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Renal and Urology > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What test results are usually associated with CKD?

A
  • High creatinine (advanced kidney disease)
  • High potassium (poor GFR)
  • Metabolic acidosis= low bicarbonate
  • High blood pressure
  • Haemoglobin low = tired, short of breath
  • Calcium low= cramps
  • Phosphate high= itchy skin
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2
Q

What type of effects does the kidneys have?

A

-Exocrine / excretory
=Fluid and electrolyte balance
(Blood pressure / electrolyte fine balance)
=Removal of toxins

-Endocrine effects
=Blood / Bone / Blood pressure

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3
Q

What is CKD?

A

GFR of less than 60 ml/min for >90 days /3 months

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4
Q

What are the causes of CKD?

A
  • Diabetes
  • Hypertension
  • Glomerulonephritis
  • Cystic kidney disease (APCKD)
  • Renovascular disease
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5
Q

What are the consequences of CKD?

A
  • Many of the problems caused by CKD start early
  • Excretory / Endocrine effects
  • Dialysis / Transplant / increased mortality and morbidity
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6
Q

How do we estimate renal function?

A

-Normal GFR= 125 ml/min/1.73m2
-Serum Creatinine – can be very misleading
-Creatinine clearance (24 hour urine collection)
=may be affected by age/ muscle mass/ drugs
=Urea and creatinine clearance more accurate
-Isotope GFRs -expensive and time consuming
-Formulae- for estimated GFR (MDRD) or Creatinine clearance (Cockcoft and Gault) – based on creatinine

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7
Q

What is needed for the Cockcoft and Gault equation?

A
  • Creatinine level
  • Lean bodyweight
  • Age
  • Adjustment factor for gender
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8
Q

What does the MDRD equation need?

A
  • Age
  • Serum creatinine
  • Sex
  • Racial adjustment factor
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9
Q

What are the stages of CKD?

A
  • 5 Stages
  • Based of GFR level
  • Stage 1= 120 to 90 (plus radiographical/ biopsy evidence)
  • Stage 2=90 to 60
  • Stage 3=60 to 30
  • Stage 4=30 to 15 (planning for dialysis)
  • Stage 5=15 to 0 (transplant)
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10
Q

How common is CKD?

A

Epidemiological data (NHANEs – 2009-14)
-6.2 % population have CKD 3 (US/UK)
=Earlier studies 4.7%
-Given elderly population have more CKD, up to >25% of elderly pts may be expected to have Stage 3 CKD or worse

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11
Q

What strategies are used to prevent progression of CKD?

A

-Control blood pressure (RAS inhibition)
-Reduce proteinuria (RAS inhibition)
-If diabetes, optimise glycaemic control
-SGLT2 inhibitors
=CREDENCE trial - Renal outcome HR 0.70 / CV outcome HR 0.61
=DAPA-CKD trial –Renal outcome HR 0.56 / CV outcome HR 0.71
=EMPA-REG – Empaglifozin (results awaited)

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12
Q

Why is treatment of Diabetes and/or proteinuria with Renin-angiotensin blockade so important?

A
  • If you have CKD, if you have minimum proteinuria= moderate risk
  • If you have CKD, if you have heavy proteinuria= high risk of progression
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13
Q

How does proteinuria pose greater risk of CKD progression?

A

-Protein in filtrate taken up into tubular cells into lysosomes, broken down into amino acids and taken up into peritubular capillaries to be recycled
-If heavy proteinuria= overload the system so cells release free oxygen radicals and die
=Fibroblasts and macrophages clear away but leaves fibrosis behind

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14
Q

What action does ACE inhibitors have on preventing fibrosis?

A
  • Efferent arteriole dilatation
  • Reduced glomerular pressure
  • Reduces proteinuria
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15
Q

What needs to be considered in drug management?

A

-Avoid potential toxins
=NSAIDs/ Contrast (imaging and CT scans)=hydration/ Gentamicin/ phosphate enemas (too much phosphate absorption)
-Drug dosing

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16
Q

Describe drug dosing in CKD

A

-Many drugs need to be given at lower doses in patients with CKD
=Especially chemotherapy agents/ antibiotics
=Many toxic agents will be contraindicated
-If in doubt, check BNF
-Rem: >25% of elderly pts may have CKD!

17
Q

Describe Hypertension in ESRD (end-stage renal disease)

A

-Cause / consequence
-Causes Left Ventricular Hypertrophy (then heart failure)/ Stroke / End-organ damage- eyes/ kidneys
-BP treatment goals
“normal” - 130/80
DM / Proteinuria 125/75
-Rate of decline in GFR increases with hypertension

18
Q

Why is controlling potassium important?

A

-Hyperkalaemia common as GFR declines < 25
=May occur at GFR>25 –Diabetes and type 4 RTA - ACE inhibitors - High K Diet
=Related to distal sodium delivery ( DND↓ with ↓ GFR decreases potassium absorption)

19
Q

How can potassium levels be managed?

A 
-Dietary advice re High K foods
=Bananas
=Crisps
=Potatoes
etc.
-Potassium binders??
Patiromer / Sodium zirconium (agents which swallow during meals to bind in gut)
20
Q

Describe Acidosis in renal failure

A

-Much acidosis in CRF is due to animal protein in food.
=Inability to acidify urine in CKD
=Phosphate / sulphates / other anions – v late
-Aim to keep Serum HCO3 >22
-Replace with NaHCO3 / Sodium Bicarbonate
=But beware fluid overload.

21
Q

What are the excretory complications of CKD?

A
  • Salt and Hypertension
  • Potassium
  • Acidosis
22
Q

What are the endocrine complications of CKD?

A
  • Anaemia
  • Renal Osteodystrophy
  • Cardiovascular risk
  • Malnutrition
23
Q

Describe anaemia in CKD

A

-Hb < 12 in males/ < 11 in females
=Generally normochromic normocytic anaemia
-Decreased response of EPO to an hypoxic stimulus (kidneys) and…..
=decreased red cell survival
=iron deficiency
=blood loss – dialysis / blood samples / GI
=aluminium / hyper PTH / B12+Folate deficiency

24
Q

What is Erythropoietin Replacement Therapy?

A

-All patients with Hb <105 and adequate iron stores should be on Epo
=Better Quality of life / less dyspnoea / reduced Left Ventricular hypertrophy
-Target Hb 100-120 (debate++)
=S/E - hypertension / thrombosis if doses too large
-If poor response to EPO
=Check iron stores / CRP / B12 +folate / PTH/Aluminium/ ?malnutrition / ?malignancy

25
Q

What is Renal Osteodystrophy?

A

-High turnover bone disease
=Secondary hyperparathyroidism
-Low turnover bone disease
=Osteomalacia
=Adynamic bone disease (exaggerated response to Vitamin D therapy= dropped PTH level)
=Aluminium bone disease (laying down of aluminium in bones= increases fracture risk)

26
Q

Why does renal osteodystrophy develop?

A

-Kidney important for production and function of Vitamin D (Final step in kidney)
=Reduced vitamin D in CKD
=Reduced calcium absorption so hypocalcaemia
=PTH level increases to increase calcium phosphate absorption from bone so osteitis fibrosa/secondary hyperparathyroidism (brown tumours in bone/ erosions)
-Hyperphosphatemia (more phosphate)

27
Q

What is the treatment for renal osteodystrophy?

A 
-Phosphate restrict (0.8-1.0g/kg/day)
=diet (0.8-1.0g/kg/day) 
=binders- calcium or non-Ca binders
-Vitamin D therapy (alfacalcidol)
=increases Ca / decreases PO4
-Monitor PTH 6/12ly
=keep 2-3 x  normal
-Parathyroidectomy may be required
28
Q

What are the consequences of hyperphosphatemia?

A

-Vessel calcification (intimal calcification= cholesterol plaques calcified, medial calcification= between layers)
=Non-compliant vessels
=Systolic hypertension – L Vent Hypertrophy
=Diastolic hypotension - Myocardial ischaemia
-Calciphylaxis
=leg ulcers

-Meat, dairy and baked goods (baking powder)

29
Q

What are the risk factors for cardiovascular disease in ESRD?

A
  • Age
  • Male
  • Smoking
  • Family history
  • Thrombogenic Lp(a)
  • Obesity
  • Homocysteinemia
  • Diabetes
  • Hypertension
  • L Vent Hypertrophy
  • Dyslipidaemia
  • HyperPO4
  • Malnutrition
  • Anaemia
  • HyperPTH
  • Uraemia
30
Q

Describe malnutrition in CKD

A

-Malnutrition common in CKD
=Decreased protein intake – dietary restrictions
=Decreased appetite
=Low albumin - ?related to inflammation/infection
-Malnourished pts do worse on dialysis
-No benefit of v low protein diet in ESRD
=But diet with 0.6-0.8 g/kg/day advised

31
Q

Who should be referred to a renal clinic?

A

-Any patient with rapid increase in creatinine/ hypertension
-Stage 3 CKD with hypertension/ proteinuria /haematuria/ rising creatinine
-Any stage 4/5 CKD who is suitable for treatment
-Late referral patients do considerably worse
=Anaemia / renal bone disease / dialysis access

32
Q

What are the types of dialysis?

A 
-Haemodialysis
=Fistula in arm joins artery and vein
=4-5 hours three times a week so time commitment
-Peritoneal dialysis
=Gut and abdominal wall
=Clean fluid in, waste fluid out
=6 hours
=Can do at home
33
Q

Describe kidney transplants

A

Cadaveric or donor graft
-Gold standard treatment
-Immunosuppressant drugs
= complications

34
Q

Describe what is involved in dialysis modality choice/ planning

A 
-When do you start dialysis?
=Recommended start when Creatinine clearance 9-14
-CAPD (perineal dialysis)
=Tenchkoff catheter insertion/ training 
-AV fistula
=Preservation of vessels in non-dominant arm
=needs 3-4 months maturation before use
-? Pre-emptive transplant
-? Conservative care

Renal and Urology (43 decks)

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