CKD Flashcards
What is chronic kidney disease?
Defined as
- reduction in kidney function or structural damage (or both) present for > 3 months with associated health implications
How is CKD classified?
Classification based on :
- the underlying cause
- GFR
- proteinuria category
What is accelerated progression of CKD defined as?
Persistent decrease in eGFR of 25% or more
AND
A change in CKD category within 12 months OR a persistent decrease in eGFR of 15mL/min/1.73m^2 within 12 months
What are the causes and risk factors for CKD?
Conditions associated with intrinsic kidney damage
Current or previous Hx of AKI
Potentially nephrotoxic drugs
Conditions associated with obstructive neuropathy
Multisystem disease with potential renal involvement e.g., SLE, vasculitis, myeloma
FHx of CKD stage 5 or hereditary kidney disease e.g., autosomal dominant polycystic kidney disease, Alport’s syndrome and familial glomerulonephritis
Cardiovascular disease
Obesity with metabolic syndrome
Gout
People with incidental finding of haematuria or proteinuria
What should people with risk factors for CKD be offered?
Testing for CKD
Using eGFR:creatinine and ACR
Monitor at least annually for people on potentially nephrotoxic drugs
List the conditions associated with intrinsic kidney damage
HTN
DM
Glomerular disease e.g., acute glomerulonephritis (typically if CKD follows a Strep URTI; may also follow hep B, C or HIV infection)
List the potentially nephrotoxic drugs
Aminoglycosides (e.g. gentamicin, neomycin, streptomycin)
NSAIDs
ACEis
Angiotensin 2 receptor blockers
Calcineurin inhibitors (e.g., ciclosporin or tacrolimus)
Diuretics
Lithium
Mesalazine
List the conditions associated with obstructive neuropathy
Structural renal tract disease
Bladder voiding problems e.g., neurogenic bladder, BPH
Urinary diversion surgery
Recurrent urinary tract calculi
What are the different types of renal calculi?
Calcium - Ca2+ oxalate/Ca2+ phosphate
Uric acid
Struvite
Cystine
Sources
https://cks.nice.org.uk/topics/chronic-kidney-disease/
https://cks.nice.org.uk/topics/renal-or-ureteric-colic-acute/background-information/causes/
https://www.nhs.uk/conditions/kidney-disease/
What are the complications of CKD?
AKI
HTN and dyslipidaemia
Cardiovascular disease e.g., ischaemic heart disease, peripheral artery disease, HF and stroke disease
Renal anaemia (Hb < 11g/dL)
Renal mineral and bone disorder - can present with bone pain, increased bone fragility, extra-skeletal calcification e.g., in skin or blood vessels
Peripheral neuropathy and myopathy
Malnutrition - may be seen in ESRD due to poor dietary intake and hypoalbuminaemia
Malignancy
ESRD
All-cause mortality - increases with progressive CKD
People in which stages of CKD may need renal replacement therapy (RRT)?
Stages 4-5
What is the classification of CKD?
Stage 1 = > 90ml/min/1.73 m2
Stage 2 = 60-89 ml/min/1.73 m2
Stage 3a = 45-59 ml/min/1.73 m2
Stage 3b = 30-44 ml/min/1.73 m2
Stage 4 = 15-29 ml/min/1.73 m2
Stage 5 = <15 ml/min/1.73 m2
In the Hx which general symptoms should you ask about for someone with suspected CKD?
General symptoms:
- lethargy
- itch
- breathlessness
- cramps (often worse at night)
- sleep disturbance
- bone pain
- loss of appetite
- vomiting
- weight loss
- taste disturbance (often present with ESRD)
In the Hx which urine output symptoms should you ask about for someone with suspected CKD?
Polyuria (tubular concentrating ability is impaired)
Oligouria
Nocturia (due to impaired solute diuresis or oedema)
Anuria (due to possible AKI, obstructive uropathy causing urine retention or ESRD)
What else should you ask in the Hx for someone with suspected CKD?
DHx - for potential nephrotoxic drugs
Any associated co-morbidities or complications of CKS
Any FHx e.g., autosomal dominant PKD
Any associated clinical features of anxiety or depression
What signs should you examine for in a patient with suspected CKD?
Uraemic odour (ammonia-like breath smell - may be present in advanced disease)
Pallor (due to renal anaemia)
Cachexia and signs of malnutrition
Cognitive impairment (language, orientation and attention may be affected)
Dehydration or hypovolaemia (risk of AKI)
Tachypnoea (may be due to fluid overload, anaemia, or co-morbid ischaemic heart disease)
HTN (may be primary or secondary to CKD)
Palpable bilateral flank masses with possible hepatomegaly (suggests PKD with possible liver cysts)
Palpable distended bladder (obstructive neuropathy)
Peripheral oedema (may be due to renal sodium retention, hypoalbuminaemia, or co-morbid HF)
Peripheral neuropathy (may present with paraesthesia, sleep disturbance, and restless leg syndrome) or myopathy
Frothy urine (proteinuria)
What blood tests should be arranged? What should you advice the patient before the test?
Serum creatinine and eGFR
- advise patient not to eat meat for at least 12 hours before the test
Early morning urine sample to measure urinary albumin:creatinine ratio (ACR)
Urine dipstick to check for haematuria
Nutritional status, BMI, BP and serum HbA1c and lipid profile
If the eGFR is less than 60 mL/min/1.73 m2 after the blood test what should you do?
Repeat the test within 2 weeks (unless the eGFR is stable)
If the eGFR remains less than 60 mL/min/1.73 m2 after the repeat, with no evidence of sudden drop in renal function suggesting AKI, what should you do?
Repeat the eGFR within 3 months
In which groups of patients should you interpret the eGFR with caution?
People with a lot of muscle
Pregnant women
People of Asian or Chinese origin
Has oedema
Malnourished
Uses protein supplements
You should arrange an early morning urine sample to measure the urinary albumin:creatinine ratio (ACR). What should you do if the result is < 3mg/mmol (no proteinuria)?
No action is needed
You should arrange an early morning urine sample to measure the urinary albumin:creatinine ratio (ACR). What should you do if the result is between 3 and 70 mg/mmol?
Repeat the test within 3 months
You should arrange an early morning urine sample to measure the urinary albumin:creatinine ratio (ACR). What should you do if the result is > 70 mg/mmol?
Repeat test not needed
As this shows significant proteinuria
Also protein:creatinine ratio (PCR) can be used as an alternative measure
When should you arrange a MSU to exclude a UTI?
If there is 1+ or more of blood on dipstick
If there is isolated persistent haematuria (two out of three urine dipstick tests show 1+ or more of blood after exclusion of a UTI), with no decrease in eGFR and no proteinuria, what should you be suspicious of?
Urological cancer
When should you make a diagnosis of CKD?
If there is persistent reduction in renal function (eGFR < 60 mL/min/1.73m^2)
AND/OR
Proteinuria (urinary ACR > 3mg/mmol)
Lasting for at least 3 months
When can a Dx of CKD be excluded?
eGFR is persistently greater than 60 mL/min/1.73 m2
AND/OR
the urinary ACR is persistently less than 3 mg/mmol, and there are no other markers of kidney damage
What imaging should be considered?
Renal tract USS if indicated
e.g., person has suspected urinary tract stones or obstruction, or a FHx of PKD and is aged > 20 years
TO DO
Look up PassMed Mx of the different complications of CKD
