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Year 3 - Met3b > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What is CKD

A
  • abnormal kidney structure or function present for greater than 3 months with implications for health
  • A GFR less than 60 for more than three months
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2
Q

How many people have CKD

A
  • We don’t know how many people have CKD

- But it might be around 10% of adults in the UK

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3
Q

What are the causes of CKD

A
  • Diabetes
  • Glomerulonephritis
  • Hypertension
  • Renovascular disease
  • Polycystic kidney disease
  • Pyelonephritis
  • urinary tract obstruction
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4
Q

Why does CKD matter

A
  • dialysis treatment is extremely expensive = £30,000 a year to treat dialysis
  • lot of morbidity for the patient
  • kills people
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5
Q

What is the most common cause of CKD

A

Diabetes is the largest cause of CKD

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6
Q

how do we measure GFR

A
  • Measure creatine and use and equation to derive an estimate of GFR (eGFR)
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7
Q

How many stages is CKD split into

A

5 stages

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8
Q

What stages in CKD are most important

A

3, 4 and 5 = have the most significant kidney disease

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9
Q

How do you measure GFR accurately

A
  • Isotopic methods

- inject them with something like radioactive and then measure the clearance

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10
Q

Describe the 5 stages of CKD as classified by GFR

A

Stage 1- any kidney problem, but eGFR over 90
- only CKD if other evidence of kidney damage: protein/haematuria, pathology on biopsy/imaging, tubular disorder, transplant

Stage 2 – any kidney problem, but eGFR between 60 and 90
- only CKD if other evidence of kidney damage: protein/haematuria, pathology on biopsy/imaging, tubular disorder, transplant

Stage 3 – eGFR between 30 and 60
(3a = 45-59, 3b = 30-44)
- mild to moderate decrease in GFR

Stage 4 – eGFR between 15 and 30
- severe decrease in GFR

Stage 5 – eGFR less than 15
- kidney failure

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11
Q

List what the kidney does as a function

A
  • Get rid of fluid (and sodium)
  • Control serum pH
  • Control serum potassium
  • Regulate blood pressure
  • Regulate haemoglobin via EPO production
  • Control bone and mineral metabolism, both through excretion of Ca/PO and through vitamin D
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12
Q

What happens in CKD in terms of loss of function

A

Get rid of fluid (and sodium)
- fluid overload and oedema

Control serum pH
- metabolic acidosis

Control serum potassium
- hyperkalaemia

Regulate blood pressure
- hypertension

Regulate haemoglobin via EPO production
- anaemia

Control bone and mineral metabolism, both through excretion of Ca/PO and through vitamin D

  • Hyperphosphataemia
  • hypocalcalcemia
  • hyperparathyroidism
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13
Q

What is the main priority in treating CKD

A
  • blood pressure
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14
Q

What happens to blood pressure in CKD

A
  • Blood pressure tends to rise in CKD

- high blood pressure makes CKD get worse faster

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15
Q

What is involved in the management of CKD

A
  1. Appropriate referral to nephrology - if stage 4 and 5
  2. treatment to slow renal disease progression
  3. treatment of renal complications of CKD
  4. treatment of other complications of CKD
  5. preparation for the renal replacement therapy - dialysis/transplantation
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16
Q

What is the second priority in treating CKD

A
  • Try to reduce proteinuria (when this is present)
  • lowering the blood pressure improves proteinuria
  • some CKD don’t have proteinuria such as polycystic kidneys
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17
Q

How can you improve proteinuria

A

By lowering the blood pressure improves proteinuria

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18
Q

Whey should you offer ACE or ARB treatment in chronic kidney disease

A
  • DM and A:CR >3mg/mmol
  • hypertension and A:CR >3mg/mmol
  • any CKD with A:CR >70 mg/mmol
  • check potassium and renal function prior to and 1-2 weeks after starting treatment
  • stop if potassium is >6mmol/L, eGFR is decreased by >25%, or creatine decreased by >30%
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19
Q

What are the supportive treatments in CKD

A

Consider treating anaemia with EPO

Treat fluid overload with diuretics and salt restriction

Consider giving vitamin D or a phosphate binder if they have a mineral metabolism problem

Consider giving bicarbonate to treat the acidosis

patients can manipulate there diet

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20
Q

What is the main things that the patient can do to help CKD

A
  • Diet manipulation
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21
Q

Why does diet manipulation help CKD

A

Kidneys struggle to get rid of sodium, potassium and phosphate

  • Moderate protein intake (decrease build up in the body and decrease proteinuria)
  • To reduce sodium = avoid potter crisps, anchovies, prawns
  • To avoid potassium - avoid bannanas, oranges, mangos, yogurt, kidney beans and lentils
  • To avoid phosphate= chicken, fish, fairy products, coke, nuts
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22
Q

Describe the classification of CKD by albuminuria

A

A1

  • Albumin excretion (mg/24hr) = <30
  • Albumin creatine ratio (mg/mmol) = <3

A2

  • Albumin excretion (mg/24hr) = 30-300
  • Albumin creatine ratio (mg/mmol) = 3-30

A3

  • Albumin excretion (mg/24hr) = >300
  • Albumin creatine ratio (mg/mmol) = >30
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23
Q

What is a decrease in GFR and albuminuria associated with

A
  • all cause mortality
  • cardiovascular mortality
  • progressive kidney disease and kidney failure
  • AKI
24
Q

What does the prognosis of CKD correlate with

A
  • hypertension
  • proteinuria
  • degree of scarring in the interstitial
25
How do you monitor renal function in CKD
GFR and albuminuria should be monitored at least annually according to risk - if high risk monitor every 6 months - if very high risk monitor at least every 3-4 months
26
What are the risk factors for a decline in CKD
- increase in blood pressure - diabetes - metabolic disturbance - volume depletion - infection - NSAIDS - smoking
27
What should the target blood pressure be for someone with CKD
- 140/90 | - if you have diabetes or A:CR is >70 then = 130/80
28
What is the target glycemic control for someone with CKD
Target Hba1c of ~53mmol/mol (7.0%)
29
What complications can CKD cause
- anaemia - renal bone disease - acid base imbalance - uraemia - restless legs/cramps
30
describe how you manage anaemia as a complication of CKD
- check haemoglobin when eGFR is <60 - check for, iron, B12, folate - don't miss chronic blood loss - iron therapy be need to given IV - consider EPO stimulating agent
31
How do you manage acidosis as a complication of CKD
- consider sodium bicarbonate supplements for patients with an eGFR <30 and low serum bicarbonate - symptomatic management and may slow CKD progression - beware of doing it in patients with hypertension and fluid overload due to sodium component
32
how do you manage oedema as a complication of CKD
- restrict fluid and sodium intake | - high doses of loop diuretics may be needed
33
How does CKD cause renal bone disease
- CKD causes an increase in serum phosphate and reduced hydroxylation of vitamin D by the kidney - measure calcium, phosphate, ALP, PTH and 25-OH, Vitamin D if eGFR <30
34
How do you manage renal bone disease as a complication for CKD
- treat if phosphate >1.5mmol/L with dietary restriction and phosphate binders - give vitamin D supplements if deficient
35
Never prescribe in renal failure before...
Never prescribe in renal failure before checking how administration should be altered due to a decreased GFR. - this is largely determined by the extent to which a drug is really excreted
36
What are the symptoms of CKD
- Malaise - loss of appetite - insomnia - nocturia and polyuria - nausea, vomiting, and diarrhoea - itching - restless leg syndrome - bone pain due to metabolic bone disease - symptoms due to anaemia - symptoms due to salt and water retention such as pulmonary oedema
37
why does anaemia happen in CKD
- EPO deficiency - most common - increased blood loss - bone marrow toxins - these are retained in CKD - due to iron or folate deficiency - increased red cell destruction - red cells have a shortened lifespan in uraemia and haemodialysis may cause a degree of haemolysis - ACE inhibitors - may cause anaemia in CKD
38
what can ACE inhibitors cause in CKD
- anaemia
39
Why is it important to control proteinuria in CKD
- proteinuria may be harmful in the tubulointerstitium and can cause interstitial scarring
40
ACE/ARBs slow...
the rate of disease progression in CKD and improve survival
41
How is proteinuria measured
- it is measured by a urine dipstick analysis
42
How do you control restless legs/cramps in CKD
- check ferritin (low levels may worsen symptoms) - Clonazepam 0.5-2mg/daily or gabapentin - Quinine sulphate 300mg note can help with cramps
43
How do you treat mineral and bone disease
Treatment: aim to reduce PTH and increase active vitamin D - treat kidney function - calcium supplements - vitamin D supplements - phosphate binders e.g. calcichew
44
What is the target blood pressure in CKD
- Target blood pressure <130/80 (125/75 if DM or ACR>70)
45
When do you refer to a nephrologist
- Stage 4 or 5 - Proteinuria (ACR>70mg/mmol) unless due to DM - Proteinuria + haematuria - Rapidly ↓GFR - Refractory hypertension (despite ≥4 antihypertensives) - Known or suspected rare or genetic cause - Suspected renal artery stenosis
46
What is the presentation of CKD
- Anaemia – pallor, lethargy, breathlessness on exertion - Platelet abnormality – epistaxis, bruising - Skin – pigmentation, pruritis, uraemic twinge - GI tract – anorexia, nausea, vomiting, diarrhoea - Endocrine/gonads – amenorrhoea, ED, infertility - Polyneuropathy - CNS – confusion, coma, fits (severe uraemia) - CVS – uraemic pericarditis, hypertension, PVD, heart failure - Renal – Nocturia, polyuria, salt and water retention (🡪 oedema) - Mineral and bone disorder – osteoporosis, osteomalacia, hyperparathyroidism, osteosclerosis, adynamic bone disease
47
What is the diagnostic criteria of CKD
- impaired renal function for >3 months based on abnormal structure or function OR - GFR <60ml/min/1.73m3 for >3 months with or without evidence of kidney damage
48
What are the risk factors of CKD
- age - most elderly have CKD stage 3 - males - ethnicity - diabetes - hypertension - vascular disease - specific cases: family history, immunological history, hepatitis B/C, HIV
49
Name some causes of CKD
- diabetes - glomerulonephritis - unknown - hypertension and renovascular disease - pyelonephritis and reflux nephropathy - rare causes
50
describe primary and secondary glomerulonephritis
Primary: Commonly IgA nephropathy, also rarer membranoproliferative GN Secondary: Systemic disorders, eg SLE and vasculitis
51
Name some rare causes of CKD
Chronic interstitial nephritis, eg myeloma, amyloid Polycystic kidney disease (APKD is most common inherited cause) Alport syndrome, Fabry disease
52
What is the natural history of diabetic nephropathy
Hyperfiltration increases GFR - due to afferent vasodilation leading to glomerular hypertension - high pressure causes hypertrophy and damage tot he glomerulus - microalbuminuria - macroalbuminuria - renal impairment = CKD stage 4
53
describe adult polycystic kidney disease
- monogenetic autosomal dominant disease - development of kidney, liver and ovarian cysts - associated with subarachnoid haemorrhage - diagnosed by renal US
54
How do you treat polycystic kidney disease
- avoid hypertension and complications - try to organise transplant pre-emptively as most will have a steady decline in renal function around age 50 leading to CKD stage 5
55
what affects GFR
- serum creatinine - age - sex - race

Year 3 - Met3b (26 decks)

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