Chronic Kidney disease and Renal failure

Question 1

What kind of homeostatic functions do kidneys have? (3)

Answer 1

-

Question 2

What kind of endocrine functions do kidneys have?

Answer 2

Question 3

What kind of excretory functions do kidneys have?

Answer 3

Question 4

How do kidneys aid glucose metabolism?

Answer 4

Question 5

What happens to the biochemistry of the blood when homeostatic function of the kidney fails?

Answer 5

Question 6

What happens when endocrine function of the kidney fails?

Answer 6

Question 7

What happens when excretory function of the kidney fails?

Answer 7

Question 8

What else happens apart from failure of homeostatic function, endocrine function, excretory function and glucose metabolism in CKD?

Answer 8

increased cardiovascular risk

Question 9

What is the biggest driver of cardiovascular disease?

Answer 9

CKD

(more so than high cholesterol and smoking)

Question 10

What is eGFR and how is it calculated?

Answer 10

mathematical estimate of GFR based on creatinine, age, sex

Question 11

What do we call fast, deep breaths that occur in response to metabolic acidosis?

Answer 11

Kussmaul respiration

Question 12

Volume assessment:

hyper/hypo or euvolemic?

Answer 12

hypoeuvolemic

Question 13

What is the acid/base assessment of this case?

Answer 13

Metabolic acidosis with respiratory compensation

Question 14

In suspected kidney failure, why do we do an ultrasound?

What can it tell us?

Answer 14

US –> to determine if this is an acute kidney injury or chronic
* if small kidneys (most likely CKD)
◦ due to fibrosis etc of glomerulus
* BUT kidney size can be preserved if you have CKD due to:
◦ diabetes,
◦ polycystic kidneys
◦ myeloma

Question 15

If you have CKD, when may kidney size be preserved?

Answer 15

diabetes,
polycystic kidneys
myeloma

Question 16

If we see small kidneys on an US what does it tell us and why are they small?

Answer 16

if small kidneys (most likely CKD)
-> due to fibrosis etc of glomerulus

Question 17

Volume assess this patient

Answer 17

normovolaemic

Question 18

What is the acid base status of this patient?

Answer 18

Mild metabolic acidosis with respiratory compensation

Question 19

salt and water…
do imbalances cause kidney disease or are they an effect of kidney disease?

Answer 19

both

Question 20

Kidney failure tends to _____ secretion of salt and water leading to:

• ___
• ___
• ___

Answer 20

REDUCE

Hypertension - Oedema - Pulmonary oedema

Question 21

Usually kidney failure presents with a reduction in secretion of salt and water -> hypervolaemia

When may it be that a patient presents as hypovolaemic with kidney disease?

Answer 21

if your cause of acute kidney disease is vomiting etc, you can be hypovolemic

Salt and water loss may be seen in tubulointerstitial disorders – damage to concentrating mechanism & hypovolemia may be the cause of AKI.

Question 22

Explain why.

Answer 22

if you have oedema, by definition you have excess extracellular fluid, and your total body sodium is increased, irrespective on your serum sodium levels

• serum sodium is not reflective on your total sodium

Question 23

Why do we typically see hyperkalaemia in acidosis?

Answer 23

hydrogen ions swap for potassium ions when you have acidosis
therefore rise in serum potassium as potassium is usually IN cells

Question 24

What may be the physiological symptoms of acidosis?

Answer 24

anorexia
muscle catabolism

Question 25

What is extracellular sodium determined by?

Answer 25

EXTRACELLULAR SODIUM IS DETERMINED BY THE RELATIVE WATER AND SODIUM, RATHER THAN THE TOTAL SODIUM

Question 26

Why does intravascular potassium have to be managed very tightly?

Answer 26

because serum potassium normal range is ±3.5-5.0

Question 27

What are some causes of hyperkalaemia? What are some symptoms with chronic hyperkalaemia?

Answer 27

Question 28

Name some changes you may see on an ECG as a result of hyperkalaemia.

Answer 28

Peaked T waves P wave - broadens - reduced amplitude - disappears QRS widening Heart block Asystole VT/VF 'sin' waves seen that flatten progressively

Question 29

What can reduced erythropoietin levels lead to? (1)

Answer 29

anaemia

Question 30

What can reduced 1-25 Vit D levels lead to? (3)

Answer 30

Reduced intestinal calcium absorption Hypocalcaemia Hyperparathyroidism

Question 31

-

Answer 31

mistake on the diagram - low Vit D **stimulates** PTH production

Question 32

What is a patient with CKD most likely to die from?

Answer 32

cardiovascular disease

Question 33

Name some standard and additional risks for cardiovascular disease.

Answer 33

Question 34

How should you initially manage hypovolaemia and hypervolaemia?

Answer 34

hypo: give fluids hyper: trial of diuretics/dialysis

Question 35

What 3 ways can we initially manage hyperkalaemia and give examples of how we do this

Answer 35

drive into cells drive out of the body gut absorption

Question 36

What treatment can we use to drive potassium into cells?

Answer 36

- sodium bicarbonate - insulin dextrose

Question 37

What treatment can we use to drive potassium out of the body?

Answer 37

diuretics / dialysis

Question 38

What treatment can we use to decrease potassium absorption in the gut?

Answer 38

potassium binders

Question 39

What kind of conservative treatment can patients with kidney disease get in the long term?

Answer 39

Question 40

What kind of home/centre therapy can patients with kidney disease get in the long term?

Answer 40

Question 41

What is the best, gold-standard treatment for end stage kidney failure?

Answer 41

transplantation (live donor ideally)

Question 42

What is the KFRE? What condition is it used for? Who do we use it for?

Answer 42

Kidney failure risk equation for CKD (not AKI) it provides the 2 and 5 year probability of treated kidney failure for a potential patient with CKD stage 3a to 5.

Question 43

How is KFRE calculated?

Answer 43

Age in years Sex CKD-EPI eGFR Urine albumin creatinine ratio (ACR)

Question 44

Why do we use the KFRE?

Answer 44

1. Patient understanding of their CKD diagnosis especially in the context of multi-morbidity 2. Identification of high risk CKD patients: - targeted patient engagement/education - aggressive risk factor management - referral to secondary care

Question 45

Why is it important to avoid unnecessary blood transfusions in potential kidney transplant recipients?

Answer 45

exposure to multiple blood donations may cause alloimmunisation to human leucocyte antigen (HLA) class I antigens on white blood cells transfusions -> sensitisation -> transplant failure

Question 46

What are some transitional methods of assessing GFR? (5)

Answer 46

urea creatinine clearance creatinine inulin clearance radionuclide studies

Question 47

What is the creatinine clearance equation

Answer 47

Creatinine Clearance = [[140 - age(yr)]*weight(kg)]/[72*serum Cr(mg/dL)] (multiply by 0.85 for women).

Question 48

Expand on the pros and cons of using urea to assess GFR.

Answer 48

Question 49

Expand on the pros and cons of using creatinine to assess GFR.

Answer 49

Question 50

Expand on the pros and cons of using radionuclide studies to assess GFR.

Answer 50

gold standard but rarely used

Question 51

Expand on the pros and cons of using creatinine clearance to assess GFR.

Answer 51

Question 52

Expand on the pros and cons of using inulin clearance to assess GFR.

Answer 52

gold standard, but rarely used

Question 53

At what number does the margin of error get large in eGFR

Answer 53

60

Question 54

What is ACR

Answer 54

albumin:creatinine ratio

Question 55

Increasing risk of...

Answer 55

CKD, AKI and CV