CKD

Question 1

What GFR level indicates abnormal kidney function?

Answer 1

GFR below 60ml/min

Question 2

What are the clinical findings for CKD?

Answer 2

Hypertension
Pallor (due to anaemia)
Abnormal fluid status
Fluid overload with peripheral and/or pulmonary oedema
Dehydration
Cachexia
Ammonia-like smelling breath due to uraemia
Tachypnoea (due to anaemia, pulmonary oedema, pleural effusion or acidosis

Question 3

What is the management of CKD?

Answer 3

ACE inhibitors or ARB first line for ACR over 30mg/mmol

-> if suboptimal control continues, indapamide should be prescribed

Question 4

When should ACE inhibitors/ARBs be avoided first line?

Answer 4

Patients with hyperkalemia over 5 mmo/L

Question 5

What is second line for CKD pharmacology?

Answer 5

SGLT2 inhibtiors for type 2 diabetics

> if this fails, indapmaide

Antiplatelet

Atorvostatin -

Question 6

What classification is used for CKD?

Answer 6

KDIGO based on GFR and ACR

Question 7

What is G1?

Answer 7

GFR over 90ml/min

Question 8

What is A1?

Answer 8

ACR over 3 mg/mmmol

Question 9

What is A2?

Answer 9

ACR 3 to 30 with moderate risk

Question 10

What is A3?

Answer 10

ACR over 30 which is very high risk

Question 11

What is G2?

Answer 11

60-89 ml.min

Question 12

What is G3A?

Answer 12

45-59 ml/min

Question 13

What is G3b?

Answer 13

30-44 ml/min

Question 14

What is G4?

Answer 14

15-29ml/min

Question 15

What is G5?

Answer 15

Less than 15ml/min with renal failure

Question 16

What causes a false positive low EGFR?

Answer 16

False-positive low eGFR results may occur due to high serum creatinine results, for example in patients with high muscle mass, or after consumption of meat

Question 17

What causes high urinary ACR?

Answer 17

Urinary ACR may also be high due to menstruation, strenuous exercise, orthostatic proteinuria or UTI

Question 18

Which electrolytes are lowered in CKD?

Answer 18

HYPOcalcaemia
Sodium

Question 20

How does CKD affect calcium levels?

Answer 20

Sustained parathyroid stimulation due to low vitamin D synthesis initially causes low calcium and high phosphate known as secondary hyperparathyroidism with lethargy and intermittent pins and needles.

Question 21

How does hyperparathyroidism progress in CKD?

Answer 21

This causes the development of an autonomous parathyroid nodule, resulting in high PTH and hypercalcaemia known as tertiary hyperparathyroidism with renal stones, back pain and confusion

Question 22

What warrants a referral to nephrology with the use of antihypertensives?

Answer 22

Failure to control hypertension after a trial fo 4 different antihypertensives

Question 23

What is the general criteria for referral to nephrology

Answer 23

eGFR <30eGFR decreased by >5 in 1 year
Albumin:creatinine ratio (ACR) >70 (unless known to be associated with diabetes)
ACR >30 with persistence haematuria (must exclude UTI first)
Suspected rare or genetic causes of CKD
Suspected renal artery stenosis
Suspected complications of CKD e.g. anaemia, gout, secondary hyperparathyroidism

Question 24

What is given for anaemia?

Answer 24

Anaemia is typically normocytic normochromic and should be treated with EPO subcutaneous injections UNLESS it is microcytic

Question 25

What are the principles for EPO treatment?

Answer 25

Any existing iron defieicny must be treated, indicated by low ferritin or transferrin despite normal MCV

Question 26

What is the most common cause of mortality in CKD from diabetes?

Answer 26

Cardiovascular disease

Question 27

What is a side effect of EPO treatment?

Answer 27

Rapid rise in BP can cause hypertensive encephalopathy and thrombosis

Question 28

Which scan is used to estimate renal function?

Answer 28

DMSA scan based on radio-isotope uptake

Question 29

What causes an Enlarged left kidney on ultrasound and raised serum urea and creatinine?

Answer 29

Hydronephrosis