Chronic renal failure Flashcards
3 most common causes of chronic Renal failure
Diabetic nephropathy 35%
Glomerulonephritis 23%
Hypertensive vascular disease 15%
How common is Chronic renal failure
1 in 3 adults is at increased risk of developing CKD
1 in 9 adults has some sign of CKD
10% of people attending general practice have CKD (most do not know it!)
Risk factors for chronic Renal failure
Age >60 years or older Diabetes Family history of kidney disease Established cardiovascular disease Hypertension Obesity Smoking Aboriginal or Torres Strait Islander origin (9% of people commencing RRT) Albuminuria are both independent risk factors.
Presentation of chronic renal failure
Loss of 90% of kidney function before symptomatic Lethargy Nocturne Malaise Anorexia/nausea/vomiting Pruritus Restless legs Dyspnoea
Complication of Kidney disease
loss of lean body mass Oedema CVS disease Pericarditis Encephalopathy Neuropathy RLS Erectile dysfunction Depression metabolic acidosis Osteodystrophy - ↓Vit D, ↓Ca absorption, ↑PTH Anaemia Bleeding - PLT dysfunction due to uraemia.
Symptoms and pathogenesis of uraemia
Nausea, vomiting, gastrointestinal bleeding, anaemia, itching.
Pathogenesis - increase BUN , Creatine, and urea
Signs of chronic kidney disease
GI - wasting, hyperventilation, HTN
Skin - not seen often as we tx first. Pallor, hyper pigmentation (melanin deposition), Sallow or yellow skin (urochrome deposit), petechia or ecchymoses (PLT dysfunction), Excoriation due to itching (↑PO4 or uraemia), Ureic frost
Graft, fistula or needle marks
Chest - Pericardial and pleuritic friction rub, pulmonary oedema
Abdo- Mass, Renal bruits, pain, costovertebral tenderness - pyelonephritis
Neuro - drowsy, confused, inattentive, slurred speech, asterixis
Describe the symptoms progression by stage
Stage 1 and 2
- Hypertension
Stage 3 and 4
Anemia
Decreasing appetite
Poor nutrition
Abnormalities in Calcium, Phosphorus metabolism
Sodium, water, potassium and acid base abnormalities
Stage 5
- All of the above – accentuated
- Overt uremia
Ix for suspected chronic kidney failure
Bloods Full blood count Urea/electrolytes/creatinine Fasting lipids and glucose Urine microscopy, culture and sensitivity Urine ACR and PCR (preferably on first morning void) 24 hr urinary Protein – gold standard Urinary tract ultrasound scan look for underlying cause
Ix to determine underlying cause
Blood film - MAHA Screen for Myeloma Screen for vasculitis - ANA, ds-DNA, ANCA, anti GBM, Cryo Complements Hep B/C Other
Stages of chronic kidney disease
Stage 1: GFR >90 mL - Asymptomatic. Stage 2: GFR 60 to 89 mL - Asymptomatic. Stage 3: GFR 30 to 59 mL - Mild kidney failure. features of uraemia Stage 3a - 45-59 Stage 3b 30-44 Stage 4: GFR 15 to 29 mL – Moderate Stage 5: GFR
Treatment based on yellow staging and albuminuria levels
Ix to exclude treatable kidney disease
Reduce progression of kidney disease
Assessment of absolute cardiovascular risk
Avoidance of nephrotoxic medication or volume depletion
Treatment based on Orange staging and albuminuria levels
Ix to exclude treatable kidney disease
Reduce progression of kidney disease
Assessment of absolute cardiovascular risk
Avoidance of nephrotoxic medication or volume depletion
Early detection and Mx of complications
Adjustment of medication doses to levels appropriate for kidney function
Appropriate referral to a nephrologist when indicated
Treatment based on Red staging and albuminuria levels
Ix to exclude treatable kidney disease
Reduce progression of kidney disease
Assessment of absolute cardiovascular risk
Avoidance of nephrotoxic medication or volume depletion
Early detection and Mx of complications
Adjustment of medication doses to levels appropriate for kidney function
Appropriate referral to a nephrologist when indicated
Prepare for dialysis or preemptive transplant if eGFR
How regular to monitoring Chronic kidney disease
1-3 monthly clinical review (nephrologist)- BP, Wt, oedema, ongoing education Ix full blood count Fe/B12/Folate urine ACR urea, creatinine and electrolytes eGFR fasting lipids calcium and phosphate parathyroid hormone Vit D
How do you reduce progression of underlying kidney disease
Mx underlying cause Intraglomerular HTN and Hypertrophy Phosphate retention with interstitial CaPO4 deposition Increased prostaglandin synthesis Hyperlipidemia, especially in the nephrotic syndrome Metabolic acidosis Proteinuria Tubulointerstitial disease Retained “uremic” toxins Filtered iron in nephrotic syndrome
Indications for renal replacement therapy
Pericarditis or pleuritis (urgent indication).
Progressive uremic encephalopathy (urgent indication).
A clinically significant bleeding diathesis attributable to uremia (urgent indication)
Fluid overload refractory to diuretics
Hypertension poorly responsive to antihypertensive medications
Persistent metabolic disturbances that are refractory to medical therapy.
Persistent nausea and vomiting
Evidence of malnutrition
Relative indications - decreased attentiveness and cognitive tasking, depression, persistent pruritus, or the restless leg syndrome.
How to Mx the Cx of HTN in CKD
Lifestyle changes - smoking, nutrition, alcohol, physical activity, salt intake
Proteinuria CKD
How to Mx the Cx of proteinuria in CKD
ACEI/AIIRB
Non dihydropyridine calcium channel blocker
BP
How to Mx the Cx of Anaemia in CKD
occur in stage >3. Treat with erythropoiesis-stimulating agent (ESA). target 110-115.
workup for all other causes first.
How to Mx the Cx of Hyperphosphateia of in CKD
Treat with dietary phosphate binders and dietary phosphate restriction
How to Mx the Cx of Hypocalcaemia of in CKD
Treat with calcium supplements
How to Mx the Cx of Hyperparathyroidism of in CKD
Treat with calcitriol, vitamin D analogues, or calcimimetics Phosphate- Dietary restriction Binders – Calcium based /Non calcium based Increase Dialysis Vit D supplementation Specific treatment Cinacalcet Parathyroidectomy
