Chronic Kidney Disease (CKD)

Question 1

What are the Sx of CKD?

Answer 1

Often asymptomatic until advanced (fatigue/anorexia)
Polyuria/nocturia
Restless legs syndrome
Sexual dysfunction
Nausea & Pruritis
Yellow pigmentation, encephalopathy, pericarditis
Pedal/pulmonary oedema

Question 2

What are the signs of CKD?

Answer 2

Pallor due to anaemia
Excoriations due to pruritis
HTN/fluid overload signs
Pericardial rub

Question 3

What are the appropriate initial investigations for CKD?

Answer 3

Bloods - FBC, U&E, LFTs, Ca, PO4, PTH, Glucose
Urinalysis & MCS - quantify proteinuria, exclude infection
24h urinary protein - assess severity
CXR - suspected pulmonary oedema
Renal USS - suspected obstructive causes

Question 4

How is CKD diagnosed?

Answer 4

Two tests 3/12 apart showing reduced eGFR

Question 5

How is CKD staged?

Answer 5

According to eGFR

Question 6

Describe Stage 1 CKD

Answer 6

eGFR >90
Normal kidney function
Urine findings/structural abnormalities/genetic traits point to kidney disease

Question 7

Describe Stage 2 CKD

Answer 7

eGFR 60-89
Mildly reduced kidney function
Urine findings/structural abnormalities/genetic traits point to kidney disease

Question 8

Describe Stage 3 CKD

Answer 8

eGFR 30-59

Moderately reduced kidney function

Question 9

Describe Stage 4 CKD

Answer 9

eGFR 15-29

Severely reduced kidney function

Question 10

Describe Stage 5 CKD

Answer 10

eGFR <15

V. severe/established renal failure

Question 11

What is eGFR?

Answer 11

An estimate of GFR based on a plasma level of creatinine

Question 12

What are the common causes of CKD?

Answer 12

DM (20-40%)
HTN
AKI
Renal Disease
   -Polycystic kidney disease
   -Chronic glomerulonephritis
   -Chronic pyelonephritis
Obstructive uropathy
Renovascular disease
Drugs (NSAIDs)

Question 13

What additional specialist investigations may be required in CKD?

Answer 13

DTPA scan (investigates vascular supply)
Renal biopsy
Bone imaging

Question 14

What are the management options for CKD?

Answer 14

Treat reversible causes (obstruction, nephrotoxic drugs)
BP/DM control
   -BP <130/80 OR <125/75 if proteinuric
   -ACEIs 1st line, also statin + ld aspirin
Complication control
   -EPO
   -ca/vit D supplementation
   -K+ restriction if hyperkalaemic
Renal replacement therapy (Stage 5)

Question 15

When should renal replacement therapy be started?

Answer 15

Any symptomatic CKD Stage 5 pt

-often try to delay dialysis

Question 16

What are the three main complications of CKD?

Answer 16

Renal anaemia
Renal bone disease
2o HTN

Question 17

What is the underlying pathophysiology of renal anaemia in CKD?

Answer 17

Loses ability to secrete EPO –> anaemia

Question 18

How is renal anaemia managed?

Answer 18

Recombinant EPO as part of renal replacement therapy

Question 19

What factors contribute to renal anaemia?

Answer 19

CKD
Bone marrow toxins
Increased blood loss
Abnormal red cell membrane

Question 20

What is the underlying pathophysiology of renal bone disease in CKD?

Answer 20

Low vit D –> hypocalcaemia, hyperphosphataemia, osteomalacia –> 2o hyperparathyroidism –> cyst formation & marrow fibrosis –> 3o hyperparathyroidism –> osteopenia

Question 21

How can osteopenia be detected radiologically?

Answer 21

Pseudofractures

Subperiosteal erosions

Question 22

How is renal bone disease managed?

Answer 22

Restrict dietary phosphate
Give phosphate binders
AdCal supplementation

Question 23

What is the underlying pathophysiology of 2o HTN in CKD?

Answer 23

Overactivation of RAAS –> HTN
Thickened renal artery walls (afferent)
Chronic ischaemia, progressive loss of glomeruli

Question 24

What are the different options for renal replacement therapy?

Answer 24

Haemodialysis
Peritoneal dialysis
Transplantation

Question 25

What is haemodialysis?

Answer 25

Diffusion of solutes b/w blood & dialysate - flow in opposite directions - semi-permeable membrane b/w

Question 26

How is vascular access typically achieved for haemodialysis?

Answer 26

Arteriovenous Fistula - wrist/cubital fossa - can also use double lumen venous lines

Question 27

How often must haemodialysis occur?

Answer 27

4hrs, 3x/wk, normally in hospital

Question 28

What is the main issue in haemodialysis?

Answer 28

Haemodynamic instability during dialysis

Question 29

What is haemofiltration?

Answer 29

Variant of haemodialysis where blood is continuously filtered across highly permeable membrane - more efficient - more haemodynamically stable - more expensive

Question 30

How is peritoneal dialysis performed?

Answer 30

2l of isotonic/hypertonic solution inserted into peritoneal cavity -equilibrates w/ blood in peritoneal capillaries through peritoneal membrane

Question 31

How often must peritoneal dialysis occur?

Answer 31

3-4x/daily Fluid drained after 4-6hrs -can be performed at night (automated peritoneal dialysis)

Question 32

What is the main risk of peritoneal dialysis?

Answer 32

Peritonitis

Question 33

What are the complications of dialysis?

Answer 33

``` Mortality 20% Infection CVD Renal bone disease/anaemia Bleeding Renal malignancies ```

Question 34

What factors must be measured in a patient assessment pre-transplantation?

Answer 34

Virology/TB status (active infection = contraindication) Blood group/HLA monitoring Full systemic examination (co-morbid disease = contraindication)

Question 35

What are the potential complications of renal transplantation?

Answer 35

Operative complications Rejection Ciclosporin/tacrolimus toxicity (immunosuppressants) Infection/malignancy (immunosupression)

Question 36

What are the potential operative complications of renal transplantation?

Answer 36

Bleed Thrombosis Infection Urinary leaks

Question 37

Describe the risk of rejection in renal transplantation

Answer 37

Risk highest in 3mo Lifelong immunosuppression Episodes of rejection reversible Immunological tolerance develops

Question 38

What malignancies are most likely post renal transplant?

Answer 38

Skin cancer Anal cancer Lymphoma

Question 39

What is the prognosis of a renal transplant?

Answer 39

Good | 1yr graft survival rate 80-95%

Question 40

What three ways can DM affect the kidney?

Answer 40

Direct glomerular damage Ischaemia Ascending infection

Question 41

Describe direct glomerular damage caused by DM

Answer 41

Basement membrane thickening - increased leakiness of capillary wall - proteinuria - glomerular hyalinisation --> CKD

Question 42

How is polycystic kidney disease inherited?

Answer 42

AD or AR | -AD more common (1/800)

Question 43

What is the long term consequence of PKD?

Answer 43

Both kidneys replaced by enlarging fluid filled cysts

Question 44

How do ADPKD sufferers present?

Answer 44

Systemic HTN CKD Abdo swelling (bilateral, ballotable kidneys) Renal failure (later in life)

Question 45

Where else may cysts develop in ADPKD?

Answer 45

Liver Lungs Pancreas

Question 46

How do ARPKD sufferers present?

Answer 46

Earlier onset | Chronic renal failure earlier in life

Question 47

What is the potential effect of liver cysts in PKD?

Answer 47

Portal HTN | Fibrosis

Question 48

What is the main condition associated w/ PKD?

Answer 48

Berry aneurysms --> SAH

Question 49

How is PKD managed?

Answer 49

As CKD | Screen for berry aneurysms

Question 50

What are the two forms of chronic interstitial nephritis?

Answer 50

Reflux associated | Obstructive

Question 51

Describe reflux associated chronic interstitial nephritis

Answer 51

Incompetent vesicoureteric valves -predisposition to inflammation/scarring Presents in eraly adulthood w/ deteriorating renal funcn

Question 52

Describe obstructive chronic interstitial nephritis?

Answer 52

Recurrent episodes of infection due to anatomical abnormality/stone

Question 53

What are the histological hallmarks of chronic interstitial nephritis?

Answer 53

Irregular areas of scarring | Chronic inflammatory infiltrate

Question 54

What drugs typically require dose reduction in the presence of a decreased eGFR?

Answer 54

``` Gentamicin Cephalosporins Heparin Lithium Opiates Digoxin ```