Chronic kidney disease

Question 1

Chronic kidney insufficiency: general definition

Answer 1

• A kidney disease that develops over years, and is characterized by progressively decreasing GFR and increasing albuminuria
• The Stage 5 CKD is the “end stage kidney”, where accumulation of toxins, fluid, and electrolytes accumulate and result in uremic syndrome -> leads to death, unless toxins are removed by RRT: dialysis or kidney transplant

Question 2

Clinical symptoms of CKD associated with uremia and azotemia:

Answer 2

General symptoms:

• nausea, loss of appetite
• weakness, fatigue
• encephalopathy -> causing asterixis (tremor in the hands) -> coma, death
• uremic frost: crystals in the skin
• uremic fetor

Cardiovascular symptoms:

• ventricular arrhythmias/fibrillation -> due to hyperkalemia
• HTN: due to low kidney perfusion -> stimulation of renin secretion -> increased BP -> HTN. HTN is also a cause of CKD, creates a vicious cycle
• Pericarditis
• bleeding -> less clot formation
• pericarditis
• Fluid overload -> HF, pulmonary congestion

Biochemical abnormalities:

• hyperkalemia -> v.arrhythmias
• hyperphosphatemia -> could cause high anion gap metabolic acidosis
• hypocalcemia
• metabolic acidosis -> hyperventilation

Hormonal abnormalities:

• decreased vit D production -> hypocalcemia -> leads to increased PTH -> increased bone resorption -> leading to renal osteodystrophy
• decreased EPO -> anemia
• general: nausea, loss of appetite
• Encephalopathy -> causing asterixis (tremor of the hand) -> can lead to coma and death
• Uremic frost: crystals deposition in the skin

Question 3

Major disorders leading to CKD:

Answer 3

• HT, diabetes -> the most common
• glomerulonephritis
• pyelonephritis
• Autoimmune disorders -> SLE, rheumatoid arthritis
• cystic kidney diseases (PCKD)
• infections: HIV
• medication: NSAIDs
• toxins: tabacco

Question 4

What is acute on chronic kidney failure:

Answer 4

• AKI on top of CKD

Question 5

Stages of chronic kidney disease:

Answer 5

Stage 1

• kidney damage, but normal GFR
• renal function >90 ml/min/1.73m2

Stage 2

• kidney damage, mild decreased GFR
• renal function: 60-89 ml/min/1.73m2

Stage 3

• moderate decrease in GFR
• renal function: 30-59 ml/min/1.73m2

Stage 4

• severe decrease in GFR
• renal function: 15-29 ml/min/1.73m2

Stage 5

• end-stage renal disease
• renal function: less than 15 ml/min/1.73m2

Question 6

Diagnosis: 1. History + physical examination

Answer 6

• family history of CKD, history of HT, DM, medications etc…
• physical exam -> look for any of the symptoms

Question 7

Diagnosis: 2. Labs

Answer 7

Search for any clues of the underlying disease

• presence of autoAbs if autoimmune disease
• HIV, HBV, or HCV infection
• hemoglobin, iron, VitB12, folate to look for anemia
• 24h urine collection to determine protein excretion

Question 8

Diagnosis: 3. imaging

Answer 8

• renal US -> look for kidney size, cysts, renal masses, obstruction
• CT, MRI

Question 9

Diagnosis 4: Renal biopsy

Answer 9

Performed to comfirm the diagnosis, look for glomerulosclerosis

Contraindications:

• bilateral small kidneys: hard to reach, greater likelihood to cause bleeding and other adverse effects
• uncontrolled HT
• active infection
• ongoing anticoagulant treatment
• severe obesity

Question 10

Treatment:

Answer 10

Aim: to slowdown the progression of CKD

• Control hypertension: ACEi and ARBs, Ca2+ channel blockers (diltiazem and verapamil for vasodilation)
• treat the underlying diseases:
  Optimize blood glucose control in DM, immunosuppressive agents in GN
• RRT: dialysis or kidney transplant