Chronic Kidney Disease and Chronic Renal Failure Flashcards

1
Q

Why is CKD common, increasing and here to stay?

A
  1. Demand for services often outstrips supply
  2. CKD receives too little attention
  3. Epidemiology focuses on ESRF not CKD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Clinical non-modifiable risk factors for CKD?

A
  1. diabetes
  2. hypertension
  3. autoimmune diseases
  4. neoplasm
  5. low birth weight
  6. urinary stones
  7. lower urinary tract obstruction
  8. reduction in kidney mass
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Infectious risk factors for CKD?

A
  1. systemic infections
  2. urinary tract infections
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Exposure to which drugs are a risk factor for CKD?

A
  1. Radiographic contrast
  2. Selected antimicrobial agents
    e.g. aminoglycosides and amphotericin B
  3. Nonsteroidal anti-inflammatory agents
    e.g. cyclo-oxygenase type 2 inhibitors, cyclosporine and tacrolimus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Sociodemographic risk factors for CKD?

A
  1. old age
  2. ethnic status - African, American, Indian, Hispanic, Asian or pacific Islander
  3. low income/education
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Criteria for CKD?

A
  1. Kidney damage for ≥ 3 months
  2. markers of kidney damage - one or more
  3. reduced GFR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the markers of kidney damage?

A
  1. Albuminuria – Allbumin excretion Rate >30mg/24hrs
  2. Albumin : Creatinine ratio (ACR) >30mg/dl (>3mg/mmol)
  3. Urine sediment abnormalities
  4. Electrolyte and other abnormalities due to tubular disorders
  5. Abnormalities on histology
  6. Structural kidney abnormalities
  7. History of kidney transplantation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the reduced GFR?

A

eGFR <60 mls/min

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How many stages of CKD are there?

A

5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe CKD stage 1?

A
  1. Description
    kidney damage with normal or increased GFR
  2. GFR >90
  3. Features
    albuminuria, proteinuria, hematuria
  4. Frequency of features
    12 monthly
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Describe CKD stage 2?

A
  1. description
    kidney damage with mild decreased GFR
  2. GFR = 60 to 89
  3. features
    albuminuria, proteinuria, hematuria
  4. frequency of features
    12 monthly
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe stage 3 CKD?

A
  1. description
    moderate decreased GFR
  2. GFR = 30 - 59
  3. features
    early and chronic renal insufficiency
  4. frequency in features
    6 monthly (12 monthly if stable)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Describe stage 4 CKD?

A
  1. description
    severe decreased GFR
  2. GFR = 15 - 29
  3. features
    late and chronic insufficiency, pre-ESRD
  4. frequency of features
    3 monthly (6 monthly if stable)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe stage 5 of CKD?

A
  1. description - kidney failure
  2. GFR = <15 (or dialysis)
  3. features
    renal failure, uremia, ESRD
  4. frequency of features - 3 monthly
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the grading categories for albuminuria?

A

A1, A2, A3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

A1 category grading of albuminuria?

A
  1. albumin excretion rate
    - <30mg/24hrs
  2. albumin to creatinine ratio
    - <3mg/mmol or 30mg/g
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

A2 category grading of albuminuria?

A
  1. albumin excretion rate
    - 30 - 300 mg/24hrs
  2. albumin to creatinine ratio
    - 3-30 mg/mmol or 30-300 mg/g
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

A3 category grading of albuminuria?

A
  1. albumin excretion rate
    - >300 mg/24hrs
  2. albumin to creatinine ratio
    - >30mg/mmol or >300mg/g
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

MDRD equation for eGFR?

A

eGFR = [186.3 × (creatinine in mg/dl) –1.154 × (age in years)−0.203 x (0.742 if female) × (1.21 if black)]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Cockroft and Gault equation for eGFR?

A

(140-age) x weight in kg/Creatinine (mg/dl) x 72
Note: Multiply by 0.85 if female

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Describe the presentation of CKD?

A
  1. Often asymptomatic until advanced
  2. Can have general body weakness, anemia, loss of appetite, changes in taste, vomiting without any precipitating factors, pins and needles (neuropathy)
  3. Discovered as a complication of existing illness
  4. Discovered incidentally as a result of tests and further evaluation required
  5. Late presentation common
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Important history findings in CKD?

A
  1. fatigue, anorexia, nausea, vomiting
  2. breathlessness, haemoptysis
  3. ankle swelling
  4. dysuria, haematuria, oliguria
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Past medical history to note in CKD?

A
  1. previous renal history
  2. enuresis
  3. UTIs
  4. family history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Examination findings in CKD?

A
  1. crackles
  2. vomiting
  3. tachypnea
    - pulmonary edema
    - acidosis
  4. pericardial rub
  5. oedema
  6. rectal examination
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Investigations in identifying renal disease?

A
  1. Urine dipsticks
  2. Lab measures of protein
  3. Blood tests
  4. USS
  5. Renal biopsy
  6. Nephrologists
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Characteristics of urine that point to a UTI?

A
  1. pH
  2. sediment
  3. smell
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What characteristic feature of urine points to heavy proteinuria?

A

frothy

28
Q

What characteristic feature of urine points to diabetes?

A

sweet taste

29
Q

What can a change in colour of urine represent?

A
  1. Blood
  2. jaundice
  3. chyluria
  4. haemoglobin
  5. myoglobin
  6. rifampicin
30
Q

What features of urine determine the concentration?

A
  1. volume
  2. colour
31
Q

What can you find in urine microscopically?

A
  1. Casts
  2. Cells
  3. Organisms
  4. Crystals
  5. Schisto
32
Q

What are the urinary casts with clinical significance?

A
  1. hyaline
  2. granular
  3. waxy
  4. fatty
  5. erythrocyte
  6. hemoglobin
  7. leukocyte
  8. epithelial
  9. myoglobin
33
Q

Hyaline cast main clinical associtions?

A
  1. normal subject
  2. renal disease
34
Q

Granular cast main clinical associations?

A

renal disease

35
Q

Waxy cast main clinical associations?

A
  1. renal insufficiency
  2. rapidly progressive glomerulonephritis
36
Q

Fatty cast main clinical associations?

A
  1. marked proteinuria
  2. nephrotic syndrome
37
Q

Erythrocyte cast main clinical associations?

A
  1. glomerular bleeding
  2. proliferative/necrotizing glomerulonephritis
38
Q

Hemoglobin cast main clinical associations?

A
  1. glomerular bleeding
  2. proliferative/necrotizing glomerulonephritis
  3. hemoglobinuria
39
Q

Leukocyte cast main clinical associations?

A
  1. acute pyelonephritis
  2. acute interstitial nephritis
  3. proliferative glomerulonephritis
40
Q

Epithelial cast main clinical associations?

A
  1. acute tubular necrosis
  2. acute interstitial nephritis
  3. glomerulonephritis
41
Q

Myoglobin cast main clinical associations?

A

rhabdomyolysis

42
Q

What other investigations can you do besides urine microscopy?

A
  1. USS
  2. IVU
  3. plain X-rays
  4. renal biopsy
43
Q

Managing CKD in a well resourced environment?

A
  1. Identify CKD (early)
  2. Identify cause
  3. Treat underlying cause (reversible)
  4. Delay progression
  5. Treat complications
  6. Involve MDT
  7. Prepare for RRT
  8. Dialysis or transplant
44
Q

Managing CKD in a poorly resourced environment?

A
  1. Identify CKD (late)
  2. Cause often unclear
  3. No specific therapy
  4. Delay progression
  5. Treat complications
  6. Little expertise
  7. Often unavailable
  8. The domain of the wealthy
45
Q

Non-modifiable mechanisms of renal disease progression?

A
  1. race/ethnicity
  2. gender
46
Q

Modifiable mechanisms of renal disease progression?

A
  1. cigarette smoking
  2. ↑ protein intake
  3. ↑ NaCl intake
  4. Proteinuria
  5. Angiotensin II
  6. Hyperglycemia
  7. Hyperlipidemia
  8. ↑ plasma Homocysteine
  9. NSAIDS
  10. Excess aldosterone
  11. K depletion
  12. ↑ procoagulants
47
Q

Clinical conditions that are mechanisms of renal disease progression?

A
  1. hypertension
  2. anemia
  3. insulin resistance
48
Q

How can you delay progression of renal disease?

A
  1. BP ≤ 125/75 esp. if proteinuria
  2. Proteinuria ≤ 0.3 g/24h
  3. HbA1C ≤ 7
  4. Protein intake 0.8 - 1 g/Kg
  5. Dietary sodium ≤ 2g/24h
  6. LDL ≤ 120 mg/dl (?)
  7. Stop smoking
  8. Avoid NSAIDS/nephrotoxins
  9. Exercise/weight loss/ low alcohol intake
  10. Correct anemia (? Optimal Hb)
  11. Control Homocysteine
  12. Avoid hypokalemia
  13. Control phosphate
  14. Low dose aspirin
49
Q

What are the treatments of chronic renal failure?

A
  1. haemodialysis
  2. peritoneal dialysis
  3. renal transplant
50
Q

Describe the haemodialysis setup?

A
51
Q

What are the pros and cons of haemodialysis?

A

pros
1. no immunosuppression
2. suitable for all patient sizes
cons
1. risks of cardiac disease
2. high cost
3. inconvnience - 3-4h/week
4. other complications of CRF
5. fluid restriction
6. need for vascular access

52
Q

Describe the peritoneal dialysis setup?

A
53
Q

Pros and cons of peritoneal dialysis?

A

pros
1. cheaper than haemodialysis
2. no immunosuppression
con
1. risk of cardiovascular disease
2. inconvenience - though at home
3. fluid restriction
4. not suitable for large patients

54
Q

Describe the renal transplant procedure?

A
55
Q

Pros and cons of renal transplant?

A

pros
1. increased well being
2. less complications of CRF
3. long-term mortality benefit
4. pregnancy possible
5. cheaper
cons
1. risks of cardiovascular disease
2. 5-10% annual graft failure rate
3. immunosuppression with risks of infection + malignancy
4. organ scarcity

56
Q

Functions of the kidneys?

A
  1. salt and water homeostasis
  2. BP control
  3. removal of uremic toxins
  4. calcium/phosphate balance
  5. erythropoietin production
  6. potassium balance
  7. acid-base balance
57
Q

Effect of kidney failure on salt and water homeostasis? Treatment?

A

effect
1. Fluid overload
- peripheral oedema
- pulmonary oedema
2. Fluid depletion

treatment
1. diuretics
2. dialysis

58
Q

Effect of kidney failure on BP control?
Treatment?

A

effect
hypertension

treatment
1. anti-hypertensives
2. dialysis

59
Q

Effect of kidney failure on removal of uremic toxins?

A

Uremia
1. encephalopathy
2. pericarditis
3. nausea
4. vomiting
5. hiccup
6. bleeding tendency
7. neuropathy

60
Q

Treatment of failure of removal of uremic toxins?

A
  1. dialysis
  2. ddAVP
61
Q

Effect of kidney failure on calcium/phosphate balance function of the kidneys?

A
  1. Hyperphosphatemia
  2. Hypocalcaemia
  3. Renal bone disease
  4. Tertiary hyperparathyroidism
62
Q

Treatment of failure to balance calcium and phosphate due to kidney failure?

A
  1. Reduced PO4 diet
  2. PO4 binders
  3. 1-α hydroxyvitamin D
  4. parathyroidectomy
63
Q

Effect of kidney failure on erythropoietin production? Treatment?

A

effect - anemia
treatment - EPO

64
Q

Effect of kidney failure on potassium balance?

A

effect - hyperkalemia
treatment - Potassium diet restriction
dialysis

65
Q

Effect of kidney failure on acid base balance?

A

effect - metabolic acidosis
treatment - sodium bicarbonate dialysis

66
Q

Patient factors that will cause long term issues?

A
  1. Distance and money
  2. Understanding need for F/U
  3. Low priority cf HIV, TB etc
  4. Asymptomatic disease
  5. Intervention may not result in obvious benefit
67
Q

Non-patient factors that are long term issues?

A
  1. Availability of drugs
  2. Cost of drugs
  3. Importance of drugs cf HIV, TB, malaria
  4. Access to bloods for monitoring/screening
  5. Clear documentation
  6. Difficult to address all aspects of renal disease