Chronic Kidney Disease

Question 1

Why do you get fluid overload in CKD?

Answer 1

When your kidneys are not working as well as they should, they cannot take out enough fluid. This can cause the extra fluid in your blood to build up in your body. Having too much fluid in your body can cause problems with your heart and lung

Question 2

What is CKD?

Answer 2

CKD describes abnormal kidney function and/ or structure, abnormalities must be present for more than 3 months. Often co-exists with other conditions such as CVD and diabetes.

Question 3

Risk of CKD ______ with age

Answer 3

Increases with age as kidney function declines in the elderly

Question 4

What does CKD diagnosis require?

Answer 4

A minimum of 2 samples at least 90 days apart. eGFR is reported along side creatinine levels

Question 5

Define accelerated progression of CKD?

Answer 5

A sustained decrease in GFR of 25% or more
and a change in GFR category within 12 months

OR A sustained decrease in GFR of 15ml/min/1.73 squared per year

Question 6

Describe the stages and severity of CKD?

Answer 6

G1-G2: A1 = no CKD in absence of kidney damage markers
G1-2:A2= mild 
G3a: A1= mild
G1-G2: A3= moderate
G3A: A2= moderate
G3b: A1= moderate 
G3a: A3= severe
G3b: A2-3= severe
G4-G5: A1-3= severe

Question 7

Describe 9 risk factors for CKD progression?

Answer 7

CVD, Hypertension, African/ Afro Caribbean/ Asian Descent, proteinuria, diabetes, chronic NSAIDs use, AKI, Smoking, untreated urinary outflow tract obstruction

Question 8

Globally 2/3 of CKD is caused by ________

Answer 8

Diabetes Mellitus and hypertension

Question 9

Describe some clinical signs of CKD

Answer 9

Anaemia > conjunctival pallor and palmar pallor
Signs of weight loss
Advanced uraemia > lemon yellow skin, uraemia frost, twitching, encephalopathy flap, confusion, pericardial rub or effusion, kussmaul breathing in metabolic acidosis

Question 10

Why does anaemia occur in CKD?

Answer 10

Kidneys are producing less erythropoietin which is needed to make RBCs

Question 11

Why does weight loss occur in CKD?

Answer 11

Build of urea can cause nausea, vomiting and loss of appetite

Question 12

What is lemon yellow skin and uraemic frost due to?

Answer 12

deposition of urea in the skin

In uraemic frost crystals are deposited on the surface which results in a frosted appearance as sweat evaporates

Question 13

Describe some symptoms of CKD?

Answer 13

DUE TO URAEMIA: Nausea, vomiting, anorexia, weight loss, fatigue, itch, altered taste, restless legs and muscle twitching, difficulties concentrating, confusion.
DUE TO ANAEMIA: Fatigue, Muscle weakness
PAIN: can be bony, neuropathic, ischaemic or visceral
Nocturia due to decreased urine concentrating ability

Question 14

Describe some renal consequences of CKD?

Answer 14

Pain, haemorrhage, infection, haematuria, proteinuria, impaired salt and water handling, hypertension, electrolyte abnormalities, acid base disturbance, ESRD

Question 15

Describe some extra renal consequences of CKD?

Answer 15

CVD, Mineral and Bone disease, anaemia, nutritional consequences

Question 16

Describe CVD in CKD?

Answer 16

Pericarditis can occur due to high urea or phosphate or is severe hyperparathyroidism. Fluid overload and hypertension can cause LVH or dilated cardiomyopathy.

Question 17

General management of CVD in CKD?

Answer 17

Advice on smoking cessation, weight loss, aerobic exercise, limiting salt intake, control of hypertension and hyperlipidaemia

Question 18

Describe why bone disease occurs in CKD?

Answer 18

Due to poorly functioning kidneys get renal phosphate retention and inadequate renal vitamin D activation resulting in poor calcium absorption from the gut so decrease in calcium and increase in phosphate. This causes a rise in PTH causing secondary hyperparathyroidism.
Eventually PTH secretion can become autonomous and fail to fall even when hypocalcaemia is treated. This is termed tertiary hyperparathyroidism.

Question 19

Treatment of bone disease in CKD?

Answer 19

Phosphate, salt, potassium and fluid restriction potentially. Correct any metabolic acidosis. May need active vitamin D supplements, phosphate binders (Adcal, phoslo, alucaps, lanthanum)

Question 20

Who is more at risk of renal anaemia?

Answer 20

Diabetics more at risk

Question 21

Management of renal anaemia?

Answer 21

Must exclude other causes of anaemia

Synthetic human erythropoiesis stimulating agents (ESAs) can be given

Question 22

Describe BP control in CKD?

Answer 22

Aim to keep systolic < 140mmHG and diastolic < 90mmHg

With CKD and diabetes or ACR of 70mmHg or more aim for systolic <130mmHg and diastolic < 80mmHg

Question 23

Describe dosing of ACEi and ARBs in CKD?

Answer 23

Watch GFR
If GFR decrease less than 25% or serum creatinine increase > 30% don’t modify the dose (ie don’t want GFR decreasing by > 25% or creatinine increasing by > 30%)

Question 24

Describe lipid lowering therapy in CKD?

Answer 24

Offer Atorvostatin 20 mg for the primary or secondary prevention of CVD to people with CKD