CKD

Question 1

Main cause of anaemia in CKD

Answer 1

lack of erythropoietin

Question 2

What type of anaemia is seen in CKD

Answer 2

normochromic normocytic anaemia

Question 3

Anaemia in CKD predisposes to which cardiac condition with increased mortality rates?

Answer 3

left ventricular hypertrophy (LVH)

Question 4

Why is there reduced iron absorption in CKD

Answer 4

• 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⁺

Question 5

Management of CKD anaemia

Answer 5

• 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

Question 6

Impaired 1-alpha hydroxylation due to CKD causes low levels of which vitamin?

Answer 6

Vitamin DD

Question 7

Describe the appearance of calcium and phosphate in patients with CKD

Answer 7

low calcium (lack of vitamin D) high phosphate

=> secondary hyperparathyroidism (high PTH trying to raise the calcium)

Question 8

Bone disease commonly seen in CKD

Answer 8

Osteitis fibrosa cystica
- hyperparathyroid bone disease

Adynamic
- reduction in osteoblasts and osteoclasts activity
- over treatment with vitamin D

Osteomalacia
- low vitamin D

Osteosclerosis

Osteoporosis

Question 9

Give examples of common causes of CKD

Answer 9

• diabetic nephropathy
• chronic glomerulonephritis
• chronic pyelonephritis
• hypertension
• adult polycystic kidney disease

Question 10

Factors which may affect the GFR or eGFR calculation

Answer 10

pregnancy
muscle mass
eating red meat 12 hours prior to the sample being taken

Question 11

eGFR >90 ml/min, with some sign of kidney damage on other tests

Answer 11

CKD stage 1

Question 12

eGFR 60-90 ml/min with some sign of kidney damage

Answer 12

CKD stage 2

Question 13

eGFR 45-59 ml/min, a moderate reduction in kidney function

Answer 13

CKD Stage 3a

Question 14

eGFR 30-44 ml/min, a moderate reduction in kidney function

Answer 14

CKD Stage 3b

Question 15

eGFR 15-29 ml/min, a severe reduction in kidney function

Answer 15

CKD Stage 4

Question 16

eGFR <15 ml/min, established kidney failure - dialysis or a kidney transplant may be needed

Answer 16

CKD Stage 5

Question 17

The majority of patients with chronic kidney disease (CKD) will require multiple drugs to treat hypertension. TRUE/FALSE?

Answer 17

TRUE
- most will require >2 drugs to manage HTN

Question 18

First line antihypertensive in CKD

Answer 18

ACE inhibitors

Question 19

What can occur after starting an ACEi in a patient with CKD

Answer 19

Slight rise in creatinine/ fall in eGFR

(If greater than expected may have underlying renovascular disease)

Question 20

Furosemide is a useful antihypertensive in CKD. TRUE/FALSE?

Answer 20

TRUE
- when GFR <45

Question 21

Management of CKD associated bone disease (i.e. high PO4, low Ca2+ and low vit D)

Answer 21

• reduce dietary phosphate
• phosphate binders (e.g. Sevelamer)
• vitamin D: alfacalcidol, calcitriol
• parathyroidectomy may be needed

Question 22

Investigations used to monitor proteinuria

Answer 22

ACR
PCR

Question 23

When should an ACR sample be taken?

Answer 23

first-pass morning urine specimen

Question 24

An ACR greater than what is considered significant proteinuria?

Answer 24

> 3mg/mmol

Initial ACR 3 -70 mg/mmol
- repeat sample for confirmation

Initial ACR >70 mg/mmol
- no repeat sample

Question 25

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

Answer 25

Yes

Question 26

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)

Answer 26

Yes

Question 27

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

Answer 27

Yes

Question 28

Management of proteinuria in CKD

Answer 28

• ACEi/ARB
• SGLT-2 inhibitors

Question 29

When should ACEi/ARBs be introduced in proteinuria

Answer 29

ACR >30 and concurrent HTN

ACR >70 always initiate

Question 30

Mechanism of action of SGLT2 inhibitors in proteinuria

Answer 30

• block reabsorption of glucose in the proximal tubule => glycosuria
• block cotransporter and reduce sodium reabsorption
  => reduces BP and intraglomerular pressure