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Renal Pathology > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

Functions of the kidney

A 
Body fluid homeostasis
Electrolyte balance
Excretory function 
Regulation of vascular tone
Acid base homeostasis
Endocrine function
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2
Q

Traditional definition of chronic renal failure

A

Irreversible and significant loss of renal function and thus problems with the functions of the kidneys

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3
Q

Definition of chronic kidney disease

A

Either the presence of kidney damage (abnormal blood, urine or x ray findings) or GFR <60ml/min/1.7m^3 that is present for >3 months

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4
Q

What are the stages of CKD?

A

1 - kidney damage / normal or high GFR - GFR > 90
2 - kidney damage / mild reduction in GFR - GFR = 60-89
3a/b - moderately impaired = 45-59, 30-44
4 - severely impaired = 15-29
5 - Advanced or on dialysis = < 15

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5
Q

What does pressure difference in the glomeruli lead to?

A

Glomerular filtration

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6
Q

What is GFR measured in?

A

ml/min

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7
Q

What crosses the GBM?

A

Water
Electrolytes
Urea
Creatinine

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8
Q

What crosses the GBM but is reabsorbed in the proximal tubule?

A

Glucose

Low molecular weight proteins (a2 microglobulin)

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9
Q

What does not cross the GBM?

A

Cells (RBCs, WBCs)

High molecular weight proteins (albumin, globulins)

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10
Q

Should there be blood or protein measurable in urine if filtering properly?

A

No

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11
Q

How is protein in the urine quantified?

A

Protein creatinine ratio (PCR)

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12
Q

What stage of CKD is most prevalent?

A

3

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13
Q

What is kidney failure replaced by?

A

Dialysis

Transplant

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14
Q

Complications of CKD

A 
Acidosis
Anaemia
Bone disease
CVD
Death and dialysis
Electrolytes
Fluid overload
Gout
HTN
Iatrogenic issues
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15
Q

Complications of CKD are more likely with worsening what?

A

eGFR

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16
Q

What does RRT stand for?

A

Renal replacement therapy

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17
Q

What is RRT for?

A

End stage renal disease

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18
Q

Causes of CKD

A 
DM
GMN
HTN
Renovascular disease 
- renal artery stenosis from atherosclerosis or fibromuscular dysplasia 
- leads to ischaemic nephropathy 
Polycystic kidney disease
Myeloma
IgA nephropathy 
Nephrocalcinosis
Sarcoidosis
Chronic exposure to nephrotoxins (NSAIDs, lithium, lead, certain herbs)
Reflux nephropathy 
Chronic obstructive nephropathy 
- prostate disease
- metastatic cancer
- retroperitoneal fibrosis
- PUJ obstruction
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19
Q

Presentation of CKD

A 
Pallor secondary to anaemia of CKD
HTN
SOB
Cognitive changes
GI symptoms
- Anorexia
- vomiting
- taste disturbance 
- uraemic odour
Polyuria
Nocturia 
Frothy urine
Haematuria
Proteinuria
Peripheral oedema
Itch 
Cramps
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20
Q

When are cramps mostly common in CKD?

A

At night

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21
Q

Why do cramps occur in CKD?

A

Neuronal irritation caused by the biochemical abnormalities of CKD

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22
Q

Investigations of CKD

A 
USS
XRAY
CT
MRI 
Bloods + blood film 
Biochemistry 
Coagulation screen
Urine protein:creatinine ratio 
CK
Anti-GBM
ANCA or ELISA
C3, C4, auto antibody scren
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23
Q

USS advantages

A

Non invasive
Non ionising radiation
May provide info about chronicity of renal disease
No functional data
Can be used to detect progressive obstruction

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24
Q

What are key goals of treatment of CKD?

A

Slowing the rate of decline

Assessment of complications related to reduced GFR

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25
Q

How is it possible to slow the rate of renal decline in CKD?

A 
BP control
Control proteinuria 
Treat causes
Allopurinol 
Dietary protein restriction 
Fish oils
Lipid lowering
Control acidosis
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26
Q

What is high BP associated with in CKD?

A

Faster decline in GFR

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27
Q

Investigations of the complications of CKD

A

Bicarbonate, pH (acidosis)
Blood count, film, haemantics (anaemia)
Calcium phosphate albumin parathyroid hormone (bone disease)
Electrolytes including K (electrolytes)
Exam including BP, oedema, JVP, CXR (fluid overload)
BP +/- 24 hour tape (HTN)
Ask about medication (iatrogenic issues)

28
Q

What GFR level would metabolic acidosis be seen in?

A

<20mls/min

29
Q

What does metabolic acidosis worsen?

A

Hyperkalaemia

Renal bone disease

30
Q

Treatment of metabolic acidosis

A

Oral Na Bicarbonate

31
Q

What GFR does anaemia usually manifest at?

A

< 20mls/min

32
Q

What type of anaemia is seen in renal disease?

A

Normochromic normocytic

33
Q

What does reduced GFR have an effect on phosphate?

A

Hyperphosphatemia

34
Q

Effect of CKD on vitamin D

A 
Loss of renal tissue
Lack of activated vit D
Low 1a hydroxylation in CKD, so low activation of vit D 
Low Vit D levels lead to low calcium 
- reduced intestinal absorption 
- reduced tubular resorption
35
Q

Management of renal bone disease

A

Control phosphate
- diet
- phosphate binders
- CaCO3, Ca acetate, sevelamer, lanthanum
Normalise calcium and PTH
- active vit D analogues (calcitriol)
- tertiary disease; parathyroidectomy and calcimetrics (cinacalet)

36
Q

What is potassium normally excreted with in the distal tubule?

A

Na+

37
Q

What happens to Na+ excretion as GFR falls?

A

Reduced delivery of Na+ to distal tubule as GFR falls

38
Q

What level of K+ may induce fatal cardiac arrhythmia?

A

> 7mmol/l

39
Q

Treatment of hyperkalaemia

A 
Acute
- stabilise - calcium gluconate
- shift = salbutamol + insulin dextrose
- Remove dialysis and calcium resonium
Chronic 
- diet
- drug modifications
40
Q

Examples of high potassium foods

A 
Avocadoes
Bananas
Mangoes
Kiwi 
Oranges
Peas
Pumpkins
Sweet potatoes
Tomatoes 
Ice cream 
Milk 
Dairy 
Chocolate
Seeds and nuts
41
Q

Examples of food that contain low potassium

A 
Apples
Berries
Grapes
Watermelon 
Carrots
Lettuce
Onion
Unsalted popcorn
42
Q

At what GFR is fluid/volume overload usually problematic?

A

GFR < 20mls/min

43
Q

Why do people get volume overload?

A

Unable to excrete an excess Na+ load

44
Q

What does volume overload lead to?

A

Oedema

Hypertension

45
Q

Treatment of volume/fluid overload

A

Na+ restriction
Fluid restriction
Loop diuretics

46
Q

What is HTN as a complication of CKD often assosiated with?

A

Volume overload

47
Q

What BP is aimed for in CKD with and without proteinuria?

A

With - < 125/75

Without - 130/80

48
Q

What does a build up of urea toxin lead to?

A

Uraemic pericarditis

49
Q

Management of acidosis due to reduced GFR

A

Bicarb

50
Q

Management of anaemia due to reduced GFR

A

EPO

Iron

51
Q

Management of CV risk due to reduced GFR

A 
BP
Drugs
Aspirin 
Cholesterol 
Exercise
Weight loss
52
Q

Management of risk of dialysis and death due to reduced GFR

A

Counsel and prepare

53
Q

Management of electrolyte imbalance due to reduced GFR

A

Diet

Consider drugs

54
Q

Management of fluid overload

A

Salt and fluid restriction

Diuretics

55
Q

Modalities of renal replacement therapy

A

Haemodialysis
Peritoneal dialysis
Transplant
Conservative care

56
Q

How many stages are there of CKD?

A

5

57
Q

What are the stages of CKD according to their GFR levels?

A 
Stage 1 - GFR > 90
Stage 2 - GFR 60 - 90
Stage 3a - GFR 45 - 60 
Stage 3b - GFR - 30 - 45
Stage 4 - GFR - 15 - 30 
Stage 5 - GFR - 0 - 15
58
Q

What level of GFR cannot be measured above?

A

> 60

59
Q

What is erythropoietin released by and in response to what?

A

Kidney

In response to cellular hypoxia

60
Q

What are the main uses of erythropoieitin as treatment?

A

Treat anaemia associated with CKD

Treat anaemia associated with cytotoxic therapy

61
Q

S/Es of erythropoietin treatment

A

Accelerated HTN potentially leading to encephalopathy and seizures (BP increases in 25% of patients)
Bone aches
Flu like symptoms
Skin rashes, urticaria
Pure red cell aplasia (due to Abs against erythropoietin)
Raised PCV increases the risk of thrombosis (e.g. fistula)
Iron deficiency 2ndry to increased erythroporesis

62
Q

What is the angion gap used for?

A

To classify metabolic acidosis into either

  • raised anion gap e.g. seen in DKA
  • normal anion gap e.g. seen in patients with diarrhoea due to GI bicarb loss
63
Q

How to calculate the anion gap

A

(Na + K) - (Cl + HCO3)

64
Q

Who is iron deficiency anaemia a worrying sign in?

A

Elderly

65
Q

Are erythropoietin injections any use in patients who are iron deficient?

A

No

66
Q

How can CKD result in osteomalacia?

A

Due to high phosphate levels - this ‘drags’ calcium from the bones

67
Q

If prescribing fluids, what is someones glucose requirements per day? Is this calculated with their weight?

A

50 - 100g/day

Irrespective of their weight

Renal Pathology (13 decks)

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