Chronic Kidney Disease

Question 1

Define CKD

Answer 1

• Reduced kidney function present > 3months

Question 2

What are the causes of CKD?

Answer 2

• Diabetic nephorpathy
• Glomerulopathies
• Hypertensive nephorpathy
• Ischameic nephorpathy
• PKD
• NSAIDs, PPI, Lithium
• Obstructive uropathy
• Tubulointerstitial disease

Question 3

What are the RF of CKD?

Answer 3

• Old age
• HTN
• Diabetes
• Smoking
• Nephrotoxic medications

Question 4

What are examples of nephrotoxic medications?

Answer 4

• NSAIDs
• ACEi
• Penicillamine
• Phenytoin
• Penicillin, Rifampicin
• Aminoglycosides, Cyclosporins
• Lithium
• Diuretics
• Metformin

Question 5

How can CKD be classified?

Answer 5

• GFR
• ACR (albumin:creatinine ratio)

Question 6

Describe the G-score for CKD

Answer 6

• G1: >90: Only CKD if porteinuria/haematuria
• G2: <90 :
• G3a: <60 : Mild-moderate dec GFR
• G3b: <45 : Moderate-severe dec GFR
• G4: <30 : Severe dec. GFR
• G5: <15 : Kidney failure

Question 7

Describe the a score in CKD

Answer 7

• A1 = < 3mg/mmol
• A2 = 3 – 30mg/mmol
• A3 = > 30mg/mmol

Question 8

What is the prognosis of CKD?

Answer 8

low GFR and albuniuria > high risk of

• all-cause mortality
• cardiovascular mortality
• progressive kidney disease + kidney failure
• AKI

Question 9

How will CKD present?

Answer 9

• uraemic pruritus
• loss of appetite
• nausea
• oedema
• muscle cramps
• peripheral neuropathy
• pallor
• HTN
• bone pain
• impotence

Question 11

On ex, what signs will you see in CKD?

Answer 11

• Periphery
  
  • peripheral oedema
  • nuropathy
  • uraemic flap
  • gout
• Face
  
  • Anaemia
  • xanthelasma
  • yellow tinge
  • jaundice - from hepatorenal syndrome
• CVS
  
  • BP
• Resp
  
  • Pulmonary oedema
• Abdomen
  
  • catheter, signs of transplant, PKD

Question 12

What Ix would you oder for CKD?

Answer 12

• Bedside
  
  • dipstick
  • a:cr / p:cr
  • mc&s
  • Bence Jones - check for multiple myeloma
  • ECG - high risk of CVD
• Bloods
  
  • U&E - check eGFR
  • FBC - Hb
  • Bone profile
  • ANA,ANCA, APA, anti-GBM
• Imaging
  
  • USS
  • MRI
• Special test
  
  • Renal biopsy

Question 13

What are the Cx of CKD?

Answer 13

• Anaemia
• Acidosis
• Oedema
• Peripheral neuropathy
• Renal bone disease
• CVD

Question 14

When will you refer CKD to specialist?

Answer 14

• eGFR <30
• ACR ≥ 70 mg/mmol
• Accelerated progression defined as a decrease in eGFR of 15 or 25% or 15 ml/min in 1 year
• Uncontrolled hypertension despite ≥ 4 antihypertensives

Question 15

What are the two target tx for CKD?

Answer 15

1. Tx to slow renal disease progression
2. Tx of cx of CKD

Question 16

How would you tx to slow renal disease progression?

Answer 16

1. Optimise hypertensive control
2. Optimise glycaemic control
3. Lifestyle (exercise, smoking cessation, reduce salt intake)

Question 17

How would you mx anaemia in CKD?

Answer 17

1. Check Hb when eGFR <60
2. Check Iron, B12, Folate def.
3. Start IV iron or Iron supplements first
4. Start Erythropoietic Stimulating Agent
5. Limit blood transfusion as they can cause allosensitisation > reject transplant

Question 18

What is the Px of CKD-MBD?

Answer 18

1. Reduce phosphate excretion in PCT
2. Reduce Vit D hydroxylation > red. cal absorption
3. Inc. Phosphate and red. cal in blood > secondary hyperparathyroidism > inc. osteoclast activity

Question 20

What are the features of CKD-MBD?

*3Os

Answer 20

• Osteomalacia - due to increase bone turnover
• Osteosclerosis - inc osteoblast activity to match osteoclast activity
• Osteoporosis - could be due to long term steroid use

Question 21

How would you mx CKD-MBD?

Answer 21

• Low phosphate diet
• Phosphate binders
  
  • biphosponates
  • calcium based binders
  • sevelamer
• Vit D supplements
• Parathyroidectomy

Question 22

What are the xray features of CKD-MBD?

Answer 22

• Sclerosis of both ends of vertebrae
• osteomalacia in centre
• *Rugger jersey sign

Question 23

How would you mx CVD in CKD?

Answer 23

• Low dose aspirin
• Atorvastatin 20mg

Question 24

Which risk is higher from ckd, CVD or Renal failure?

Answer 24

• CVD

Question 25

What are markers for kidney damage?

Answer 25

• Albuminuria (> 3 mg/mmol, i.e. A2/3)
• Abnormalities (including electrolyte derangement) secondary to tubular disorders
• Structural abnormalities
• Abnormalities on histology
• History of kidney transplant

Question 26

What equation is used to calculate eGFR?

Answer 26

• Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)

Question 27

What are the indications for CKD testing?

Answer 27

• Diabetes
• Hypertension
• Acute kidney injury
• Obesity with metabolic syndrome
• Cardiovascular disease
• Structural renal tract disease
• Proteinuria or persistent haematuria
• Family history

Question 28

What are general principals of managing CKD in primary care?

Answer 28

1. Patient education
2. eGFR monitoring
3. DM and HTN medication optimisation
4. CVD prevention
5. CKD-MBD mx
6. Hyperphosphataemia mx
7. Anaemia mx
8. Renal replacement therapy

Question 29

What patient education should be given in primary care for CKD?

Answer 29

• Diet
  
  • Low sodium diet <2.4g/day
  • Low protein diet 0.75g/kg/day
  • vit D supplements
  • Folic acid and VitB supplements
• Exercise
• Smoking cessation
• Avoid nephortoxins (IV radiocontrast, NSAIDs, aminoglycosides)
• Immunisation against influenxa and pnuemococcal

Question 30

How should the eGFR monitoring be performed in primary care?

Answer 30

• If newly confirmed CKD
  
  • x3 eGFR taken over 90 days
• If initial abnormal eGFR detected
  
  • repeat test within 2 weeks
• Porteinuria assessed at least yearly
  
  • early morning specimen

Question 31

What is the CVD prevention mx like in primary care for CKD?

Answer 31

• Atorvastatin 20mg
• Aspirin
• Consider Apixaban

Question 32

How would you mx hyperphosphatemia in primary care?

Answer 32

• refer to specialist renal dietician
• Phosphate binders
  
  • Calcium acetate (first line)
  • Calcium carbonate if x tolerate above