CKD Flashcards
What is CKD?
CKD is defined as an Abnormality in kidney function lasting >3 months.
Patient with CKD normally go on to develop some complications. The kidney is the main site of EPO production and so a normocytic anaemia occurs due to reduced RBC production. Patients can develop secondary hyperparathyroidism due to a loss of Vitamin D hydroxylation that normally occur in the kidney (Causes hypocalcaemia and leads to increased PTH). The mina cause of death in CKD patients is a cardiovascular event due to increased CVS risk factors associated with CKD. Patients are commonly malnourished caused other complications like iron deficiency anaemia. A diagnosis of CKD requires symptoms (Proteinuria/Haematuria) as well as reduced eGFR
What is the staging systems used for CKD?
Staging System: GFR G1 - >90 G2 - 60-89 G3a - 45-59 G3b - 30-44 G4 - 15-29 – Normally start to get symptoms here G5/Renal Failure- <15
Add p suffix to indicate significant proteinuria
Add T suffix to show that patient has had a renal transplant
Add D suffix to show that patient is on dialysis
What are the causes of CKD?
Causes:
Renal - Renovascular disease, Chronic Pyelonephritis, Glomerulonephritis, Tubulointerstitial Nephritis, Polycystic kidney disease, AKI progressing to CKD (Rare)
Systemic - Diabetes, HTN, Vasculitis, Lupus, Idiopathic
What will you find in a history of CKD?
Symptoms: Normally when GFR < 30 Fluid overload Anorexia Nausea vomiting Restless leg syndrome Fatigue Weakness Pruritis Bone pain Pericarditis Poor Sleep Seizures Amenorrhoea - Absence of periods impotence Coma Frothy urine if proteinuria Nephrotic syndrome - proteinuria, hypoalbuminemia and fluid retention Nephritic syndrome - haematuria, proteinuria, a fall in GFR, salt and water retention and hypertension Fever, Rash, Eosinophilia - Think intrinsic renal disease
Risk Factors:
HTN
Diabetes
Renal colic
Systemic conditions like SLE
Family history of renal conditions
Family history of subarachnoid haemorrhage - Shows abnormal hypertension
CVS risk factors - Atheroma of renal artery
Drugs causing tubulointerstitial necrophilist or glomerulonephritis - Beta-lactams, NSAIDs, 5-ASA, Ciclosporin
Specific Questions to ask:
Previous UTI
Lower urinary tract symptoms
Ask about systemic signs like anorexia and weight loss - systemic disease or malignancy
Have they use renal replacement therapy before?
What will you find on examination of CKD?
End of the bed: Vasculitis Rash Confusion Yellow skin - Uraemia Hands: Joint Disease Uraemic Flap Hypertension Neck: JVP - High or low Face: Anaemia - Eyes Xanthalasma Yellow tinge to eyes - jaundice (hepatorenal syndrome) Features of Cushing’s - Steroid use Periorbital oedema - Nephrotic syndrome Facial lipodystrophy (loss of face fat)- Glomerulonephritis Fundoscopy - Looking for HTN or diabetic changes Chest: Pulmonary crackles - Pulmonary oedema Signs of pulmonary effusion Pericardial Rub - Pericarditis Abdomen: Renal Bruit Ballotable kidneys - Polycystic Hepatomegaly - hepatorenal syndrome Legs: Peripheral oedema Look for peripheral vascular disease (CVS risk factor) Look for neuropathy - Diabetes Joint Disease PR exam - prostate may be enlarged causing obstruction
What investigations will you order in CKD?
Bedside:
Urine Dipstick
Urinary Mc and S - Albumin: creatinine ratio and Bence Jones protein (lymphoma)
ECG - Looking for arrhythmia or pericarditis
Bloods:
U&E - To compare to previous, do this annually
FBC - Looking for normocytic anaemia (Caused by reduced EPO)
Glucose - Diabetes
Calcium - Looking for secondary hyperparathyroidism that can occur in CKD
Phosphate - Looking for secondary hyperparathyroidism that can occur in CKD
Parathyroid hormone – Looking for secondary hyperparathyroidism that can occur in CKD
LFT’s – Used to look for Hepatorenal syndrome, Hypalbuminaemia (as a result of proteinuria), Raised ALP (Due to CKD mineral bone problems)
Imaging:
USS - Looking at size of kidneys (excludes obstruction, small kidneys in CKD, large in polycystic kidney). If asymmetrical could be renovascular disease
Special Tests:
If intrinsic renal disease suspected - ANA, ANCA, anti GBM, Paraprotein, complement, antiphospholipid antibodies
Renal Biopsy if disease worsening, nephrotic syndrome or systemic disease (not diabetes)
What is the treatment of CKD?
Lifestyle:
Exercise
Smoking cessation
BMI optimisation
Low salt diet - Refer to dietitian as low protein diet may be needed
Reduce CVS risk factors
Dietitian referral - May need increased protein if lots being lost by kidney. Also, may need diet higher in calcium
Medical:
Symptom management – Anaemia, Oedema, Acidosis
Treat anaemia - Replace any iron/b12/folate or EPO if indicated
Treat acidosis in patient with low HCO3- and EGFR<30 with HCO3- supplements
Treat oedema - Fluid restriction and low salt diet, use diuretics if symptomatic but use cautiously. High dose of loop diuretic
Complication Management – Hypertension, Secondary Hyperparathyroidism, Cardiovascular Risks
Hypertension - Ace inhibitor used as first line hypertension treatment in CKD sufferers.
Secondary Hyperparathyroidism – Treat hyperphosphatemia if >1.5mmol/l with dietary restriction and phosphate binders, and treat hypocalcaemia with Vitamin D analogues and Calcium supplements
Treat CVS risk factors – As well as reducing lifestyle risk factors, optimise CVS risk factor medical therapy (Statins, Diabetic Control, Antiplatelet Therapy etc)
Renal Replacement Therapy (See Card)
What is renal replacement therapy, when is it indicated and what are the advantages of each type
Renal Replacement Therapy:
Indications - Stage G4+, Uncontrollable hypertension (>4 medications), Rapidly Worsening CKD
Referral should be done very early, at least a year before required to allow time for RRT choice making and preparation e.g. placing suitable patients on donor list or setting up AV fistulas
In general kidney transplant is the bets option if possible. Then Peritoneal dialysis is recommended unless haemodialysis is needed (Worse CKD function, Lot of co-morbidities)
Kidney Transplant – Best outcome but not always possible. Match requires blood type and antigen matching
Contraindications – Previous Cancer, HIV, Severe Liver, Heart, Lung disease
Pre-operative immunosuppression with Anti IL-2 Monoclonal Antibodies and Post-Operative Immunosuppression with Ciclosporin/Tacrolimus and Monoclonal Antibodies
Complications – Graft rejection (Treated with steroids), Infection, Cancer
Peritoneal Dialysis - Dialysate infused into peritoneal cavity, interacts with blood in peritoneal capillaries dialysing it. Requires 4 exchanges of the fluid per day but is carried out by patient at home. Fits better around lifestyle. Easy access and less prep time needed before PD. Risk of peritonitis.
Haemodialysis – Blood is taken from an A-V fistula and surrounded by dialysate (solution of electrolytes) within a partially permeable membrane, then pumped back through fistula. In Leicester Heparin given continuously. Requires 4 hours in hospital multiple times a week and requires 2-3-month fistula formation in arm. However, it is more predictable filtration, better quality filtration,
Hemofiltration - used in intensive care setting to treat AKI
