Chronic Kidney Disease

Question 1

What defines CKD?

Answer 1

kidney damage (ie albuminuria) or decreased kidney function (GFR <60 ml/minute per 1·73 m²) for 3 months or more

Question 2

Give 2 epidemiological facts on CKD

Answer 2

Common, frequently unrecognised + often exists together with other conditions (CVD + diabetes).

Question 3

List 6 unmodifiable risk factors for CKD

Answer 3

Age  
African, African-Caribbean or Asian family origin.
Male
FH
AI diseases e.g. SLE
Chronic NSAIDs use

Question 4

List 2 modifiable risk factors for CKD

Answer 4

Smoking.

Obesity

Question 5

List 4 conditions that are risk factors for CKD

Answer 5

DM
HTN
CVD.
AKI

Question 6

What is kidney function assessed on?

Answer 6

GFR + albumin:creatinine ratio (ACR)

Question 7

What characterises stage 1 and stage 5 of CKD?

Answer 7

Stage 1: normal eGFR >90 ml/min/1.73 m2 with other evidence of chronic kidney damage
Stage 5: eGFR < 15 ml/min/1.73 m2 or on dialysis.

Question 8

List 5 examples of evidence of chronic kidney damage

Answer 8

Persistent microalbuminuria.
Persistent proteinuria.
Persistent haematuria
Structural abnormalities of the kidneys eg, PKD, reflux nephropathy.
Biopsy: proven chronic glomerulonephritis.

Question 9

List 5 symptoms that may present in severe CKD

Answer 9

Fatigue 
N+V
Pruritus
Anorexia
Late disease: Dyspnoea

Question 10

What may be revealed on examination in CKD?

Answer 10

Underlying cause (eg, SLE, severe arteriosclerosis, HTN)
Complications of CKD (eg, anaemia, bleeding diathesis, pericarditis).

Question 11

What 7 signs of CKD may be found on examination?

Answer 11

Pulmonary + peripheral oedema 
HTN 
Postural hypotension
LV hypertrophy
Peripheral vascular disease
Peripheral neuropathy
Restless legs syndrome.

Question 12

Why are both serum urea and creatinine not good assessments of renal function?

Answer 12

Urea: varies with hydration + diet, is not produced constantly + is reabsorbed by the kidney.
Creatinine: can remain within the normal range despite loss of >50% of renal function.

Question 13

What is the gold standard assessment of renal function? What is used in practice?

Answer 13

Isotopic GFR (expensive + not widely available.)
eGFR used in primary care

Question 14

Which serum electrolytes are tested in CKD? What are the levels seen

Answer 14

Na: N/ L
K: HIGH
HCO3: LOW.
Ca: N, L or H
Phosphate HIGH

Question 15

What other biochemical markers are tested in suspected CKD? What may levels of these indicate?

Answer 15

Plasma glucose: identify/ assess diabetes
ALP: high when bone disease develops.
PTH: high with declining renal function.
Cholesterol + triglycerides: dyslipidaemia common.
Albumin: hypoalbuminaemia in nephrotic +/or malnourished

Question 16

What is the haematological picture in CKD?

Answer 16

Normochromic normocytic anaemia; Hb falls with progressive CKD.
White cells + platelets usually normal.

Question 17

What is checked for in serology in suspected CKD?

Answer 17

Autoantibodies: ANA (SLE), c-ANCA (granulomatosis with polyangiitis), Anti-GBM (Goodpasture’s syndrome)
Hepatitis serology
HIV serology

Question 18

What is checked for in urinalysis in CKD? Why?

Answer 18

Proteinuria + haematuria
Degree of proteinuria correlates with rate of progression of underlying kidney disease + is the most reliable prognostic factor in CKD.

Question 19

Why perform serum and urine protein electrophoresis in suspected CKD?

Answer 19

to screen for multiple myeloma.

Question 20

What imaging investigations may be performed in CKD? What can be detected in each?

Answer 20

US: small/ large kidneys, structural abnormalities
CT/MRI: renal stones/ renal artery stenosis
X-Ray: renal stones

Question 21

Describe 7 features in management of CKD

Answer 21

eGFR monitoring
BP control
Lifestyle: Exercise, Lose weight, Smoking cessation
Good glycaemic control in DM
Review all prescribed medication
Avoidance of nephrotoxins: eg, NSAIDs, aminoglycosides.
Immunise against influenza + pneumococcus.

Question 22

In decreasing order, what are the most common causes of CKD in the UK?

Answer 22

Diabetes 24%
Glomerulonephritis 13%
High BP/ renovascular disease 11%