Chronic kidney disease Flashcards

1
Q

Define CKD

A

Reduction in kidney function or structural damage (or both) present for >3 months, with implications for health.

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2
Q

Causes of CKD

A
Diabetes - most common
Hypertension
Glomerular disease 
PKD
Pyelonephitis 
Other e.g. nephrotoxic drugs, toxins, SLE, vasculitis, myeloma, HIV
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3
Q

Consequences + complications of CKD

A

AKI
Anaemia (reduced EPO production)
Hypertension (increased renin due to falling GFR)
Osteodystrophy (low calcium due to not activating vit D, causes PTH release and so bone resorption –> secondary hyperparathyroidism)
Hyperkalaemia (kidneys normally excrete potassium)
Azotemia (high urea)

Dyslipidaemia
Cardiovascular disease 
Peripheral neuropathy and myopathy
Malnutrition
Malignancy
End-stage renal disease 
All-cause mortality
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4
Q

Signs/symptoms/consequences of high urea

A

Nausea and loss of appetite
Encephalopathy - asterixis, coma, death
Pericarditis
Bleeding (urea makes platelets less sticky), Uremic frost (crystals deposit in skin)

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5
Q

How does hypertension lead to CKD?

A

Walls of artery supplying kidney become narrow

  • -> less blood + oxygen to kidney
  • -> ischaemic injury to glomeruli
  • -> Immune cells (macrophages and foam cells) secrete growth factors
  • -> mesangial cells secrete extracellular matrix
  • -> glomerulosclerosis
  • -> nephrons have diminished ability to filter blood
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6
Q

How does diabetes lead to CKD?

A

Excess glucose

  • -> non-enzymatic glycation
  • -> efferent arteriole becomes stiff and narrow
  • -> more difficult for blood trying to leave glomerulus
  • -> increased pressure within glomerulus, causing hyperfiltration
  • -> mesangial cells produce more and more matrix
  • -> glomerulosclerosis
  • -> nephrons have diminished ability to filter blood
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7
Q

CKD should be diagnosed in people with…?

A

1) Markers of kidney damage e.g. urinary albumin:creatinine ratio (ACR) >3 mg/mmol, urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, and a history of kidney transplantation

AND/OR

2) A persistent reduction in renal function
e. g. eGFR <60

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8
Q

What to ask in history?

A

PC/HPC - lethargy, itch, SOB, cramps, sleep disturbance, bone pain, loss of appetite, vomiting, weight loss, taste disturbance
ROS - urine output, mood
PMH - previous AKI, risk factors for CKD, previous CVD/stroke
DH - any nephrotoxic drugs?
FH - renal disease e.g. ADPKD
SH

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9
Q

Signs of CKD on examination

A

Uraemic odour (ammonia-like smell of the breath, may be present in advanced disease).
Pallor
Cachexia
Cognitive impairment
Dehydration or hypovolaemia
Tachypnoea (fluid overload, anaemia, or co-morbid ischaemic heart disease)
Hypertension
Palpable bilateral flank masses with possible hepatomegaly (polycystic kidney disease)
Palpable distended bladder (obstructive uropathy)
Peripheral oedema (renal sodium retention, hypoalbuminaemia, or co-morbid heart failure)
Peripheral neuropathy or myopathy
Frothy urine (may indicate proteinuria)

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10
Q

Define G1

A

eGFR >= 90

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11
Q

Define G2

A

eGFR 60-89

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12
Q

Define G3a

A

eGFR 45-59

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13
Q

Define G3b

A

eGFR 30-44

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14
Q

Define G4

A

eGFR 15-29

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15
Q

Define G5

A

eGFR <15

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16
Q

Define A1

A

Urinary ACR <3 mg/mmol

17
Q

Define A2

A

Urinary ACR 3-30 mg/mmol

18
Q

Define A3

A

Urinary ACR >30 mg/mmol

19
Q

Investigations for CKD

A

Serum creatinine and eGFR
Early morning urine sample for urinary ACR
Urine dipstick for haematuria + MSU if positive
–> Repeat within 3 months to diagnose + classify CKD

Check nutritional status, BMI, BP, HbA1c, lipid profile

Consider renal tract ultrasound if indicated

20
Q

What is accelerated progression of CKD?

A

Sustained decrease in eGFR of 25% or more from baseline and a change in CKD category within 12 months; or a sustained decrease in eGFR of 15 mL/min/1.73 m2 within 12 months.

21
Q

How to monitor CKD?

A

Monitor creatinine, eGFR and urinary ACR - how often depends on their stage and trajectory
FBC if stages 3b, 4, 5
Serum calcium, phosphate, vit D, PTH if stages 4 or 5

22
Q

When to refer to nephrology?

A
eGFR < 30
Accelerated progression
ACR of 70 or more
ACR of 30 or more + persistent haematuria
Uncontrolled HTN with four drugs
Suspected/confirmed rare or genetic cause e.g. PKD
Suspected renal artery stenosis
Suspected complication of CKD
23
Q

How to manage in primary care

A

Assess for and manage risk factors and co-morbidities
Assess for hypertension - use lisinopril or losartan if ACR > 30 or diabetic, TARGET IS 140/90 or 130/80 if ACR >70 or if diabetic
Optimise diabetic control
Statin
Antiplatelet drug
Immunisations - flu and pneumococcal disease

24
Q

Management of CKD bone/mineral disorders

A

Reduced dietary intake of phosphate
Phosphate binders - calcium based binders, sevelamer (non-calcium based)
Vitamin D: alfacalcidol, calcitriol
Parathyroidectomy may be needed in some cases

25
Q

Dietary requirements of patients with advanced CKD

A

Healthy diet, reduce alcohol
May be asked to cut down on fluids
Reduced salt
May be advised to have low potassium diet or a low phosphate diet