CKD

Question 1

what is the definition of CKD?

Answer 1

reduction in kidney function or structural damage (or both) present for more than 3months, with associated health implications.

Question 2

what are the causes of CKD?

Answer 2

-conditions associated with intrinsic kidney damage (HTN, DM, glomerular disease, current/previous AKI, potentially nephrotoxic drugs)
-conditions associated with obstructive uropathy (structural renal tract disease, neurogenic bladder, BPH, recurrent kidney stones)
-multisystem disease with renal involvement (SLE, vasculitis, myeloma)

Question 3

what are some of the common potentially nephrotoxic drugs that could cause CKD?

Answer 3

-aminoglycosides (vancomycin, gent)
-ACEis/ARBs
-bisphosphonates (alendronic acid)
-calcinuerin inhibitors (ciclosporin, tacrolimus)
-diuretics
-lithium
-mesalazine
-NSAIDs

Question 4

what are the risk factors for CKD?

Answer 4

-having any of the conditions listed as causes
-FH of CKD stage 5 or hereditary kidney disease or familial glomerulonephritis
-cardiovascular disease
-obesity with metabolic syndrome (obesity itself not risk factor)
-gout

Question 5

what is metabolic syndrome?

Answer 5

having a combination of diabetes, high blood pressure (hypertension) and obesity.

Question 6

what are 2 examples of hereditary kidney disease?

Answer 6

autosomal dominant polycystic kidney disease
alport’s syndrome

Question 7

what is alport’s syndrome?

Answer 7

sex linked recessive disease which typically causes haematuria as well as deafness and eye issues

Question 8

what sort of monitoring do people on potentially nephrotoxic drugs need?

Answer 8

yearly monitoring of eGFR and urine ACR

Question 9

what are the symptoms of CKD and why?

Answer 9

-anaemia cos kidney makes EPO: pallor, lethargy, breathlessness
-urea buildup: skin pigmentation and itchiness, bruising (platelet dysfunction), confusion, coma, fits, polyneuropathy, uraemic pericarditis
-toxin buildup: N+V, anorexia
-renal: nocturia, polyuria, oedema, bubbly urine
-renal bone disease: osteomalacia, bone pain, osteosclerosis, muscle weakness, cramps
-endocrine: amenorrhoea, erectile dysfunction, infertility
-CV: HTN, peripheral vascular disease

Question 10

what are the signs/examinations you need to do for CKD?

Answer 10

-general examination: cachexia, signs of malnutitrion, uraemic odour
-CV exam: pallor, dehydration/hypovalaemia, tachypnoea, HTN, peripheral oedema, pulmonary oedema
-neurological exam: cognitive impairment, peripheral neuropathy, peripheral myopathy
-abdo exam: palpable bilateral flank masses with possible hepatomegaly suggests PCKD with possible liver cysts, palpable distended bladder suggests obstructive uropathy

Question 11

when do you do initial investigations for CKD?

Answer 11

-someone with any risk factors for CKD
-incidental findings of: raised creatinine/eGFR <60, proteinuria (ACR>3), persistent haematuria, urine sediment abnormalities
-possible clinical features of CKD

Question 12

what is persistent haematuria?

Answer 12

2/3 urine dipsticks showing 1+ or more of blood after exclusion of a UTI

Question 13

what are the initial investigations for someone to do for CKD?

Answer 13

-serum creatinine and eGFR
-early morning urine sample to measure ACR
-urine dip for haematuria
-CV risk factors: BMI, BP, serum Hba1c, lipid profile
-renal tract USS if ?stones or ?PCKD

Question 14

what’s a rule on what you can’t do before having your serum creatinine and eGFR measured?

Answer 14

can’t eat meat 12 hours before test

Question 15

what do you do with the results of the initial serum creatinine/eGFR measurement?

Answer 15

if <60 repeat within 2 weeks. if remains <60 repeat within 3 months -obvi if reduced still and spanning 3 months indicates CKD

Question 16

in which groups do you have to interpret eGFR with caution?

Answer 16

extremes of muscle mass
pregnant
oedema
malnourished
uses protein supplements
asian or chinese in origin

Question 17

what do you do with the initial ACR results?

Answer 17

<3: no action needed
3-70: repeat test in 3 months
70+ no repeat needed as significant proteinuria

Question 18

what do you do with the results of the urine dip for haematuria?

Answer 18

1+ or more -arrange MSU testing for ?UTI
isolated persistent haematuria -think about referral for ?urological cancer

Question 19

what are the diagnostic criteria for CKD?

Answer 19

1) markers of kidney damage: urine ACR >3, urine sediment abnormalities (eg RBCs, WBCs, casts, renal tubular epithelial cells), electrolyte abnormalities, histological abnormalities, structural abnormalities, history of kidney transplant
2) a persistent reduction in renal function (3 months or more) shown by an eGFR <60.

Question 20

what is accelerated progression of CKD?

Answer 20

decrease in eGFR or 25% or more AND change in CKD category within 12 months, or persistent decrease in eGFR of 15 within 12 months.

Question 21

what is the staging of CKD?

Answer 21

Gs are stage 1-stage 5 and based on GFR. stage 1=90+, stage 2=60-90, stage 3=45 up to <60, stage 4=15 up to <30, stage 5=<15 (kidney failure)
As are A1-A3 and and based on ACR. 1=<3, 2=3-30, 3=30+

Question 22

what is the management of CKD?

Answer 22

-proteinuria: if they have ACR>7- prescribe ACEi/ARB no matter what BP is-renoprotection
-manage HTN: 1st line =ACEi/ARB. targets =<130/80 if ACR 70+, <140/90 if ACR >70, <150/90 if 80+ with diabetes
-manage anaemia risk: measure FBC, check for other causes of anaemia, refer to nephrologist if renal anaemia suspected. iron tablets -> iron infusions -> EPO
-manage renal bone disease risks: arrange serum calcium, phosphate, vit D, and PTH tests for everyone with CKD. low phosphate diet, calcium supplements
-CVD prevention: atorvastatin 20mg for everyone with CKD, antiplatelet drug for everyone, consider dapagliflozin if optimised on ACEi/ARB and have DM or ACR>23
-flu and pneumococcal vaccines