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BS - Renal System > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What is the acronym for the functions of the kidney?

A

A - acid base balance

W - water removal
E - erythropoiesis
T - toxin removal

B - blood pressure control
E - electrolyte balance
D - vitamin D activation

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2
Q

How is the kidney involved in acid base balance?

A

It reabsorbs and produces bicarbonate

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3
Q

How is the kidney involved in water removal?

A

It produces urine

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4
Q

How is the kidney involved in erythropoiesis?

A

The kidney produces erythropoietin in the peritubular interstitial fibroblasts

This stimulates RBC production in bone marrow

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5
Q

How is the kidney involved in blood pressure control?

A

It is involved in the renin-angiotensin-aldosterone system

Renin is activated when blood pressure is low

This leads to Na+ and water retention that increases BP

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6
Q

What electrolytes are involved in electrolyte balance in the kidney?

A

sodium

potassium

chloride

magnesium

glucose

phosphate

bicarbonate

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7
Q

How is the kidney involved in Vitamin D activation?

A

It produces calcitriol

This promotes Ca2+ absorption in the gut and renal reabsorption of phosphate

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8
Q

What is involved in glomerular filtration?

A

The movement of substances from the blood within the glomerulus into the capsular space

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9
Q

What is involved in tubular reabsorption?

A

The movement of substances from the tubular fluid back into the blood

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10
Q

What is involved in tubular secretion?

A

The movement of substances from the blood into the tubular fluid

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11
Q

What is the main function of the glomerulus?

A

It filters small solutes from the blood

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12
Q

What is the main function of the Bowman’s capsule?

A

It collects what is filtered through the glomerulus

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13
Q

What is the main function of the proximal convoluted tubule?

A
  1. reabsorbs 65% of filtrate volume

(nutrients, ions and water)

  1. secretes toxins

(ammonia, creatinine, some drugs)

  1. adjusts filtrate pH
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14
Q

What is the main function of the descending limb of the loop of Henlé?

A

Water reabsorption through aquaporins

This increases osmolarity

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15
Q

What is the main function of the ascending limb of the loop of Henle?

A
  1. It reabsorbs Na and Cl

This reduces osmolarity

  1. Urea is secreted
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16
Q

What is the function of the distal convoluted tubule?

A

Aldosterone leads to reabsorption of Na+ (and Cl-) and secretion of K+

PTH causes Ca2+ reabsorption

It also reabsorbs bicarbonate and water and synthesises bicarbonate

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17
Q

What is the function of the collecting duct?

A

ADH leads to water reabsorption

It reabsorbs and secretes various ions to maintain blood pH

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18
Q

What does glomerular filtration rate refer to?

A

The ultrafiltrate of plasma which crosses the glomerular barrier into the urinary space

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19
Q

What is GFR equivalent to?

What is it used to measure?

A

It is equal to the total filtration rates of all functioning nephrons

It is a surrogate for the amount of functioning renal tissue

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20
Q

What is normal GFR?

A

90 mL/min/1.73 m^2 or higher

It cannot be measured directly and is adjusted for body surface area

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21
Q

What are the 2 different calculations that can be used to estimate GFR?

A
  1. CKD-EPI

2. MDRD

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22
Q

What is CKD-EPI based on?

When can it not be used?

A

It uses serum creatinine, sex, age and race

It cannot be used for children, pregnant women, elderly and some ethnic groups

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23
Q

What is the problem with MDRD calculations?

A

They underestimate GFR

CKD-EPI is a better predictor of risk

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24
Q

What must be taken into account when using formulae based on serum creatinine?

A
  1. higher average muscle mass in African patients means higher creatinine generation rate
  2. men have a greater muscle mass than women
  3. younger people have a greater muscle mass
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25
Q

What is chronic kidney disease?

How is it defined?

A

It describes abnormalities of kidney function or structure

eGFR of less than 60 ml/min/1.73m2 must be present on at least 2 occasions 90 days apart

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26
Q

How many stages of chronic kidney disease are there?

What are the GFR rates for each stage?

A
  1. mild reduction - eGFR 60 - 89
  2. mild to moderate reduction - eGFR 45-59
  3. moderate-severe reduction - eGFR 30-44
  4. severe reduction - eGFR 15-29
  5. kidney failure - eGFR < 15
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27
Q

What is normal eGFR?

A

> 90

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28
Q

What is CKD related to in terms of increasing risk of other conditions?

A
  1. cardiovascular disease
  2. acute kidney injury
  3. falls and frailty
  4. mortality

It can progress to end-stage renal failure

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29
Q

What ethnic minorities are more affected by CKD?

A

South Asians and black people

There are genetic factors

30
Q

If someone has a eGFR of >60 ml/min, do they have CKD?

A

NO!!

They only have CKD is there are other signs of kidney damage as well

31
Q

What is the aetiology of CKD?

A
  1. raised intraglomerular pressure
  2. glomerulosclerosis
  3. tubulointerstitial fibrosis
  4. loss of renal cortex
  5. shrunken kidneys
32
Q

What is glomerulosclerosis?

A

Expansion of glomerular mesangium and deposition of extracellular matrix

33
Q

What is tubulointerstitial fibrosis?

A

Tubular atrophy, interstitial inflammatory cell infilitrate and deposition of EC matrix in the interstitium

34
Q

What conditions may people have that warrant a test for CKD?

A
  1. diabetes
  2. hypertension
  3. acute kidney injury
  4. CVD
  5. detection of haematuria or proteinuria
  6. chronic nephrotoxin use
  7. family history of stage 5 kidney disease
35
Q

If someone has CKD risk factors, what tests are carried out on them?

A
  1. bloods and eGFR
  2. urinalysis to look for blood/protein
  3. blood pressure
36
Q

What signs are seen in an unhealthy kidney?

A
  1. fluid overload
  2. elevated wastes - urea, creatinine, K+
  3. changes in hormone levels controlling BP, RBC production and calcium uptake
37
Q

When do the symptoms of CKD tend to present?

A

It is generally asymptomatic in stages 1-3

38
Q

What are the visible clinical manifestations of CKD?

A
  1. vomiting
  2. reduced urinary output
  3. loss of lean body mass/muscle weakness
  4. skin pigmentation
  5. bleeding/bruising
  6. loss of appetite, nausea, metallic taste
39
Q

What are the non-visible clinical manifestations of CKD?

A
  1. salt and water retention
  2. aches and pains
  3. lethargy, impaired immune function
  4. sleep disturbance
40
Q

What is uraemia?

A

This is the accumulation of toxins

It involves a raised level in the blood of urea and other nitrogenous waste compounds

41
Q

What are the symptoms of uraemia?

A
  1. pericarditis
  2. encephalopathy (impaired cognition, confusion, coma, seizures)
  3. uraemic frost (urea and urate deposits on the skin)
42
Q

What further investigations are performed to look for the underlying cause of CKD?

A
  1. bloods
  2. renal biopsy
  3. imaging
43
Q

What further investigations are performed to look for the complications of CKD?

A
  1. blood count for anaemia
  2. Ca2+, phos, ALP, vit D for renal bone disease
  3. bicarbonate for metabolic acidosis
44
Q

What further investigations are performed to look for the end-organ damage relating to complications of CKD?

A

ECG and echocardiogram

45
Q

What further investigations are performed to look for the CV risk?

A

Lipid profile

46
Q

When should a renal ultrasound scan be performed?

A
  1. accelerated progression of CKD
  2. visible or persistent invisible haematuria
  3. symptoms of urinary tract obstruction
  4. polycystic kidney disease and over 20
47
Q

What are the non-modifiable factors influencing CKD progression?

A
  1. underlying cause of kidney disease

2. race

48
Q

What are examples of modifiable factors influencing CKD progression?

A
  1. dyslipidaemia
  2. exposure to nephrotoxic agents
  3. metabolic acidosis
  4. anaemia
  5. smoking
  6. glycaemic control (diabetics)
  7. blood pressure
  8. level of proteinuria
49
Q

What is the blood pressure aim for someone with CKD and ACR < 70?

A

Target BP < 140/90

50
Q

What is the blood pressure aim for someone with CKD, DM and ACR >70?

A

Target BP < 130/80

51
Q

When are ACEi or ARBs the first choice of treatment for high blood pressure in CKD?

A

Diabetic patients with hypertension or microalbuminuria

Hypertensive patients with ACR >/= 30 mg/mmol

All patients with ACR >/= 70 mg/mmol

52
Q

What treatment is given for proteinuria?

A

ACE inhibitors or ARBs

53
Q

What is the treatment for dyslipidemia?

A

Statins are given to patients over 50

They are given to patients <50 with risk factors for stroke, DM or CVD

54
Q

What is hyperphosphataemia?

A

An electrolyte disorder in which there is an elevated level of phosphate in the blood

55
Q

What is the risk of calcium phosphate deposition in hyperphosphataemia?

A

It can potentially lead to interstitial fibrosis and tubular atrophy

56
Q

What is metabolic acidosis?

What may it result in?

A

Increased acid secretion as the number of functioning nephrons decline

It may result in complement activation and interstitial damage

57
Q

Why are sodium bicarbonate supplements given in metabolic acidosis?

A
  1. to buffer the acid
  2. to prevent osteopenia
  3. to prevent muscle wasting
58
Q

What type of anaemia is present in CKD and why?

A

Normocytic anaemia

It is due to an erythropoietin deficiency

59
Q

What treatments are given for anaemia as a result of CKD?

A
  1. erythropoiesis stimulating agents

2. iron supplements

60
Q

What are the 6 main complications of CKD?

A
  1. anaemia
  2. CKD mineral bone disorder
  3. cardiovascular disease
  4. volume overload
  5. hyperkalaemia
  6. malnutrition
61
Q

What is the underlying cause of CKD-MBD?

A

Hyperphosphataemia leading from reduced renal clearance

62
Q

What are the other contributing factors to CKD-MBD?

A
  1. reduced renal hydroxylation of 25-hydroxyvitamin D
  2. reduced calcium
  3. secondary hyperparathyroidism
63
Q

What are the treatments for CKD-MBD?

A
  1. dietary restricition of phosphate and phosphate binders
  2. 1a-hydroxylated analogues
  3. calcimimetics
  4. vitamin D replacement
  5. parathyroidectomy
64
Q

What is the role of 1a-hydroxylated analogues?

A

e.g. calcitriol

They suppress PTH and control secondary hyperparathyroidism

65
Q

What are the treatments for cardiovascular disease in CKD?

A
  1. statins
  2. antiplatelets
  3. antihypertensives
66
Q

What are the treatments for volume overload?

A
  1. fluid and salt restriction
  2. diuretics
  3. renal replacement therapy
67
Q

What must the ACR be for a patient to be referred for further treatment?

A
  1. stage 4/5 CKD
  2. ACR > 70 mg/mmol (not due to diabetes)
  3. ACR > 30 mg/mmol plus haematuria
68
Q

What must the GFR decrease be for someone to be referred for further treatment?

A
  1. sustained decrease in GFR of >25% and a change in GFR category within 12 months
  2. sustained decrease in GFR of > 15 ml/min/1.73m2 per year
69
Q

What are the other factors that cause someone to be referred for further treatment?

A
  1. raised BP despite 4 or more antihypertensives at therapeutic dose
  2. known or suspected rare or genetic causes of CKD
70
Q

What is involved in advanced CKD?

A
  1. transplantation
  2. haemodialysis
  3. peritoneal dialysis
  4. conservative management
71
Q

What are the indications for renal replacement therapy?

A
  1. uraemia
  2. severe metabolic acidosis
  3. hyperkalaemia
  4. fluid overload

BS - Renal System (8 decks)

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