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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
Q

How do you monitor renal function in CKD

A

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
Q

What are the risk factors for a decline in CKD

A
  • increase in blood pressure
  • diabetes
  • metabolic disturbance
  • volume depletion
  • infection
  • NSAIDS
  • smoking
27
Q

What should the target blood pressure be for someone with CKD

A
  • 140/90

- if you have diabetes or A:CR is >70 then = 130/80

28
Q

What is the target glycemic control for someone with CKD

A

Target Hba1c of ~53mmol/mol (7.0%)

29
Q

What complications can CKD cause

A
  • anaemia
  • renal bone disease
  • acid base imbalance
  • uraemia
  • restless legs/cramps
30
Q

describe how you manage anaemia as a complication of CKD

A
  • 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
Q

How do you manage acidosis as a complication of CKD

A
  • 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
Q

how do you manage oedema as a complication of CKD

A
  • restrict fluid and sodium intake

- high doses of loop diuretics may be needed

33
Q

How does CKD cause renal bone disease

A
  • 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
Q

How do you manage renal bone disease as a complication for CKD

A
  • treat if phosphate >1.5mmol/L with dietary restriction and phosphate binders
  • give vitamin D supplements if deficient
35
Q

Never prescribe in renal failure before…

A

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
Q

What are the symptoms of CKD

A
  • 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
Q

why does anaemia happen in CKD

A
  • 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
Q

what can ACE inhibitors cause in CKD

A
  • anaemia
39
Q

Why is it important to control proteinuria in CKD

A
  • proteinuria may be harmful in the tubulointerstitium and can cause interstitial scarring
40
Q

ACE/ARBs slow…

A

the rate of disease progression in CKD and improve survival

41
Q

How is proteinuria measured

A
  • it is measured by a urine dipstick analysis
42
Q

How do you control restless legs/cramps in CKD

A
  • check ferritin (low levels may worsen symptoms)
  • Clonazepam 0.5-2mg/daily or gabapentin
  • Quinine sulphate 300mg note can help with cramps
43
Q

How do you treat mineral and bone disease

A

Treatment: aim to reduce PTH and increase active vitamin D

  • treat kidney function - calcium supplements
  • vitamin D supplements
  • phosphate binders e.g. calcichew
44
Q

What is the target blood pressure in CKD

A
  • Target blood pressure <130/80 (125/75 if DM or ACR>70)
45
Q

When do you refer to a nephrologist

A
  • 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
Q

What is the presentation of CKD

A
  • 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
Q

What is the diagnostic criteria of CKD

A
  • 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
Q

What are the risk factors of CKD

A
  • age - most elderly have CKD stage 3
  • males
  • ethnicity
  • diabetes
  • hypertension
  • vascular disease
  • specific cases: family history, immunological history, hepatitis B/C, HIV
49
Q

Name some causes of CKD

A
  • diabetes
  • glomerulonephritis
  • unknown
  • hypertension and renovascular disease
  • pyelonephritis and reflux nephropathy
  • rare causes
50
Q

describe primary and secondary glomerulonephritis

A

Primary: Commonly IgA nephropathy, also rarer membranoproliferative GN

Secondary: Systemic disorders, eg SLE and vasculitis

51
Q

Name some rare causes of CKD

A

Chronic interstitial nephritis, eg myeloma, amyloid

Polycystic kidney disease (APKD is most common inherited cause)

Alport syndrome, Fabry disease

52
Q

What is the natural history of diabetic nephropathy

A

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
Q

describe adult polycystic kidney disease

A
  • monogenetic autosomal dominant disease
  • development of kidney, liver and ovarian cysts
  • associated with subarachnoid haemorrhage
  • diagnosed by renal US
54
Q

How do you treat polycystic kidney disease

A
  • 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
Q

what affects GFR

A
  • serum creatinine
  • age
  • sex
  • race

Year 3 - Met3b (26 decks)

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