Chronic Kidney Disease Flashcards
1
Q
What is CKD?
A
Chronic reduction in kidney function as a result of damage to the kidneys, their vessels or pathology in lower urinary tract
2
Q
Clinical definition of CKD?
A
Reduction in GFR to <60mL/min for at least 3 months
OR
Persistent proteinuria/haematuria
3
Q
Causes of CKD?
A
- Diabetes
- HT
- Age-related decline
- Glomerulonephritis
- Polycystic kidney disease
- Medications eg NSAIDs, PPI, Ciclosproin, lithium
- SLE
4
Q
Risk factors for CKD?
A
- Older
- HT
- Diabetes
- Smoking
- Use of kidney affecting meds
- Renal tract infections
5
Q
Who gets CKD?
A
- African-Carribean
-South Asian
(probably because of prevalence of HT/T2DM)
-Acute kidney injury
-Hereditary diseases
6
Q
Presentation of CKD?
A
Asymptomatic usually diagnosed on routine screening
7
Q
Signs which suggest CKD?
A
- Pruritus
- Loss of appetite
- Nausea
- Oedema
- Muscle cramps
- Peripheral neuropathy
- Pallor
- HT
8
Q
Complications arising from CKD?
A
- Anaemia
- Renal bone disease
- CVS
- Peripheral neuropathy
- Dialysis related problem
9
Q
Investigation for CKD?
A
- U&E blood test (Find eGFR)
- Albumin: creatinine ratio to check for Proteinuria
- Urinalysis dip stick: check for haematuria
- Renal USS
- Urine microscopy: WBC, RBC
- Urine electrolytes
- FBC
- Biopsy if cause unclear
10
Q
What is checked in a blood test for CKD?
A
- Urea, creatinine, eGFR
- Electrolytes
- Calcium
- Phosphate
- PTH
- FBC
- Complement components
11
Q
2 aspects of staging CKD?
A
G score (based on eGFR) A score (based on albumin: creatinine ratio)
12
Q
What is G score?
A
G1: eGFR= >90 G2: eGFR = 60-89 G3A: eGFR = 45-59 G3b: eGFR = 30-44 G4: eGFR 15-29 G5: eGFR <15
13
Q
What is G5 also known as?
A
End stage renal failrue
14
Q
What is A score?
A
A1: <3mg/mmol
A2: 3-30mg/mmol
A3: >30mg/mmol
15
Q
What must a patient have for a diagnosis of CKD?
A
eGFR of <60
OR
Proteinuria
16
Q
NICE suggest to refer to a specialist when?
A
- eGFR < 30
- ACR > 70mg/mmol
- ACR 30mg/mmol or more + haematuria
- Accelerated progression defined as a decrease in eGFR of 15 or 25% or 15ml/min in 1 year
- Uncontrolled HT despite 4 or more anti-HTs
- rare/genetic causes of CKD suspected or suspected renal artery stenosis
17
Q
Reducing risk of complications with CKD?
A
- Exercise, diet, stop smoking, weight loss
- Special dietary advice about Phosphate, sodium, potassium and water intake
- Offer atorvastatin 20mg for primary prevention of CVD to people who have CKD
18
Q
Treating complication: metabolic acidosis?
A
-Oral sodium bicarbonate
19
Q
Treating complications: anaemia?
A
- Iron supplementation
- Erythropoietin
20
Q
Treating complications: Renal bone disease?
A
Vit D
21
Q
Treating HT?
A
1st line = ACEis However monitor serum K+ ONLY modify dose if - GFR decrease >25% or - serum creatinine increase>30% if less than these don't modify
22
Q
What do healthy kidney cells produce?
A
Erythropoietin
23
Q
What is erythropoietin?
A
Hormone which stimulates production of RBCs
24
Q
What can anaemia be treated with?
A
Erythropoiesis stimulating agents such as exogenous erythropoietin
25
What is renal bone disease AKA?
Chronic kidney disease- Mineral and bone disorder (CKD MBD)
26
Features of renal bone disease?
- Osteomalacia
- Osteoporosis
- Osteosclerosis
27
X-ray changes in renal bone disease?
Rigger jersey spine
- Sclerosis of both ends of vertebra (denser white)
- Osteomalacia in centre of vertebra (less white)
28
Why does high serum phosphate happen in CKD?
Occurs due to reduced phosphate excretion
- Low active Vit D occurs because kidney is essential in metabolising Vit D to active form
- Vit D also regulates bone turnover
29
What can be caused by CKD?
- High serum phosphate
- Secondary hyperparathyroidism
- Osteomalacia
- Osteosclerosis
- Osteoporosis
30
Why does secondary hyperparathyroidism happen in CKD?
Parathyroid glands react to low serum calcium and high serum phosphate by excreting more PTH
- This leads to increased osteoclast activity
- Osteoclast activity leads to absorption of calcium from bone
31
What can be used to treat osteoporosis?
Bisphosphonates
32
what is the pattern of CKD?
frequently unrecognised
often co-exists with other conditions e.g. CVD, DM
moderate to severe CKD - increased risk of
- AKI
- falls
- fragility
- mortality
risk of developing CKD increases with age
33
aim of CKD treatment?
prevent/delay progression
reduce/ prevent complications
reduce risk of CVD
34
As people with AKI have an increased risk of CKD how should AKI patients be managed?
monitor people for development/ progression of CKD for 2-3 years after AKI even if serum Cr has returned to normal
35
when should atorvastatin be increased in patient with CKD to prevent CVD?
increase dose if
- non-HDL cholesterol is not decreased by >40%
and
- eGFR is > 30ml/min/1.73m2 or more
higher doses need to be agreed with renal specialist if eGFR <30ml/min/1.73m2
36
what is eGFRcystatinC used for?
at initial diagnosis - confirms/rules out CKD in people with eGFR creatinine 45-59 sustained for at least 90 days
no proteinuria (ACR <3mg/mol)/other marker of kidney disease
CKD if <60ml/min/1.73m2
37
what are the possible conditions/possible pathogenesis that lead to CKD?
```
diabetes mellitus
hypertension
glomerulonephritis
- primary - membranous/IgA/FSGS
- secondary - membranous/lupus/FSGS due to HIV/heroin/obesity
vascular (macro and micro)
- RAS
- ischaemic/hypertensive nephrosclerosis
- microangiopathic - HUS/TTP
- SVV - GPA/MPA/EGPA
tubulointerstitial
- acute interstitial nephritis
- tubulointerstitial nephritis
- ADPKD
- Reflux nephropathy
post-renal (obstructive)
- calculi: renal/ureteric/bladder
- prostatic: BPH, cancer
- bladder: malignancy, bladder wall thickening
- urethral stricture
```
38
how does CKD present?
```
anaemia - conjunctival and palmar pallor, fatigue, muscle weakness
signs of weight loss
advanced uraemia
uraemic symptoms
- N&V
- anorexia
- weight loss
- fatigue
- itch
- altered taste
- restless legs
- muscle twitching
- difficulties concentrating
- confusion
pain
- bony
- neuropathic
- ischaemic
- visceral
oedema
- swelling
- breathlessness
```
39
what is accelerated progression of CKD?
sustained decrease in GFR of 25% or more and change in GFR category within 12 months
or
sustained decrease in GFR of 15ml/min/1.73m2/year
40
risk factors for accelerated progression of CKD
```
CVD
proteinuria
AKI
hypertension
diabetes
smoking
African, African-Caribbean, Asian
chronic NSAID use
untreated urinary outflow tract obstruction
```
41
renal consequences of CKD
local - pain, stones, haemorrhage, infection
urinary - haematuria, proteinuria, nocturia, oliguria
impaired salt and water handling - pee at night, difficulty concentrating
hypertension
electrolyte abnormalites
acid-base disturbance
ESRD
42
extra renal consequences of CKD
cardiovascular disease - 10-20 fold higher risk of death than general population for ESRD. It starts early: eGFR <50ml/min. The risk is increased with microalbuminuria
mineral and bone disease
anaemia - less common if eGFR >45, diabetics are more at risk
43
how is the risk of CV disease managed?
- smoking cessation
- weight loss
- aerobic exercise
- limiting salt intake
control of hypertension
other prophylaxis
- lipid-lowering therapy
- consider aspirin for secondary prevention (bleeding :( )
44
what causes the mineral and bone disease related to CKD?
```
different adaptive changes in
- calcium
- phosphate
- PTH
- Vitamin D
- FG-23
seriously compromised homeostatic mechanisms
bone abnormalities and vascular calcification and laboratory abnormalities
```
45
what are the consequences of the bone and mineral abnormalities associated with CKD?
```
secondary/ tertiary HPT
vascular calcification
bone pain
fractures
CV events
lower QoL
higher morbidity and mortality
```
46
how are bone and mineral abnormalities associated with CKD managed?
```
phosphate restriction
also consider
- salt reduction
- potassium restriction (if persistentily >5.5 mmol/L)
- fluid restriction: 1-1.5L/day
- dietary restrictions also - DM/coeliac disease
correct metabolic acidosis: NaHCO3 can result in Na overload
medications
alfacalcidol - active vitamin D
phosphate binders
- calcium based
- aluminium
- non-calcium based
calcimimetic = cinacalcet
```
47
how is anaemia managed?
target Hb:100-12 g/L
- lower level acceptable if Hb fails to rise despite adequate iron replacement & epoetin therapy
investigation
- exclude other causes: B12/folate deficiency
- check ferritin & iron stores: ferritin >100, T Sats > 20%
- consider MDS/ other haematological causes
management
- ferinject - ferric carboxymaltose
- venofer - iron sucrose
- if oral fails - IV iron
