CKD Flashcards
What is the definition of chronic kidney disease?
Haematuria and proteinuria, or a reduction in eGFR <60ml/min/1.73m^2 for >3 months.
What are the most common causes of CKD?
- Diabetes mellitus and hypertension top two
2. PKD, obstructive uropathy, glomerular nephrotic/nephritic syndromes.
What are the factors considered when classifying CKD?
- eGFR category - creatinine, age, gender, ethnicity
- Presence of albuminuria
- Cause of kidney disease
What are the eGFR categories in CKD?
G1 - normal or high >90 G2 - mildly decreased 60-89 G3a - mildly-moderately decreased 45-59 G3b - moderately to severely decreased 30-44 G4 - severely decreased 15-29 G5 - kidney failure <15
What are the persistent albuminuria categories in CKD?
A1 - normal to mildly increased <30mg/g
A2 - moderately increased 30-300mg/g
A3 - severely increased >300mg/g
When might CKD become symptomatic and what are the signs and symptoms?
- If eGFR <30
- Fluid overload - SOB/peripheral oedema
- Anorexia, N&V, restless legs, fatigue, weakness, pruritus, bone pain, amenorrhoea, impotence.
What are the risk factors for developing CKD?
- > 50 years old, obese, male
- Diabetes mellitus, smoking, HTN, PMHx autoimmunity
- Black, Hispanic, FHx
- Long term analgesia use
How is a suspected CKD investigated?
- FBC (normocytic, normochromic anaemia), U&Es (low Ca, high phosphate, high PTH), bone profile, vitamin D.
- Autoantibodies if suspect systemic disease (ANA, antiphospholipid)
- Urinalysis - Bence Jones/casts
- Urine albumin - creatinine ratio
- USS kidney
What is considered a rapid progression of CKD?
Fall in eGFR >5/year
What is the most common cause of death in CKD and thus what needs to be managed first?
- Cardiovascular disease
2. Optimise glycaemia, BP, and lipids.
What is the target BP and salt intake for a CKD patient?
- Systolic <140mmHg, <130mmHg in diabetics.
2. <2g per day of salt
What is the first line medication for BP control in CKD?
ACEi, in chronic cough switch to ARB.
Why should you not combine RAAS blockade medications in CKD?
Risk of hyperkalaemia:
- Measure K+ before and after starting
- Stop if K+ >6, or eGFR falls by 25%
What is the target HbA1c in glycaemic control of CKD?
7.0% (53mmol/mol)
What medications should you give for CVD secondary prevention in CKD?
- Atorvastatin 20mg
2. Anti-platelet - if risk outweighs risk of bleeding
What is the management for oedema in CKD?
- Restrict fluid and sodium intake
2. Loop and thiazide diuretics may be used
What is the treatment for anaemia in CKD?
- Consider EPO when eGFR <30, Hb <100 (target 100-110)
- Must exclude other causes of anaemia before giving EPO
- Iron may be given IV due to anaemia of chronic disease
What is the treatment for acidosis in CKD?
Sodium bicarbonate
What is the treatment for bone disease in CKD?
- Calcium low, phosphate high, vitamin D low, PTH high.
- Dietary modification and phosphate binders
- Activated vitamin D supplements if PTH high (1a-calcidol/calcitriol)
What are the complications of an AV fistula and what are the downsides of haemodialysis?
- Thrombosis, stenosis, infection, blockage.
2. Hypotension, time consuming.
What is haemodialysis?
Blood passed over semi-permeable membrane against dialysis fluid flowing in opposite direction.
What is peritoneal dialysis?
Uses peritoneum as semi permeable membrane, ultrafiltration achieved by adding osmotic agents (glucose polymers) to fluid.
What are the two types of peritoneal dialysis?
- Ambulatory - bag changes
2. Automated - machine
What are the side effects of peritoneal dialysis?
Catheter site infection, peritonitis, hernia, loss of membrane function over time.
What is an absolute contraindication to renal transplant?
Cancer with metastases
What are some temporary contraindications to renal transplant?
Active infection, HIV with high viral load, unstable cardiovascular disease.
In which conditions is there a relative contraindication to renal transplant?
Congestive heart failure, cardiovascular disease.
What are the four types of graft for a renal transplant?
- Living donor
2a. Donor after brain death (heart beating)
2b. Deceased donor but old/CVD/BP to CKD
2c. Donor after cardiac death
What are the options for immunosuppression in CKD renal transplant, and how do they work?
- Calcineurin inhibitors (tacrolimus, ciclosporin) - inhibits T-cell activation and proliferation
- Mycophenolate mofetil - inhibits DNA in T and B cells
- Glucocorticoids are 1st line for acute rejection
What are the complications of renal transplant?
- Surgical - bleed, thrombosis, infection, urinary leaks, hernia
- Delayed graft function - affects 40%, more common in deceased cardiac dead
- Rejection - acutely Ab mediated/cellular or chronically donor Ab mediated
- Infection - CMV and PCP prophylaxis given
- Malignancy - lymphoproliferative, skin, and gynaecological
- CVD - 3-5x increased risk
