Chronic Kidney Disease Flashcards
List some causes of CKD?
Congenital Diseases e.g. PCKD Glomerular disease Vascular disease Hypertension Autoimmune UTI Tubulointerstitial diseases Age Diabetes Chronic NSAID use and other medications
How does CKD typically present?
Patients are usually asymptomatic and it is an incidental finding or diagnosed on routine check up Main symptoms include: - Pruritus - Nausea - Oedema - Muscle cramps - Peripheral neuropathy - Pallor - Hypertension
What are the typical investigations for CKD?
eGFR
urine albumin:creatinine ratio for proteinuria (>3mg/mmol)
Renal USS can be indicated in patients with accelerated CKD / family history or evidence of obstruction
At hat level of eGFR does the patient qualify as CKD?
eGFR <60 (stage 3a)
OR
positive proteinuria
What are some common complications of CKD?
Anaemia Renal bone disease Renal dialysis complications Peripheral neuropathy Cardiovascular disease
What can be given to help manage metabolic acidosis?
Sodium bicarbonate
Why does a patient with CKD need their serum potassium monitored?
CKD and ACE inhibitors are both causes of hyperkalemia so patients need to be regularly monitored for that
What medication (and dose) can be offered in CKD as primary cardiovascular disease prevention?
Atorvastatin 20mg
What are the three features of renal bone disease?
Osteoporosis
Osteomalacia
Osteosclerosis
How does CKD lead to anaemia?
The damaged kidney cells have a reduced production of erythropoietin which leads to a depletion in the production of red blood cells.
How can we manage CKD related anaemia?
Erythropoietin stimulating agents such as exogenous erythropoietin
Why should blood transfusions be avoided if possible in CKD related anaemia?
Allosensitization
when the immune system is sensitised and can lead to organ rejection at a later date
If haematuria is detected in an older patient, even those who are asymptomatic, what must be ruled out?
Cancer (bladder)
What is the A score?
This is a score based on the albumin:creatinine ratio
A1 - <3 mg/mmol
A2 - 3-30 mg/mmol
A3 - >30 mg/mmol
An A1 score is definitive of chronic kidney disease. True or false?
False
An A 1 score is indicative of <3 mg/mmol, which is not proteinuria. For a patient to be classified as chronic kidney disease, a score of A2 or more is required.
How do we slow the progression of CKD?
Optimise diabetic control
Optimise hypertensive control
Treat any glomerulonephritis
What antihypertensive medication is first line in CKD?
ACE inhibitors
What is the three main categories for an ACE inhibitor to be prescribed for hypertension in CKD?
Diabetes plus ACR >3 mg/mmol
Hypertension plus ACR >30 mg/mmol
ALL patients with ACR >70 mg/mmol
What is another term for renal bone disease?
Chronic kidney disease-mineral and bone disorder (CKDMBD)
What hormone is produced by healthy kidney cells, which when reduced in CKD can lead to anaemia?
Erythropoietin
What does erythropoietin stimulat?
It stimulates the production of red blood cells
What must be managed before initiating exogenous erythropoietin and how is this done?
Iron deficiency
intravenous iron especially in dialysis patients
In patients with renal bone disease (CKD-MBD) what x-ray features might you see and what is this classically known as?
- Sclerosis of both ends of the vertebrae
- Osteomalacia of the centre of the vertebra
aka “rugger jersey” (looks stripey)
(NOTE: this is each individual vertebrae - the centre of each one will be dark and their outsides will be bright white)
Why do patients with CKD have low active vitamin D levels?
The kidneys play an important role in metabolism responsible for activating vitamin D from its inactive form
Low levels of active vit D lead to the reduction in absorption of _____ from the intestines
Calcium
What is the main responsibilities of active Vitamin D?
Aiding absorption of calcium from intestines
Regulating bone turnover
In CKD there is a high level of serum ______ due to decreased excretion.
Phosphate
What causes secondary hyperparathyroidism in CKD?
High levels of phosphate and low serum calcium. This stimulates the production of parathyroid hormone
An increased secretion of parathyroid hormone leads to increased ______ activity?
Osteoclast
Osteoclast activity is responsible for the increased absorption of what from where?
Calcium from the bones
WHy does osteomalacia occur in CKD-MBD?
Increased bone turnover without the adequate calcium supply
What is the mechanism behind the development of osteosclerosis in CKD MBD?
The osteoblasts respond to the increased activity of the osteoclasts. This in turn leads to increased bone turnover and bone tissue development which is not properly mineralised.
Why does osteoporosis occur in CKD MBD?
This actually occurs to secondary factors including age and steroid use. It is not directly associated with the mineral bone disease itself
Give some examples of active vitamin D supplements?
Alfacalcidol
Calcitriol
A low ______ diet is essential in bone protection for patients with CKD?
Low Phosphate diet
What medications can be used to treat osteoporosis?
Bisphosphonates e.g. alendronic acid
What is the basic mechanism of action for bisphosphonates?
Reduce osteoclast activity which reduces the rate of bone turnover, in the aim of increasing bone density.
What is the chief cause of death in CKD?
Cardiovascular event
What are the three forms of kidney donation for transplant?
DCD - donor cardiac death
DBD - donor brain death
LD - living donor
How is donor matching done?
Human Leukocyte Antigen (HLA) types A, B, and C
Dont need to be perfect - the closer the higher the chance of success
Where is the HLA gene found?
Chromosome 6
What type of scar is seen in renal transplant patients?
Hockey stick scar
Where is a donor kidney placed?
Anteriorly in the abdomen, often can be palpated in the iliac fossa region.
How is a donor kidney transplanted?
The own kidney is left in its place
New kidney placed anteriorly
Donor kidneys blood vessels are anastomosed to the pelvic vessels
Donor ureter anastomosed directly to the bladder
What vessels are often used to anastomose a donor kidneys blood supply to?
External iliac vessels
What is the usual immunosuppression regime following kidney transplant?
Tacrolimus
Mycophenolate
Prednisalone
Give some examples of other immunosuppressants which can be used post transplant?
Cyclosporine
Sirolimus
Azathioprine
What are the main complications following renal transplant?
Acute / hyperacute / chronic transplant rejection
TRansplant failure
Electrolyte embalances
What are some complications which can occur from long term immunosuppression?
Squamous cell carcinoma T2 DM Ischaemic heart disease Unusual infections e.g. PCP, CMV, TB Non hodgkin lymphoma Infections in general
What are the survival rates like for kidney transplant?
1 year 91-96% (depending on type of donation)
10 year 60-80%
