CKD Flashcards
Main cause of anaemia in CKD
lack of erythropoietin
What type of anaemia is seen in CKD
normochromic normocytic anaemia
Anaemia in CKD predisposes to which cardiac condition with increased mortality rates?
left ventricular hypertrophy (LVH)
Why is there reduced iron absorption in CKD
- hepcidin levels increase due to inflammation and reduced renal clearance
- elevated hepcidin prevents gut iron absorption or release of iron stores (hepatocytes and macrophages)
- metabolic acidosis also prevents Fe³⁺ changing to absorbable Fe²⁺
Management of CKD anaemia
- erythropoiesis-stimulating agents (ESA) e.g. erythropoietin/darbapoietin
- oral iron if not on ESA or haemodialysis
- IV iron if Hb still suboptimal after 3 months of oral iron
Impaired 1-alpha hydroxylation due to CKD causes low levels of which vitamin?
Vitamin DD
Describe the appearance of calcium and phosphate in patients with CKD
low calcium (lack of vitamin D) high phosphate
=> secondary hyperparathyroidism (high PTH trying to raise the calcium)
Bone disease commonly seen in CKD
Osteitis fibrosa cystica
- hyperparathyroid bone disease
Adynamic
- reduction in osteoblasts and osteoclasts activity
- over treatment with vitamin D
Osteomalacia
- low vitamin D
Osteosclerosis
Osteoporosis
Give examples of common causes of CKD
- diabetic nephropathy
- chronic glomerulonephritis
- chronic pyelonephritis
- hypertension
- adult polycystic kidney disease
Factors which may affect the GFR or eGFR calculation
pregnancy
muscle mass
eating red meat 12 hours prior to the sample being taken
eGFR >90 ml/min, with some sign of kidney damage on other tests
CKD stage 1
eGFR 60-90 ml/min with some sign of kidney damage
CKD stage 2
eGFR 45-59 ml/min, a moderate reduction in kidney function
CKD Stage 3a
eGFR 30-44 ml/min, a moderate reduction in kidney function
CKD Stage 3b
eGFR 15-29 ml/min, a severe reduction in kidney function
CKD Stage 4
eGFR <15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed
CKD Stage 5
The majority of patients with chronic kidney disease (CKD) will require multiple drugs to treat hypertension. TRUE/FALSE?
TRUE
- most will require >2 drugs to manage HTN
First line antihypertensive in CKD
ACE inhibitors
What can occur after starting an ACEi in a patient with CKD
Slight rise in creatinine/ fall in eGFR
(If greater than expected may have underlying renovascular disease)
Furosemide is a useful antihypertensive in CKD. TRUE/FALSE?
TRUE
- when GFR <45
Management of CKD associated bone disease (i.e. high PO4, low Ca2+ and low vit D)
- reduce dietary phosphate
- phosphate binders (e.g. Sevelamer)
- vitamin D: alfacalcidol, calcitriol
- parathyroidectomy may be needed
Investigations used to monitor proteinuria
ACR
PCR
When should an ACR sample be taken?
first-pass morning urine specimen
An ACR greater than what is considered significant proteinuria?
> 3mg/mmol
Initial ACR 3 -70 mg/mmol
- repeat sample for confirmation
Initial ACR >70 mg/mmol
- no repeat sample
Should this be referred to the Renal specialist team?
Urine ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
Yes
Should this be referred to the renal specialist team?
Urine ACR of 30 mg/mmol or more, with persistent haematuria (after exclusion of a UTI)
Yes
Should this be referred to the renal specialist team?
ACR 3-29 mg/mmol with persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease
Yes
Management of proteinuria in CKD
- ACEi/ARB
- SGLT-2 inhibitors
When should ACEi/ARBs be introduced in proteinuria
ACR >30 and concurrent HTN
ACR >70 always initiate
Mechanism of action of SGLT2 inhibitors in proteinuria
- block reabsorption of glucose in the proximal tubule => glycosuria
- block cotransporter and reduce sodium reabsorption
=> reduces BP and intraglomerular pressure
