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CCC > CKD > Flashcards

CKD Flashcards

1
Q

How long must symptoms be present to make a diagnosis of CKD?

A

CKD is defined as abnormality of kidney structure or function, present for >3 months, with implications for health

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2
Q

What is AKI?

A

This is sudden deterioration of the kidney in the absense of a prior abnormality.

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3
Q

What is acute-on-chronic renal failure?

A

This is the sudden deterioration on a background of CKD

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4
Q

Name as many causes of CKD

A

Diabetic nephropathy
Glomerulonephritis
Hypertension
Systemic disease e.g. SLE, vasculitis, amyloid, myeloma
Renal Artery Stenosis
Hereditary e.g. polycystic kidney disease
Chronic pyelonephritis/vesicoureteric reflux
Urinary tract obstruction (e.g. prostatic disease)
Heart failure
Drugs e.g. NSAIDs
Unknown

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5
Q

Which types of patients should receive continuous monitoring due to their risk of contracting CKD?

A 
Nephrotoxic drugs (inc NSAIDs, lithium)
Diabetes
Hypertension
Cardiovascular disease (IHD, CCF, CVD, PVD)
Structural renal disease (prostatic hypertrophy, recurrent calculi)
Multisystem illness (e.g. SLE)
Family history ESRD
Opportunistic detection of haematuria
Following episode of acute kidney injury
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6
Q

What are the eGFR values with each stage of CKD?

A

Stage 1 <90, Stage 2 60-90, Stage 3a 45-60, Stage 3b 30-45, Stage 4 15-30 Stage 5 <15

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7
Q

When can you only make a diagnosis of stage 1 and 2?

A

In the presence of other evidence of CKD, ie not just on eGFR alone.

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8
Q

How is proteinuria classically measured?

A

24 hour urine collection
In practice – quantified by spot urine sample (preferably morning) for protein/creatinine ratio (PCR) in urine, or albumin/creatinine ratio (ACR)

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9
Q

Why are these ratios important?

A

PCR, ACR are ratios of concentrations of protein or specifically albumin, to creatinine – both measured in urine; this gives a quantitative measure of overall protein (or albumin) excretion which correlates with 24hr excretion

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10
Q

What happens to serum urea in reduced kidney function and why?

A

Serum urea increased with reduced renal excretion
Breakdown of amino acids (protein catabolism)
Relatively high serum urea
Catabolic state, high protein intake, gastrointestinal bleed, glucocorticoids
Dehydration/cardiac failure
Relatively low urea
Low protein intake, liver failure

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11
Q

What happens to serum creatinine in reduced kidney function?

A

Serum concentrations increased with reduced renal excretion

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12
Q

What is the production of creatinine linked to?

A

Muscle mass, so young muscular male will have a higher serum creatinine than an old frail lady.

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13
Q

How do you calculate eGFR?

A

Calculated from blood results and demographic data – e.g. age and gender (on lab reports)

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14
Q

How do you manipulate the eGFR in a black afro-carribean?

A

x1.2

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15
Q

How do you investigate for CKD?

A

Clinical history
Biochemistry / haematology
Urine – dipstick, microscopy (cells, casts)
Immunology screen (e.g. SLE, vasculitis, myeloma)
Renal Ultrasound – “normal”, obstruction, cystic disease, scarring, renovascular (e.g. renal asymmetry/Dopplers), small kidneys
+/- renal biopsy, angiography in some cases

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16
Q

What are the specific complications of CKD?

A

Anaemia- due to reduced erythropoeitin production, bone-mineral disorder (low serum Ca and high phosohate, high parathyroid hormone), METABOLIC ACIDOSIS and hyperkalaemia.

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17
Q

What are the clinical features of CKD?

A

Fluid retention, polyuria, nocturia ( due to loss of ability to concentrate the urine), HTN, odema, LVH dysfunction, vascular disease, dyslipidaemia (kidneys have a role in lipid metabolism), vascular calcificatio. Anorexia, nausea, vomiting, malnutrition, peptic ulceration

Neurological
Peripheral neuropathy, restless legs
Dermatological
Pigmentation, pruritus
Endocrine
Erectile dysfunction (vascular damage), oligoammenorrhea (hormone dysfunction), reduced fertility / ability to carry pregnancy
Musculoskeletal
Bone pain, fractures, arthropathy
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18
Q

Management for CKD?

A 
Treatment of underlying cause of CRF (if possible)
GFR may decline even if cause “inactive”
Lifestyle
Blood pressure control
CVS risk reduction
Diet
Anaemia – erythropoietin
Bone disease
Vitamin D analogues, phosphate control (diet, phosphate binders)
Bicarbonate supplements for acidosis
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19
Q

What are the main risk factors for progression of CKD?

A

More advanced stage, lower eGFR, BP control, proteinuria or albuminuria.

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20
Q

Other risk factors

A 
Race, Gender
Smoking
Hyperglycaemia, hyperlipidaemia
Obesity
CVS disease
Ongoing nephrotoxic drugs
21
Q

What life style advice would you give a patient?

A

Stop smoking, exercise, maintain acceptable body weight, avoid NSAIDS, lithium, radiological contrast.

Warn pt of risk of acute deterioration with DEHYDRATION, avoid fasting in hospital etc.

22
Q

Diet advice for the patient….

A

Varies according to degree of impairment eGFR and individual patient results
Salt intake restriction
Calories (avoid/treat obesity and malnutrition)
Phosphate, potassium – restrict as needed
Avoid (or treat) malnutrition

Statins – primary/secondary prevention as in general population

23
Q

How should bp be maintained in patients with CKD?

A

140/90 or less,

IF CKD + Diabetes then 130/80 OR if CKD + ACR of 70mg/mol 130/80

24
Q

What are the first line drugs for HTN in CKD?

A

Ace inhibitors and ARBs EXCEPT in renal artery stenosis- if you gave a pt this then noticed a sudden drop in eGFR query renal artery stenosis.

Risk of hyperkalaemia however so monitior U&Es baseline and 1 week after.

25
Q

Be careful what drugs you prescribe in CKD

A

NO NSAIDS, digoxin, aminoglycosides, acyclovir

26
Q

Which drugs can increase the risk of hyperkalaemia?

A

ACEi, ARBs, amiloride, spironalactone, potassium supplements

27
Q

Which diuretic has reduced efficacy in CKD?

A

Thiazides

28
Q

What must you prepare the patient about in CKD?

A

CKD may progress to point where patient develops symptoms and eventually unable to sustain life – patient should be aware of risk

Advanced education and counselling about options to facilitate decision-making when CKD more advanced
Typically discuss ESRD options when eGFR <20
Dialysis not usually needed until eGFR <10

29
Q

What are the options for ESRD management?

A

Haemodialysis
Peritoneal dialysis
Kidney transplantation
Conservative care

30
Q

Explanation to pt

A

Chronic kidney disease (CKD) is a long-term condition where the kidneys don’t work as well as they should.

It’s a common condition often associated with getting older. Anyone can get it, although it’s more common in black people and people of south Asian origin.

CKD can get gradually worse over time and eventually the kidneys may stop working altogether, but this is uncommon. Many people with kidney disease are able to live long, largely normal lives.

CKD can range from a mild condition with no or few symptoms, to a very serious condition where the kidneys stop working, sometimes called kidney failure.
Most people with CKD will be able to control their condition with medication and regular check-ups. CKD only progresses to kidney failure in around 1 in 50 people with the condition.

But if you have CKD, even if it’s mild, you’re at an increased risk of developing other serious problems, such as cardiovascular disease. This is a group of conditions affecting the heart and blood vessels, which includes heart attacks and strokes.

Cardiovascular disease is one of the main causes of death in people with kidney disease, although healthy lifestyle changes and medication can help reduce your risk of developing it.

31
Q

What is the comment cause of glomerulonephritis world wide?

A

IgA nephropathy, aka verger’s disease. (overlap with HSP)

32
Q

What conditions are associated with IgA nephropathy?

A

Coeliac disease/dermatitis herpetiformis

Henoch-Schonlein purpura

33
Q

What would you do if a pt with suspected lung ca needed a CT contrast but had a crap eGFR?

A

the evidence base currently supports the use of intravenous 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure. There is also evidence to support the use of isotonic sodium bicarbonate

34
Q

Most common nephrotic syndrome?

A

Minimal change nephropathy

35
Q

What are the associations of minimal change disease?

A

MCD mostly affects children and is associated with facial/periorbital swelling and frothy urine. Also, Note: MCD also has an association with atopy and Hodgkins lymphoma.

36
Q

Some causes of nephrotic syndrome?? (other than idiopathic)

A

drugs: NSAIDs, rifampicin
Hodgkin’s lymphoma, thymoma
infectious mononucleosis

37
Q

Why do people with nephrotic syndrome tend to develop dvts?

A

Loss of anti-thrombin 3 apparently.

38
Q

NB

A

Think compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis.

39
Q

Definition of acute kidney injury?

A
  • Rise in serum creatinine greater than 26 µmol/L within 48 hours or
  • Rise in serum creatinine 1.5 × baseline value within 1 week or
  • urine output less than 0.5 ml/kg/hr for 6 consecutive hours

(also called stage 1 AKI)

40
Q

Tx of AKI?

A
  • ABCDE
  • Obtain intravenous access for bloods as described above
  • Treat underlying cause (e.g. intravenous fluids for hypovolaemia and antibiotics for sepsis)
  • Treat complications of AKI (e.g. hyperkalaemia, pulmonary oedaema, acidosis, pericarditis)
  • Review of the drug chart (dose adjustments and to avoid nephrotoxins)
  • Renal replacement therapy if indicated (e.g. intractable hyperkalaemia, pH < 7.15, intractable pulmonary oedema, uraemic pericarditis or encephalopathy)
  • Monitor (daily volume assessment, fluid balance, U&Es, bicarbonate)
41
Q

Stage 2 AKI?

A

Serum creatinine 2-2.9x baseline

Urine output of <0.5/ml/kg for 12 hours

42
Q

Stage 3 AKI?

A

Creatinine 3x baseline or >354 or UO of less than 0.3ml/kg/hour

43
Q

How might you treat hypokalaemia?

A

Transfer to high care area with cardiac monitoring, 3 x 1litre bags of 0.9% saline with 40mmol KCL per bag over 24 hours.

44
Q

What are the symptoms of hypokalaemia?

A

Weakness, leg cramps and palpitations

45
Q

Which score is used to assess someone with an upper GI bleed?

A

Use the Blatchford score at first assessment, and

the full Rockall score after endoscopy

46
Q

CKD on haemodialysis, what is the most common cause of death?

A

Ischaemic heart disease

47
Q

Who has an inappropriately low eGFR?

A

Body builders.

48
Q

Which virus is important to consider in renal transplant patients?

A

CMV

CCC (9 decks)

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