CKD

Question 1

Define what chronic kidney disease is (CKD)

Answer 1

• Reduced GFR and/or evidence of kidney damage
• This must be proved on more than one measurement - hence chronic

Question 2

What are the common symptoms of CKD ?

Answer 2

• Fatigue
• Oedema
• Nausea with/without vomiting
• Pruritus - itch
• Anorexia - poor appetite

Question 3

Do patients tend to present early or late with symptoms of CKD ?

Answer 3

Late - usually when GFR<20ml/min

Question 4

What are the classification of the different stages of CKD ?

Answer 4

• Stage 1 – GFR >90ml/min, with evidence of kidney damage*
• Stage 2 – GFR 60-90ml/min, with evidence of kidney damage
• Stages 3-5 defined on GFR alone
• Stage 3 – GFR 30-60ml/min
• Stage 4 – GFR 15-30ml/min
• Stage 5 – GFR <15ml/min, or on renal replacement therapy

Question 5

What are some of the signs of kidney damage?

Answer 5

• Proteinuria
• Haematuria (in absence of lower urinary tract cause),
• or abnormal imaging

Question 6

What are 2 main risk factors for falling GFR to develop into CKD requiring renal replacement therapy?

Answer 6

• People who present young with CKD
• Patinets with proteinuria - faster progression of CKD

Question 7

What are the common causes of CKD ?

Answer 7

• Diabetes
• Hypertension
• Vascular disease
• Chronic glomerulonephritis
• Reflux nephropathy
• Polycystic kidneys

Question 8

What is the typical appearance of the kidneys in someone with CDK?

Answer 8

Small, scarred kidneys

Question 9

Will all patients with CKD progress to stage 5 and then require renal replacement therapy ?

Answer 9

No - some will continue to decline and require renal replacement therapy and some will progress much slower so may not end up requiring additional therapy

Question 10

What is the best and most common way to measure GFR ?

Answer 10

eGFR - estimation of creatinine clearance

Question 11

What is the draw back of eGFR ?

Answer 11

• Accurate for most people if <60ml/min

However

• Over-estimates GFR if muscle mass is low
• Under-estimates if muscle mass high
• And not great for monitoring GFR > 60

Can see in the graph how for GFR > 60 the changes in GFR do not correspond to the changed in creatinine hence not that accurate

Question 12

What in what patients would early screening for CKD be appropriate ?

Answer 12

• DM
• Hypertension
• CVD
• Structural renal disease e.g. stones, BPH
• Recurrent UTI’s
• Multisystem disorders which could affect the kindeys e.g. SLE, vasculitis
• Family history of end-stage renal failure (ESRF) or known hereditary disease e.g. APKD

Question 13

What is the principles for the management of CKD ?

Answer 13

• Slow progression
• Reduce cardiovascular risk
• Identify and treat complications of CKD
• Prepare for renal replacement therapy

Question 14

What is the target BP for patients with CKD ?

Answer 14

130/80, need to try make sure its below 140/90

Question 15

What is the treatment of stages 1-4 CKD ?

Answer 15

• 1st line = ACE or ARB + statin
• In those who cant have an ACEi or ARB - CCB + statin

Then follow the normal hypertensive treatment plan if target BP not met

Question 16

At what eGFR roughly should the discussion re dialysis be done at with patients ?

Answer 16

An eGFR roughly 20. Use the Buckmans 6-step protocol.

Question 17

What are the 2 main types of dialysis ?

Answer 17

Haemodialysis and peritoneal dialysis

Question 18

How does a patient get ready for haemodyalsis ?

Answer 18

AVF - needs 6 weeks to mature. Refer to vascular surgeons when eGFR <15

Question 19

How does a patient get ready for peritoneal dialysis ?

Answer 19

Operation to insert catheter, can be used after 1-2 weeks

Question 20

Overall what exact numbers for when to initiate and discuss dialysis treatment

Answer 20

• Conversation re dialysis at eGFR 20.
• Refer to vascular surgeons for AVF or catheter at 15
• Initiate tx for dialysis at 5-10.

Question 21

What are the main complications which can arise due to CKD which will then need to be treated ?

Answer 21

• Anaemia
• Hyperparathyoridism - this can lead to bone disease

Question 22

How does anaemia occur in patients with CKD and what is done to treat it ?

Answer 22

• Erythropoietin produced by the kidneys
• Production declines in CKD
• This results in reduced RBC hence anaemia

Treatment:

1st line - IV iron

2nd line - erythropoietin (Epo) + iron

Question 23

How does hyperparathyroism occur in CKD and how does it then lead to bone disease ?

Answer 23

1. Kidney important in Vit D metabolism - decreased kindey function results in decreased Vit D
2. Reduced Vit D means less calcium absorbed in the body
3. This causes secondary hyperparathyroidism as it tries to raised calcium levels
4. PTH produced by the parathyroid causes increases osteoclast activity in the bones which breaks down the bones to produce phosphate and calcium (what bones are made of)
5. This increases calcium levels back to normal (can become raised) and phosphate levels become raised (they were not low in the first place)

Question 24

What is the treatment for bone disease in patients with CKD ?

Answer 24

Dietary modification ± phosphate-binding drug (sevelamer, calcium acetate) or vitamin D: alfacalcidol, calcitriol

Question 25

What are the different dialysis options for patients ?

Answer 25

Haemodyalsis or peritoneal dialysis