CKD Flashcards
What is CKD?
More than 3 months reduction in kidney function or structural damage
<60 on eGFR
Diagnosis of CKD
-Markers of kidney damage
- Urinary albumin:creatinine ratio -ACR greater than 3mg/mmol
- Persistent reduction in kidney function <60
What measure determines staging of CKD?
Albumin and urea cretinine ratio
Underlyinh cause, GFR and proteinurua category
When do you offer dialysis in CKD?
On progression to kidney failure
Causes of CKD
diabetes
Hypertension
Glomerular disease
Polycystic kidney disease
History of AKI
Nephrotoxic drugs
Obstructive uropathy ass conditions eg structural renal tract disease, renal calculi
Multisystem diseases with renal involvement eg SLE, vasculutus, myeloma
FG of CKD stage 5, hereditary kidney disease
CVD
Obesity with metabolic syndrome
Gout
Incidental findings of haematuria or protein uria
Symptoms of CKD
Bubbly wee
Any changes in wee frequency
General - lethargy, itch, SOB, camps, sleep disturbance, bone pain, loss of appetite, vomitting, weight loss + taste disturbance
Features of CKD
Uraemic odour
Pallor
Cachexia + malnutrition
Cognitive impairment
Dehydration, hypovolaemua
Tachypnoea
HPTN
Palpable bilateral flank masses w possible hepatomegaly
Palpable distended bladder
Peripheral oedema
Peripheral neuropathy
How is CKD classified?
eGFR (G1-5) and urinary ACR (albumin creatinine ratio) categories (A1-3)
What is the eGFR value for each G stage of CKD?
> 90 = normal = G1
60-89 = G2 = mild reduction
45-59 = G3a - mild to mod reduction
30-44 = G3b mod to severe reduction
15-29 = G4 - severe reduction
<15 = G5 - kidney failure
ACR parameters each stage
<3 - normal to mildly increased
3-30 - moderately increased
>30 - severely increased
What is the parameters for CKD diagnosis?
eGFR consistently over 60mL/min/1.73m2 and/or urinary ACR persistently
Initial investigations for CKD
Blood tests for serum creatinine and eGFR
Urine smaple for urinary albumin to creatinine ratio
Uirne dipstick for haematuria, midstream sample if more than 1
Nutritional status, BMI, BP and serum HbA1c, lipid profile
When does a urine sample for CKD need ot be taken
Early morning
What is considered significant proteinuria in urine sample?
Over 70 mg/mmol
What values mean you repeat urine sample ACR in 3 months?
3-70mg/mmol
Indications for renal tract ultrasound
Renal tract ultrasound if indicated - urinary tract obstruction, FH of polycystic kidney disease, over 20 years
What is acclereated progression of CKD?
25% decrease in eGFR from baseleine and change in CKD category within 12 months OR
decrease in eGFR by 15mL/min/1.73min2 in a year
Assess eGFR at least 3 times over 3 months
Hoq long after an AKI do you monitor fr CKD?
2-3 YEARS even if serum creatinine has returned to baseline
When do you arrange FBC to exclude renal anaemia in CKD patients?
Stages 3b, 4 and 5 or if develop anaemia symtpoms
What do serum calcium, phosphate, vit D and parathyroid hormone tests in CKD test for?
Renal metabolic and bone disorder for stages 4-5 of CKD
When to do 2 week urgent referral in CKD?
Isolated perisitent haematuria and urological cancer suspected
When to reer to nephrology with CKD
ACR over 70mg/mmol or 30mg/mmol with persistnet hameaturia
Uncontrolled HPTN
Rare or genetic cause CKD
Sus renal artery stenosis
Accelerated progression
eGFR < 30
Sus complication of CKD
What to assess ofr with CKD in primary care?
CVD risk
Underlying causes, risk factors for progression
Nephrotoxic drugs
Anxiety and depression
HPTN
Why do yuo prescribe lipid lowering therapy in everyone with CKD?
Primary or secondary prevention of CVD
When is an antiplatelet drug prescribed in CKD
Secondary prevention of CVD
What OTC should people with kdney disease avoid?
NSAIDs eg naproxen, iburogen
Complications of CKD
AKI
HPTN
Dyslipidemia
CVS disease - IHD, Periph artery disease, HF, stroke
Renal miineral and bone disorder
Peripheral neuropathy and myopathy
MALNUTRITION
malignanacy
End stage renal disease
Mortality
Renal anaemia presenation
SOB, fatigue, pa
What is renal anaemia?
Reduced production of erythropoietin by the kidney causes reduced RBC surcical, iron deficinecy
Presentation of renal mineral and bone disorer
Bone paun
Increased bone fragility
-Extra skeletal calciication - skin, blood vessels
What causes renal mineral and bone disorder?
Disturbed vit D, calcium, PTH and phosphate metabolism due to impaired regulation of intestinal absorption and renal tubular excretion
Typical picture mineral levels in CKD
Calcium low or high
Vit D deficiency
Raised serum phosphate
Low serum calcium
Secondary or tertiary hyperparathyroidism
What is tamulosin for
BPH
Why do you test PSA before putting in a catherter?
Puting a catheter in can raise the PSA level -> false positive high
What is post obstruction diruesis
Polyuric state - salt and water are elimianated after relief of urinary tract obstruction
Resolves when kidneys normaluse volume, solutte status
Risk from post obstruction diuresis
Severe dehydration
Electrolye imbalances
Hypovolaemic shock
Death
Questions to ask in pulmonary renal syndrome
Systemic symptoms - night sweats, abdo pain, bloody diarrhoea
Sepsis - fever, lymphadenopathy
AI conditions - joint pain, myalgia, rash, sicca, epistaxis, deaf, ulcers
prev DVT/PE, thrombotic disorders, SLE, AI conditions
What is pulmonary renal syndrome?
Diffuse alveolar haemorrhage + glomerulonephritis
AI disorder - treat w corticosteroids and cytotoxic drugs
Diagnosis of pulmonary renal syndrome
Serologic tests, sometimes lung and renal biopsy
Systemic vasculitis that can cause renal damage
Behcets disease
Cryoglobulinaemia
Granulomatoisis with polyangitis
Microscopic polyangitis
Eosinophilic granulomatosis w polyangitis
IgA ass vasculitis
Causes of pulmonary renal disorder
Connective tissue disorder
Good pasteurs syndrome
Renal disorders eg IgA nephropathy
Systemic vasculitis
Drugs eg propothyouracil
HF
What antibody diagnosis for good pateurs syndrome
anti-GBM
Treatment for good pasteurs syndrome
Plasma exchange (remove antiGBM antibodies)
Prednisolone + cyclophosphamide
V rare to relapse - smoking trigger
If remain on dialysis can have transplant if anti-GBM antibodies undetectable
Markers of kidney damage
- Albuminuria >3 mg/mmol
-Abnormalities secondary to tubular disorders
-Structural abnormalities
-Abnormalities on histology
-History of kidney transplant
-Reduced eGFR <60
A staging of kidney disease
A1 - <30mg/g / <3 mg/mmol
A2 - 30-300mg/g/3-30mg/mmol (microalbuminuria)
A3 - >300mg/g/>30mg/mmol (macroalbuminuria)
How often do you monitor CKD
Low moderate risk - annually
High risk - every 6 months
V high risk - monitor every 3-4 months
Common causes CKD
Diabetes
HPTN
vascular disease
How is CKD normally detected?
HPTN
Haematuria/proteinuria
Reduction in GFR + increased serum creatinine
G staging of CKD (eGFR)
G1 - normal or high >90
G2 - mild - 60-89
G3a - mild to mod - 45-59
G3b - mod to severe - 30-44
G4 - severe - 15-29
G5 - Kidney failure <15
G5D = dialysis
Monitoring in CKD
FBC
Iron studies
Serum calcium
phosphate
PTH
General CKD symptoms
Fatigue, N+V, cramps, insomnia, restless legs, taste disturbance, bone pain, pruritis
Abnormal urine output
Fluid overload
Sexual dysfunction
Severe uraemia
Clinical findings in CKD
Uraemic fetor - ammonia smell breath
Pallor (anaemia)
Cachexia
Cognitive impairment
Tachypnoea
HPTN
Volume disturbance - overload or depletion
Peripheral neuropathy
Fundoscopy if HPNT/DM
What do bilateral masses on flank palpation signal with kidney symptoms?
Polycystic kidney disease
What does palpable bladder sugnal in kidney symptoms
Obstructive uropathy
Often accompanied by prostatic enlargement in men
Urine investigations CKD
Dipstick
Microscopy
ACR spot test
ACR 24 hour
Electrophoresis eg myeloma
What does urine electrophoresis detect?
Protein levels including M and BJ protein produced by abnormal plasma cells in multiple myeloma
Bloods in CKD
FBC
U+Es
Bone profile
PTH
Bicarbonate
LFTs
Lipid profile
AI screen - ANCA, ANA
Myeloma screen
Imaging
Renal US
MR angiograph
ECHO
ECG - high risk CVS disease
When should a renal US scan be offered
Patients with visible/persistent non visible haematuria
Evidence of obstructive uropathy
FH PCKD
Reduced eGFR <30
Accelerated progression of CKD
Prinicples of CKD management
Treat the underlying cause
Prevent or slow progression - Renoprotective therapy
Treat ass complications
CV disease prevention
Plan for RRT
General measures for management CKD
Exercise
Healthy weight loss
Smoking cessation
Good glycaemic control
Control of blood pressure
Immunisations: influenza and Pneumococcus
Avoidance of nephrotoxic medication
Diet: adequate protein intake, restricted sodium and
phosphate intake
Statin
What is renoprotective therapy
Reducing BP
Reducing protein uria
BP target for CKD + <70 ACR
<140/90
BP target CKD + ACR >70
<130/80
What drug should be prescribed where significant proteinuria in CKD
ACEi/ARB
AntiHPTN and antiproteinuric
When offer a ACEi/ARB (renin angiotensin system antagonists) in CKD
Diabetic and ACR>3
HPTNsive and ACR >30
ACR >70
1 and 3 even in absence of HPTN
When should you not prescribe a ACEi/ARB in CKD
Pretreatment potassium is over 5
When is it ok to carry on with ACEi/ARB in CKD
eGFR is less than 25% changed OR
<30% serum creatinine increase from baseline since commencing
A WET BED complications of CKD
Acidosis
Water - pulmonary oedema
Erythropoiesis - anaemia
Toxin removal - uraemic encephalopathy
BP control - CVD disease
Electrolyte balance - hyperkalaemia
Vitamin D activation -BMD of CKKD
