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renal and urology > chronic kidney disease W2 > Flashcards

chronic kidney disease W2 Flashcards

1
Q

case: 56 yr old man.
tiredness and itchy skin
BP 180/110
high urea
high creatinine
high potassium
low bicarbonate
low haemoglobin
low calcium
high phosphate

explain these results

A

poor tubule function = low bicarbonate, high potassium, high creatinine

fluid retention = hypertension

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2
Q

diagnostic definition of chronic kidney disease

A

GFR of <50ml/min for >90 days

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3
Q

causes of CKD?

A

most common = diabetes, hypertension

rarer = glomerulonephritis, cystic kidney disease, renovascular disease

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4
Q

how do we estimate kidney function?

A

serum creatinine
creatinine clearance
isotope GFRs
formulae (often used)

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5
Q

what is a normal GFR?

A

125ml/min/1.73m^2

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6
Q

what formulae do we currently use to estimate GFR

A

MDRD or CKD-EPI equation
(CKD-EPI Cystatin C equation rarely used but more accurate)

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7
Q

stages of CKD?

A

creatinine clearance (~GFR)
stage 1 = normal = 120-90
stage 2 = early CRF = 90-60
stage 3 = moderate CRF = 60-30
stage 4 = pre-ESRD = 30-15
stage 5 = ESRD = 15-0

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8
Q

CRF? ESRD?

A

chronic renal failure
end stage renal disease

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9
Q

when are you put on a renal transplant list!

A

GFR<15 (stage 5/ESRD)

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10
Q

how to prevent progression of CKD

A

control blood pressure (RAS inhibition - ACE inhibitors)
reduce proteinuria (RAS inhibition)
if diabetes, optimise glycaemic control
SGLT2 inhibitors

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11
Q

when do you have to worry about stage 1/2 CKD? (GFR>60)

A

when albuminuria is severely increased (>300mg/g or >30mg/mmol)

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12
Q

is proteinuria a marker or cause of progressive renal disease

A

both!!

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13
Q

how does proteinuria cause chronic interstitial fibrosis

A

proteinuria taken up into tubular cells, processed by lysosomes into amino acids, taken into tubular capillaries. system gets overloaded in patients with large amounts of proteinuria. cell gets overloaded and dies. fibroblasts/macrophages try remove cell, causes scarring (interstitial fibrosis)

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14
Q

how do ACE inhibitors decrease proteinuria

A

cause efferent arteriole vasodilation. drop pressure in glomerulus therefore decrease amount of protein passing through.

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15
Q

toxic drugs to the kidney?

A

NSAIDs/contrast/gentamicin
phosphate enemas

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16
Q

drug dosing and CKD?

A

lower doses of blood pressure tablets, antimicrobials etc
especially chemotherapy agents
if in doubt check BNF!!

17
Q

hypertension and CKD?

A

cause and consequence of CKD

18
Q

BP treatment goals for CKD?

A

normal - 130/80
DM/proteinuria - 125/75

19
Q

treatment of hypertension in CKD?

A

low salt diet
lifestyle modifications (exercise/alcohol/smoking)
BP meds eg ACEi

20
Q

high potassium in CKD - when does this occur and how is it managed?

A

common once GFR<25
give dietary advice
give potassium binders (sodium zirconium) but expensive - only use short term

21
Q

what is much acidosis in CRF due to? why?

A

animal protein in food
because inability to acidify urine in CKD
phosphate/sulphates/other anions

22
Q

how to treat acidosis in CKD?

A

replace with NaHCO3 (sodium bicarbonate)
but beware fluid overload
aim to keep serum bicarbonate >22

23
Q

anaemia in CKD definition?

A

Hb<12 in males
Hb<11 in females

24
Q

anaemia in CKD features

A

generally normochromic normocytic anaemia
decreased response of EPO to a hypoxic stimulus (kidneys) and decreased red cell survival in most patients

25
Q

who should be on EPO and what is the target Hb?

A

all patients with Hb<100 and adequate iron stores should be on EPO
target Hb = 100-120

26
Q

benefits of EPO therapy?

A

better quality of life
less dyspnoea
reduced left ventricular hypertrophy

27
Q

what to do if patient has poor response to EPO

A

check:
iron stores
inflammation
B12 + folate
PTH
aluminium
malnutrition
malignancy

28
Q

why do CKD patients get renal osteodystrophy

A

kidneys activation of vitamin D reduced, vit D reduced, reduced calcium absorbed from gut, develop osteomalacia. in response to low Ca, PTH increases, causes osteitis fibrosa. PTH increases Ca and PO4 reabsorption from bone.

29
Q

another name for osteitis fibrosa?

A

parathyroid bone disease

30
Q

renal osteodystrophy treatment?

A

vegan diet (restrict phosphate)
phosphate binders
vit D therapy (alfacalcidol)

31
Q

what are the consequences of hyperphosphataemia

A

vessel calcification
calciphylaxis

32
Q

cardiovascular disease in ESRD - increased risk factors?

A

diabetes
hypertension
L vent hypertrophy
dyslipidaemia
malnutrition

32
Q

what type of vessel calcification occurs in hyperphosphataemia? (explain)

A

medial calcification - calcification within the medial layer of vessel walls (makes vessels more visible in scans)

33
Q

cardiovascular disease in ESRD - unique risk factors?

A

anaemia
hyperPTH
uraemia
hyperPO4

34
Q

malnutrition in CKD - why!

A

nauseous if eat meat/dairy, protein levels decrease
decreased appetite

35
Q

features of malnourished CKD patients

A

low albumin relating to inflammation/infection
malnourished patients do worse on dialysis

36
Q

who should you refer to the renal clinic?

A

anyone with rapid increase in creatinine/hypertension

stage 3 CKD with hypertension/proteinuria/haematuria/rising creatinine

any stage 4/5 CKD suitable for treatment

37
Q

options for dialysis?

A

haemodialysis - hospital 3 times a week, blood cleaned in machine for 4 hours.

peritoneal dialysis - uses space between guts and abdominal wall, fill with fluid for 4-6 hours, drained out and repeated. waste products drift into fluid.

transplantation - young, fit. history of malignancy is contraindication.

38
Q

when do you start dialysis?

A

creatinine clearance 9-14

renal and urology (25 decks)

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