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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
CKD- vit D
Less Vit D activation --> less calcium absorbed from GI tract Mineral bone disease tends to occur only when GCF<30ml/minute/1.73m2
26
CKD- Hyperphosphataemia management
Low phosphate diet | Phosphate binder- calcium acetate
27
When does mineral bone disease tend to occur
GCF<30ml/min
28
CKD- low Vit D management
offer supplements only if Vit D deficient | if Vit D deplete + CKD bone disorders persist, offer alfacalcidiol or calcitriol
29
Alfacalcidol
1 alpha hydroxycolecalciferol
30
Calcitriol
1,25-dihydroxycolecalciferol
31
Leading cause of death in patients with CKD
Cardiovascular disease- 50%
32
CKD- CV disease, multi-factorial
``` Hypertension Underlying diabetes Vascular calcium deposits Anaemia Fluid overload Endothelial dysfunction and inflammation ```
33
CKD management- CVD prevention
Lifestyle changes Statins- offer to all CKD patients Antiplatelet- offer to all patients with CKD, but is increased risk of bleeding
34
CKD- Hypertension
Can be vicious cycle of hypertension + worsening renal function
35
CKD causes hypertension by
Reduced GFR causes production of renin | Reduced GFR leads to reduced sodium and water excretion
36
CKD- BP control
Target <140/90 For patients with diabetes, target 130/80 ACE inhibitors are good choice
37
CKD- water and electrolyte imbalance
Can result from end-stage renal failure If patient oliguric/anuric, fluid restrict to 500ml/day Can cause fluid overload + Hyperkalaemia
38
Fluid overload + hyperkalaemia are indications for
Dialysis
39
CKD- CV disease management
Lifestyle Statin Antiplatelet
40
CKD- bone mineral disease management
Low phosphate diet Phosphate binders Vit D supplementation
41
CKD- hypertension management
Tight BP control | ACE Inh also reduce albuminuria
42
CKD- anaemia management
Correct other deficiencies | EPO
43
CKD- water and electrolyte management
Fluid restrict if oliguric/anuria | Dialyse if overloaded + hyperkalaemic
44
End stage renal failure
Patients with stage 4-5 CKD Or those with rapidly progressing stage 3 CKD Should be referred to nephrologist Discuss management ESRF
45
End stage renal disease management options
Conservative management and symptom control Dialysis Renal transplant
46
End stage renal failure- Conservative care
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
End Stage RF- Dialysis
Usually starts when GFR <10, or <15 in diabetics | 2 options- haemodialysis or peritoneal dialysis
48
Peritoneal dialysis
Usually preferred in patients who: Have residual renal function Do not have significant other comorbidities
49
Haemodialysis
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
Haemodialysis access
Vascular- arterio-venous fistula Large bore central catheter Usually performed 3x week for 4 hours
51
Peritoneal dialysis MOA
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
Peritoneal dialysis times
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
Renal transplant
``` Best long term outcome Cadaveric 85-90% Receiving patient native kidneys not generally removed Transplanted kidney iliac fossa Long term immunosuppression needed ```
54
Renal transplant complications- Hyperacute
Within minutes | Due to donor-recipient mismatch
55
Renal transplant complications- Accelerated
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
Renal transplant complications- acute cellular
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
Renal transplant complications- chronic
Gradual rise serum creatinine + proteinuria, resistant hypertension Graft biopsy shows vascular changes, fibrosis + tubular atrophy Not responsive to increasing immunosuppression therapy
58
Renal transplant opportunistic infections
Viral (particularly herpes simplex in first 4 weeks, then CMV later) Fungal Bacterial
59
Renal transplant malignancies
Lymphomas | Skin cancers

Met 3b (21 decks)

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