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MBBS 3: Internal Medicine > Chronic Kidney Disease and Chronic Renal Failure > Flashcards

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
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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
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3
Q

Infectious risk factors for CKD?

A
  1. systemic infections
  2. urinary tract infections
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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
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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
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6
Q

Criteria for CKD?

A
  1. Kidney damage for ≥ 3 months
  2. markers of kidney damage - one or more
  3. reduced GFR
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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
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8
Q

What is the reduced GFR?

A

eGFR <60 mls/min

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9
Q

How many stages of CKD are there?

A

5

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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
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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
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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)
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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)
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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
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15
Q

What are the grading categories for albuminuria?

A

A1, A2, A3

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16
Q

A1 category grading of albuminuria?

A
  1. albumin excretion rate
    - <30mg/24hrs
  2. albumin to creatinine ratio
    - <3mg/mmol or 30mg/g
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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
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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
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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)]

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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

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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
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22
Q

Important history findings in CKD?

A
  1. fatigue, anorexia, nausea, vomiting
  2. breathlessness, haemoptysis
  3. ankle swelling
  4. dysuria, haematuria, oliguria
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23
Q

Past medical history to note in CKD?

A
  1. previous renal history
  2. enuresis
  3. UTIs
  4. family history
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24
Q

Examination findings in CKD?

A
  1. crackles
  2. vomiting
  3. tachypnea
    - pulmonary edema
    - acidosis
  4. pericardial rub
  5. oedema
  6. rectal examination
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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
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26
Q

Characteristics of urine that point to a UTI?

A
  1. pH
  2. sediment
  3. smell
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27
Q

What characteristic feature of urine points to heavy proteinuria?

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?

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?

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?

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

MBBS 3: Internal Medicine (72 decks)

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