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URINARY > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

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

A

~8-12%

mostly stage 3

24
Q

List some the complications CKD

A 
Acidosis
Anaemia
Bone disease
Cardiovascular 
Death &amp; Dialysis
Electrolytes
Fluid overload
Gout
Hypertension
Iatrogenic issues
25
Q

when are complications more likely to arrive

A

as eGFR get worse - more likely to suffer from complications

26
Q

how much does renal replacement therapy cost per patient per year

A

~£35,000/patient/annum

27
Q

what is the relationship between mortality and renal function

A

mortality increases with worsening renal function

28
Q

what are common causes of CKD

A
  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
Q

what are the 4 parts of the clinical approach to CKD

A
  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
Q

what are the areas to cover in taking a history to diagnose CKD

A

Previous evidence of renal disease

Family history

Systemic diseases

Drug exposure

Pre/post renal factors

Uraemic symptoms

31
Q

HISTORY: what would you look for in previous evidence of renal disease

A

Raised urea/creatinine
Proteinuria/haematuria
Hypertension
Lower urinary tract symptoms

32
Q

HISTORY: what would you look for in family history

A

(PKD/Alports)

33
Q

HISTORY: what would you look for in systemic diseases

A

Diabetes mellitus

Collagen vascular diseases -
SLE, scleroderma, vasculitis

Malignancy -
Myeloma, breast, lung, lymphoma

Hypertension

Sickle cell disease

34
Q

HISTORY: what would you look for in drug exposure

A 
NSAIDs
Penicillins/aminoglycosides
Chemotherapeutic drugs
Narcotic abuse
ACE inhibitor / ARBs
35
Q

HISTORY: what would you look for in post/pre renal factors

A 
Congestive cardiac failure
Diuretic use
Nausea, vomiting, diarrhoea
Cirrhosis
LUTS / pelvic disease
36
Q

HISTORY: what would you look for in uraemic symptoms

A

Nausea, anorexia, vomiting
Pruritis
Weight loss
Weakness, fatigue, drowsiness

37
Q

what are the areas to cover when examining a patient for CKD

A

Vital signs

Volume status

Systemic illness

Obstruction

38
Q

EXAMINATION: what would you look for in vital signs

A

fever, blood pressure

39
Q

EXAMINATION: what would you look for in volume status

A

Deplete:
Orthostatic BP, skin turgor/temperature

Overload:
Raised JVP, crepitations, ascites, oedema

40
Q

EXAMINATION: what would you look for in systemic illness

A

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
Q

EXAMINATION: what would you look for in obstruction

A

Percussible bladder, enlarged prostate, flank masses

42
Q

what investigations can be used to help diagnose CKD

A

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
Q

what chemistry investigations are used

A

Urea, creatinine, electrolytes (Na, K, Cl)

Bicarbonate

Total protein, albumin

Calcium, phosphate

Liver function tests

Creatine kinase

Immunoglobulins, serum protein electrophoresis

44
Q

what is determined in protein quantification of urine

A

24hr urine collection

  • protein creatinine ratio (PCR)
  • albumin creatinine ration
45
Q

how can the rate of renal decline be slowed

A
  1. BP control
  2. control proteinuria
  3. reverse other contributing factors
others: 
allopurinol
dietary protein restrictions
fish oils
lipid lowering
control acidosis
46
Q

how would you assess for acidosis and how would you treat it

A

check bicarbonate and pH
GFR <20

treat with oral Na bicarbonate

47
Q

how would you assess for anaemia and how would you treat it

A

blood count, film, haematinics
GFR <20 manifests

treat with iron replacement (oral vs IV), ESA therapy

48
Q

how would you assess for bone disease and how would you treat it

A

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
Q

how would you assess for CV risk and how would you reduce it

A

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
Q

how would you assess for death and dialysis and how would you manage it

A

renal function including urea creatinine eGFR

manage by counselling

51
Q

how would you assess for hyperkalaemia and how would you treat it

A

blood electrolyte count

acute:

  • stabilise (calcium gluconate)
  • shift (salbutamol, insulin-dextrose)
  • remove (dialysis, calcium resonium)

chronic:

  • diet
  • drug modifications
52
Q

how would you assess for fluid overload and how would you treat it

A

examine including BP, oedema, JVP, chest Xray
GFR <20 (Na+ and water retention)

treat by Na+ restriction, fluid restriction and loop diuretics

53
Q

how would you assess for gout and how would you treat it

A

history and exam

optimise +/- meds

54
Q

how would you assess for hypertension and how would you treat it

A

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
Q

how would you assess for iatrogenic issues (drugs and toxins)

A

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
Q

how would you prepare a patient with ESRD to start on renal replacement therapy

A

Education & information

Selection of modality
(HD / PD ?transplant ??conservative care)

Planning access

Deciding when to start RRT

Multidisciplinary team

57
Q

what are the classical symptoms and signs of uraemia

A

“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

URINARY (27 decks)

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