ckd Flashcards
def CKD
either kidney damage or GFR<60 mL/min/1.73 m2for 3 months with health implications
Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.
classification of ckd
classified based on GFR category, presence of albuminuria and cause of kidney disease
classification based on cause of ckd
glomerular
- primary - minimal change, membranous
- systemic - dm, amyloid
tubulointersititial
- primary - UTI, pyelonephritis, stones
- secondary - drugs, toxins, sarcoid
blood flow/vessels
- primary - renal limited vasculitus,
- systemic - HF, TTP
cystic/congenital
- primary - renal dysplasia
- systemic - alport syndrome, Fabry disease
transplant
- primary - recurrence of renal disease
- systemic - rejection, calcineurin toxicity
aetiology ckd
dm and HTN - most common causes
vascular disease - HTN, renal artery atheroma, vasculitis
gloimerular disease - glomerulonephritis, dm, amyloid, SLE
tubulointerstitial disease - pyelonephritis/interstitial nephritus, nephrocalcinosis, TB
obstruction and others - myeloma, HIV nephropathy, scleroderma, gout, renal tumour, inborn errors of metabolism (Fabry’s disease)
congenital/inherited - polycystic kidney disease, Alport’s syndrome, congenital hypoplasia
epi ckd
Incidence of end-stage CRF in England>110 per million population per year.
Higher incidence in Asian immigrants than native British population.
sx ckd
anorexia
nausea
malaise
pruritus
later:
- diarrhoea
- drowsiness
- convulsions
- coma
symptoms of cause and complications
face signs ckd
signs of anaemia
xanthelasma
ureamia - yellow tinge
jaundice - hepatorenal
gum hypertrophy - ciclosporin
cushingoid - steroids
periorbital oedema - nephrotic syndrome
taut skin/telangiectasia - scleroderma
facial lipodystrophy - glomerulonephritis
neck signs ckd
JVP for fluid state
tunnelled line (if removed, look for small scar over in-ternal jugular, and a larger scar in ‘breast pocket’ area),
scar from parathyroidectomy,
lymphadenopathy.
resp signs ckd
pul oedema or effusion
kussmaul’s breathing - acidosis
abdo signs ckd
PD catheter or scars from previous catheter (small scars just below umbilicus and to side of midline)
signs of previous transplant - scar, palpable graft
ballotable polycystic kidneys +- palpable liver
cvs signs ckd
BP
sternotomy
cardiomegaly
If right-sided heart failure/tricuspid regurgitation, JVP does not refl ect fl uid state.
stigmata of endocarditis
hand signs ckd
leuconychia
brown line at distal end of nail
There may be an arteriovenous fistula (buzzing lump in wrist or forearm).
Uraemic flap/encephalopathy if GFR <15.
general signs ckd
- peripheral oedema
- signs of peripheral vascular disease or neuropathy
- vasculitic rash
- gouty tophi
- joint disease
- pigmentation
- scratch marks
- Signs of immunosuppression: bruising from steroids, skin malignancy.
blood ckd
low Hb normochromic, normocytic
UE - low urea and creatinine - compare with previous
eGFR (can be derived from creatinine and age using the MDRD calculator)
low ca,
high phos, alkPhos and PTH (renal osteodystrophy)
ix aetiology ckd
- ANCA
- ANA
- antiphospholipid Ab
- paraprotein
- complement
- cyroglobin
- anti-GBM
- hepatitis serology
- anti-PLA2R (membranous nephropathy)
- glucose
24hr urine collection ckd
protein
creatinine clearance - rough estimate of GFR
MC&S
Bence jones
imaging ckd
osteomalacia and hyperparathyroidism.
CXR may show pericardial effusionor pulmonary oedema
renal us ckd
measure size - may be small <9cm, except in infi ltrative disorders (amyloid, myeloma), APKD,and DM
symmetry - if asymmetrical consider renovascular disease
corticomedullary differentiation
exclude obstruction
visualise structure
scarring may be seen - isotope scans are more sensitive
renal biopsy ckd
for changes specific to the underlying disease
in progressive disease, nephrotic syndrome, systemic disease, AKI w/o recovery
DM with neuropathy/retinopathy may not need biopsy unless atypical, ie nephrotic, haematuria, other systemic symptoms.
unlikely to change treatment if GFR stable and P:CR <150.
CI for small kidneys
monitoring ckd
GFR and albuminuria should be monitored at least annually, according to risk. If high risk, monitor every 6 months, if V high risk - monitor at least every 3-4mo
Small fluctuations are common but a drop in eGFR stage with drop eGFR≥ 25% is significant. Rapid progression is drop eGFR >5/yr.
RF for ckd decline
- htn
- dm
- metabolic disturbance
- volume depletion
- infection
- NSAIDS
- smoking
- all CKD has increased risk of superimposed AKI and needs monitoring and prompt treatment during intercurrent illness
interpretation ckd
got to think whether the eGFR reflects the true GFR - ie corrected for ethnicity/drugs eg trimethoprim alters creatinine concentration but not GFR
is there a previous creatinine on record
think about possible cause
- previous UTI
- LUTI
- PMH of HTN, DM, IHD, systemic disorder, renal colic
- check drug history and when meds started
- FH - renal disease, subarachnoid haemorrhage
- Systems review: look out for more than is immediately obvious, consider rare causes, ask about eyes, skin, joints, ask about symptoms suggestive of systemic disorder (‘When did you last feel well?’) and malignancy
current state
interpreting ckd based on current state
many pts have symptomatic CKD if GFR<30
symptoms of fluid overload - SOB, peripheral oedema
anorexia
nausea
vomiting
restless legs
fatigue
weakness
pruritis
bone pain
amenorrhoea
impotence
mx of ckd
- ACEi
- statin
- control of RFs
- consider dapagliflozin
- epoetin alfa if necessary
- if hyperparathyroidism - diet modification +- phosphate binding drug
- dialysis
- transplant
complications of CKD
