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Met 3b > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

Role of Kidney

A

A WETBED

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2
Q

A WETBED

A 
Acid base balance maintaining
Water balance maintaining
Electrolyte balance
Toxin removal
BP control
Erythropoietin synthesis
Vit D metabolism
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3
Q

CKD

A 
Presence of:
Kidney damage (albuminuria)
OR
Decreased kidney function (GFR<60 ml/minute per 1.73m2)
for 3 months or more
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4
Q

CKD causes

A 
Diabetes (40%)
Hypertension (30%)
Glomerulonephridites (7%)
Polycystic kidney disease (3%)
Chronic obstruction
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5
Q

CKD Stage 1

A 
Normal eGFR (>90)
With other evidence of kidney damage (persistent microalbuminuria or proteinuria, haematuria, structural abnormalities, biopsy proven glomerulonephritis)
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6
Q

CKD Stage 2

A

eGFR 60-90

With other evidence of kidney damage

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7
Q

CKD Stage 3a

A

eGFR 45-59

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8
Q

CKD Stage 3b

A

30-44

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9
Q

CKD Stage 4

A

eGFR 15-29

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10
Q

CKD Stage 5

A

eGFR < 15

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11
Q

CKD presentation

A

Commonly asymptomatic, picked up at screening

Non specific symptoms

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12
Q

CKD non specific symptoms

A 
Fatigue
Weakness
Nausea
Anorexia
Dyspnoea
Peripheral oedema
Sore mouth
Vomiting + diarrhoea
Bad breath
Increased thirst and urine production
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13
Q

CKD screening

A

Screen by checking GFR and urine albumin-creatinine ratio (ACR)

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14
Q

Patients at risk of CKD

A 
AKI
Diabetes
Cardiovascular disease
Structural kidney disease
Uropathy (BPH, recurrent renal calculi)
Multisystem disease with potential renal involvement (SLE etc)
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15
Q

CKD vs AKI

A

Important in patients presenting with renal dysfunction, but unknown baseline level
Can be difficult

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16
Q

CKD vs AKI distinguishing features

A

Clues include:
Non-specific symptoms of CKD (fatigue, weight loss, anorexia, nocturia, pruritic)
Presence of anaemia
Renal ultrasound- small kidneys? structural abnormalities?

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17
Q

CKD annual monitoring

A

eGFR
Urine albumin:creatinine ration (ACR)
- correlates with rate of progression of disease
- most reliable prognostic factor in CKD

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18
Q

CKD specialist referral when:

A 
GFR<30
ACR>70mg/mmol
ACR>30mg/mmol in presence of haematuria
Hypertension despite 4 antihypertensives
Accelerated progression of CKD- reduction of GFR by 25% with change in GFR category within 12 months, reduction in GFR of >-15 or more within 12 months
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19
Q

CKD management

A

Underlying cause
Slow progression
Manage complications
Renal replacement therapy

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20
Q

CKD- reducing albuminuria

A 
ACE-inhibitors to patient with CKD and:
- diabetes with albuminuria >30mg/mmol
-hypertension and albuminuria >30mg/mmol
-albuminuria >70mg/mmol
Check GFR 1-2wks after starting ACE-Inh
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21
Q

CKD complications

A 
Mineral bone disease
CV disease
Electrolyte disturbance
Fluid disturbance
Hypertension
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22
Q

CKD- Anaemia due to number of factors:

A

Reduced erythropoietin levels (normochromic normocytic anaemia)
Toxic effect of uraemia on bone marrow
Anorexia/nausea due to uraemia causing Vit deficiency
Reduced red cell survival (patients on haemodialysis)

–> may lead to LVH and 3x mortality rates

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23
Q

CKD anaemia- management

A

Ensure not iron deficient (and B12 + folate)

Give erythropoietin

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24
Q

CKD complication- Mineral bone disease

A

Reduced renal function leads to reduced filtration and excretion of phosphate
Raised serum phosphate binds to serum calcium, leading to reduced free calcium
–> stimulates parathyroid gland to release PTH
PTH stimulates osteoclasts
Mobilises calcium and phosphate from skeleton
Further elevates serum phosphate

25
Q

CKD- vit D

A

Less Vit D activation
–> less calcium absorbed from GI tract
Mineral bone disease tends to occur only when GCF<30ml/minute/1.73m2

26
Q

CKD- Hyperphosphataemia management

A

Low phosphate diet

Phosphate binder- calcium acetate

27
Q

When does mineral bone disease tend to occur

A

GCF<30ml/min

28
Q

CKD- low Vit D management

A

offer supplements only if Vit D deficient

if Vit D deplete + CKD bone disorders persist, offer alfacalcidiol or calcitriol

29
Q

Alfacalcidol

A

1 alpha hydroxycolecalciferol

30
Q

Calcitriol

A

1,25-dihydroxycolecalciferol

31
Q

Leading cause of death in patients with CKD

A

Cardiovascular disease- 50%

32
Q

CKD- CV disease, multi-factorial

A 
Hypertension
Underlying diabetes
Vascular calcium deposits
Anaemia
Fluid overload
Endothelial dysfunction and inflammation
33
Q

CKD management- CVD prevention

A

Lifestyle changes
Statins- offer to all CKD patients
Antiplatelet- offer to all patients with CKD, but is increased risk of bleeding

34
Q

CKD- Hypertension

A

Can be vicious cycle of hypertension + worsening renal function

35
Q

CKD causes hypertension by

A

Reduced GFR causes production of renin

Reduced GFR leads to reduced sodium and water excretion

36
Q

CKD- BP control

A

Target <140/90
For patients with diabetes, target 130/80
ACE inhibitors are good choice

37
Q

CKD- water and electrolyte imbalance

A

Can result from end-stage renal failure
If patient oliguric/anuric, fluid restrict to 500ml/day
Can cause fluid overload + Hyperkalaemia

38
Q

Fluid overload + hyperkalaemia are indications for

A

Dialysis

39
Q

CKD- CV disease management

A

Lifestyle
Statin
Antiplatelet

40
Q

CKD- bone mineral disease management

A

Low phosphate diet
Phosphate binders
Vit D supplementation

41
Q

CKD- hypertension management

A

Tight BP control

ACE Inh also reduce albuminuria

42
Q

CKD- anaemia management

A

Correct other deficiencies

EPO

43
Q

CKD- water and electrolyte management

A

Fluid restrict if oliguric/anuria

Dialyse if overloaded + hyperkalaemic

44
Q

End stage renal failure

A

Patients with stage 4-5 CKD
Or those with rapidly progressing stage 3 CKD
Should be referred to nephrologist
Discuss management ESRF

45
Q

End stage renal disease management options

A

Conservative management and symptom control
Dialysis
Renal transplant

46
Q

End stage renal failure- Conservative care

A

Dialysis may not improve QOL in patients with extensive comorbidities
Very elderly or unwell patients may not have their lives prolonged by dialysis
Many patients opt for symptom control- EPO, bone mineral disease management, antipruritics, antiemetics

47
Q

End Stage RF- Dialysis

A

Usually starts when GFR <10, or <15 in diabetics

2 options- haemodialysis or peritoneal dialysis

48
Q

Peritoneal dialysis

A

Usually preferred in patients who:
Have residual renal function
Do not have significant other comorbidities

49
Q

Haemodialysis

A

Pump blood through artificial kidney
Blood surrounded by a solution of electrolytes (the dialysate)
Solutes in the serum (urea, potassium, creatinine) diffuse into the dialysate and are removed
Ultrafiltration used to regulate distribution of water
Vol of water can be controlled by altering pressure on either side of membrane

50
Q

Haemodialysis access

A

Vascular- arterio-venous fistula
Large bore central catheter
Usually performed 3x week for 4 hours

51
Q

Peritoneal dialysis MOA

A

Dialysate infused into peritoneal cavity
Blood flowing through peritoneal capillaries acts as blood source
Ultrafiltration controlled by altering the osmolality of the dialysate + drawing water out of the intravascular compartment

52
Q

Peritoneal dialysis times

A

Continuous ambulatory peritoneal dialysis (CAPD)- 4 exchanges of 20 mins spaced throughout the day
OR automated peritoneal dialysis which can be used to do number of exchanges overnight
Can be performed at home, aiding independence

53
Q

Renal transplant

A 
Best long term outcome
Cadaveric 85-90%
Receiving patient native kidneys not generally removed
Transplanted kidney iliac fossa
Long term immunosuppression needed
54
Q

Renal transplant complications- Hyperacute

A

Within minutes

Due to donor-recipient mismatch

55
Q

Renal transplant complications- Accelerated

A

Within few days
Aggressive- mainly T cell mediated
Fever, swollen transplanted kidney, rapidly increasing serum creatinine
Can be salvaged with high dose steroids + antilymphatic antibodies but long term survival affected

56
Q

Renal transplant complications- acute cellular

A

Usually in 1-3 weeks but can occur up to 12 weeks
25% patients
Fluid retention, rising BP, rapid creatinine increase
IV steroids after diagnosis by biopsy

57
Q

Renal transplant complications- chronic

A

Gradual rise serum creatinine + proteinuria, resistant hypertension
Graft biopsy shows vascular changes, fibrosis + tubular atrophy
Not responsive to increasing immunosuppression therapy

58
Q

Renal transplant opportunistic infections

A

Viral (particularly herpes simplex in first 4 weeks, then CMV later)
Fungal
Bacterial

59
Q

Renal transplant malignancies

A

Lymphomas

Skin cancers

Met 3b (21 decks)

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