Chronic kidney disease

Question 1

What is CKD?

Answer 1

Abnormal kidney structure or function present for >3 months.

Question 2

List causes of CKD? (8)

Answer 2

Diabetes 
Glomerulonephritis 
Hypertension 
Pyelonephritis/ UTI 
Kidney stone 
Renal vasculitis 
Heart failure 
TTP

Question 3

Things to gather from the history: PMH. Family Hx, systemic r/v

Answer 3

PMH: HTN, DM, IHD, renal colic.
Family Hv - Renal disease, SAH
systemic r/v - eyes, skins, joints, malignancy

Question 4

Symptoms of CKD? (9)

Answer 4

Asymptomatic 
Pruritis 
Loss of appetite 
Nausea 
Oedema 
Muscle cramps 
Peripheral neuropathy. 
Pallor. 
HTN

Question 5

Signs of CKD?

Answer 5

None
Oedema
Uraemic flap
Conjunctivial pallor. 
Uraemia 
Periorbital oedema. 
Fascial lipodystrophy 
Ballotable kidney. 
HTN.

Question 6

Suspect CKD when? (3)

Answer 6

High creatinine + eGFR <60.
A:Cr >3 (proteinuria)
Persistent heamaturia.

Question 7

Initial Ix for diagnosis? (4)

Answer 7

Repeat U+E and urine dipstick in 3 months = if still have high Cr and eGFR <60 OR A:Cr >3 = Diagnose CKD
Urine dipstick - rule out UTI
Renal USS - accelerated CKD, haematuria, PKD, obstruction
CVD + DM = BMI, lipid profile, HbA1c >53 mmol.

Question 8

Blood tests for CKD complications + underlying cause? (9)

Answer 8

Anaemia - FBC
Renal osteodystrophy - Ca (low), phosphate (high), PTH, Vit D.
Intrinsic renal disease - ANA, ANCA, paraprotein, anti-GBM.

Question 9

Complications of CKD (5)

Answer 9

Anaemia 
Renal bone disease 
CVD 
Peripheral neuropathy 
Dialysis related problems

Question 10

Refer to nephrology (4)

Answer 10

eGFR <30,
ACR >70 mg/mmol
Accelerated progression.
Uncontrolled HTN (on 4 drugs).

Question 11

Aims of treatment of CKD? (3)

Answer 11

1. Slow down disease progression.
2. Reduce complication risk
3. Treat complications

Question 12

CKD Tx - slow down disease progression (3).

Answer 12

1. BP control - >140/90. ACEi (monitor K, CKD and ACEi cause hyperkalaemia)
2. Glycaemic control - HbA1c >53mmol.
3. Tx glomerulonephritis

Question 13

CKD Tx - Reduce complication risk (2)

Answer 13

1. Lifestyle - Stop smoking, lose weight, Low salt and phosphate diet.
2. CKD - Atorvastatin.

Question 14

CKD Tx - Treat complications (4)

Answer 14

1. Metabolic acidosis - Sodium bicarb PO
2. Anaemia - iron supplements + erythropoietin
3. Renal bone disease - active vit D (cholecalciferol), , low phosphate diet, bisphosphnates.
4. End stage renal failure - dialysis + renal transplant.

Question 15

Renal bone disease causes (6)

Answer 15

High phosphate. 
Low active Vit D 
Secondary hyperparathyroidism 
Osteomalacia 
Osteosclerosis 
osteoporosis

Question 16

Renal bone disease pathopyshiology:

Answer 16

1. High phosphate by reduced excretion.
2. Reduced active vit D - normally needed for Ca absorption + regulating born turnover.
3. Secondary hyperparathyroidism = Low Ca and high phosphate causes increase PTH secretion. PTH increases osteoclast activity and absorbs calcium from bone.
4. Osteomalacia = increased bone turnover wo Ca supply.
5. Osteosclerosis = Osteoblast activity increase to match osteoclast activity BUT low Ca means new tissue isin’t properly mineralized.