what would you look for in post/pre renal factors
``` Congestive cardiac failure Diuretic use Nausea, vomiting, diarrhoea Cirrhosis LUTS / pelvic disease ```
36
HISTORY: what would you look for in uraemic symptoms
Nausea, anorexia, vomiting Pruritis Weight loss Weakness, fatigue, drowsiness
37
what are the areas to cover when examining a patient for CKD
Vital signs Volume status Systemic illness Obstruction
38
EXAMINATION: what would you look for in vital signs
fever, blood pressure
39
EXAMINATION: what would you look for in volume status
Deplete: Orthostatic BP, skin turgor/temperature Overload: Raised JVP, crepitations, ascites, oedema
40
EXAMINATION: what would you look for in systemic illness
Skin: Rash – malar (lupus), purpuric (vasculitis), macular (AIN) ``` Auscultation: Cardiac murmurs (endocarditis) ``` Abdomen: Bruits, palpable organs ``` Extremities: Livedo reticularis (vasculitis, atheroembolism), splinter haemorrhages (endocarditis) ``` Pulses: Absent (vascular disease) Bones and joints: Tender (malignancy) Inflammed (lupus) Gouty tophi
41
EXAMINATION: what would you look for in obstruction
Percussible bladder, enlarged prostate, flank masses
42
what investigations can be used to help diagnose CKD
Blood tests: U&Es, FBC, coagulation screen Urine tests: Urine dipstick, urine PCR or ACR - 24 hour collection Histology: renal biopsy Imaging: US*, plain radiology, CT, nuclear medicine, MRI *best one used
43
what chemistry investigations are used
Urea, creatinine, electrolytes (Na, K, Cl) Bicarbonate Total protein, albumin Calcium, phosphate Liver function tests Creatine kinase Immunoglobulins, serum protein electrophoresis
44
what is determined in protein quantification of urine
24hr urine collection - protein creatinine ratio (PCR) - albumin creatinine ration
45
how can the rate of renal decline be slowed
1. BP control 2. control proteinuria 3. reverse other contributing factors ``` others: allopurinol dietary protein restrictions fish oils lipid lowering control acidosis ```
46
how would you assess for acidosis and how would you treat it
check bicarbonate and pH GFR <20 treat with oral Na bicarbonate
47
how would you assess for anaemia and how would you treat it
blood count, film, haematinics GFR <20 manifests treat with iron replacement (oral vs IV), ESA therapy
48
how would you assess for bone disease and how would you treat it
reduced GFR, calcium low from low Vit D, phosphate high, albumin parathyroid hormone high treatment: - control phosphate (diet, phosphate binders) - normalise calcium and PTH (active vit D analogues, parathyroidectomy)
49
how would you assess for CV risk and how would you reduce it
history chest pain, BP, cholesterol, smoking, underlying disease (e.g. diabetes), renal bone disease, uraemia paricardiits reduce by improving lifestyle factors and above factors
50
how would you assess for death and dialysis and how would you manage it
renal function including urea creatinine eGFR manage by counselling
51
how would you assess for hyperkalaemia and how would you treat it
blood electrolyte count acute: - stabilise (calcium gluconate) - shift (salbutamol, insulin-dextrose) - remove (dialysis, calcium resonium) chronic: - diet - drug modifications
52
how would you assess for fluid overload and how would you treat it
examine including BP, oedema, JVP, chest Xray GFR <20 (Na+ and water retention) treat by Na+ restriction, fluid restriction and loop diuretics
53
how would you assess for gout and how would you treat it
history and exam optimise +/- meds
54
how would you assess for hypertension and how would you treat it
BP +/- 24 hour tape treat with antihypertensives - ACE inhibitors - CKD WITH proteinuria aim for <125/75 - CKD WITHOUT proteinuria aim for 130/80 get them to reduce weight, change diet and balance fluid
55
how would you assess for iatrogenic issues (drugs and toxins)
ask about medications , check build up of urea toxins (uraemia pericarditis) certain drugs in people with CKD can cause acute kidney injury on top - beware of antibiotics, morphine, digoxin, metformin, contrast agents
56
how would you prepare a patient with ESRD to start on renal replacement therapy
Education & information Selection of modality (HD / PD ?transplant ??conservative care) Planning access Deciding when to start RRT Multidisciplinary team
57
what are the classical symptoms and signs of uraemia
"urea in the blood" - progressive weakness - easy fatigue - loss of appetite due to nausea and vomiting - muscle atrophy - tremors - abnormal mental function - frequent shallow respiration - metabolic acidosis

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