Chronic Kidney Disease

Question 1

What are the main causes of CKD?

Answer 1

Diabetes
Hypertension
Age related decline
Glomerulonephritis
Polycystic kidney disease
Medications e.g. NSAIDs, PPIs, lithium

Question 2

Which signs/symptoms may be present in CKD?

Answer 2

Pruritis
Loss of appetite
Nausea
Oedema
Muscle cramps
Peripheral neuropathy
Pallor
Hypertension

Question 3

Which investigations should be done for CKD?

Answer 3

eGFR –> two tests, 3 months apart to confirm diagnosis

Urine albumin:creatinine ratio (>3 is significant for proteinuria)

Urinalysis for haematuria

Renal USS if:
- accelerated CKD, haematuria, FHx of PKD or obstruction

Question 4

How is CKD staged?

Answer 4

G score –> based on eGFR

A score –> based on albumin:creatinine ratio

Question 5

What are the G score stages?

Answer 5

G1 = >90
G2 = 60-89
G3a = 45-59
G3b = 30-44
G4 = 15-29
G5 = < 15 (end stage renal failure)

Question 6

What are the A score stages?

Answer 6

A1 = <3
A2 = 3-30
A3 = >30

Question 7

How are the G and A scores interpreted to diagnose CKD?

Answer 7

Must have at least an eGFR or <60 or proteinuria for a diagnosis of CKD

• if score of A1 combined with G1 or G2 –> does not have CKD

Question 8

What are the complications of CKD?

Answer 8

Anaemia
Renal bone disease
Cardiovascular disease
Peripheral neuropathy 
Dialysis related problems

Question 9

When should a patient with CKD be referred to a specialist?

Answer 9

eGFR < 30
albumin:creatinine ratio >70
Accelerated progression defined as decrease in eGRF of…. in one year:
- 15
- 25%
- or 15ml/min
Uncontrolled hypertension despite 4 antihypertensives

Question 10

What are the aims of management in CKD?

Answer 10

Slow progression
Reduce risk of CVD
Reduce risk of complications
Treat complications

Question 11

What are the management components for slowing progression of CKD?

Answer 11

Optimise diabetic control
Optimise hypertensive control
Treat glomerulonephritis

Question 12

How is the risk of complications reduced in CKD?

Answer 12

Exercise, weight loss + stop smoking
Dietary advice re phosphate, sodium, potassium + water intake
Offer atorvastatin 20mg for primary prevention of CVD

Question 13

How is metabolic acidosis treated in CKD?

Answer 13

Sodium bicarbonate

Question 14

How is anaemia treated in CKD?

Answer 14

IV iron (oral is alternative)
Then Epo

Question 15

How is renal bone disease treated?

Answer 15

Vitamin D

Low phosphate diet

Question 16

How is end stage renal disease treated?

Answer 16

Dialysis

Renal transplant

Question 17

What is the first line management for hypertension in CKD?

Answer 17

ACE inhibitors

Question 18

What needs to be monitored when patients with CKD are taking an ACE inhibitor and why?

Answer 18

Potassium

–> both CKD and ACE inhibitors cause hyperkalaemia

Question 19

Why should blood transfusions be limited in anaemia of CKD?

Answer 19

Sensitise the immune system so that transplanted organs are more likely to be rejected

Question 20

What are the features of renal bone disease?

Answer 20

Osteomalacia (softening of bones)
Osteoporosis (brittle bones)
Osteosclerosis (hardening of bones)

Question 21

What are the xray changes in renal bone disease?

Answer 21

Spine xray:

• sclerosis of both ends of the vertebra (denser white)
• osteomalacia in centre of vertebra (less white)
• -> ‘rugger jersey spine’

Question 22

What will the bone profile look like in renal bone disease?

Answer 22

High phosphate (reduced excretion)
Low active vitamin D (kidney essential for activation)
Low calcium –>
Secondary hyperparathyroidism

Question 23

What are the features of diabetic nephropathy?

Answer 23

Glomerulosclerosis –> proteinuria

Question 24

What is the management form diabetic nephropathy?

Answer 24

Optimise blood glucose + BP
ACE inhibitors (even if BP normal)