CKD Flashcards
What is end-stage renal disease?
The point at which renal disease is so severe that RRT is required
What is renal replacement therapy?
Haemodialysis (HD), peritoneal dialysis (PD) and renal transplantation
How is proteinuria assessed?
using urine Protein:Creatinine (uPCR) or urine albumin:creatinine ratio (uACR)
How is renal function assessed?
GFR and eGFR
What could protein on urine dipstick suggest? (2)
Dipstick proteinuria may suggest glomerular or tubulointerstitial disease.
What are white cell casts a sign of? (2)
interstitial nephritis (especially if eosinophils are present in the urine) or urinary tract infection (UTI).
What do you look at in 24-hour urine collection?
Albumin:creatinine ratio (ACR)
If microscopic haematuria is present, what is the next test to be performed on the urine?
Sent for a culture to exclude a UTI
What do you do if non-visible haematuria persists?
refer for Urological review
What is the most important factor that can be addressed that reduces risk of cardiovascular disease?
Blood Pressure
How is CKD staged?
Based on eGFR and ACR - Look it up!
How can CKD progression be slowed? (5)
1) Diabetes control
2) Cholesterol control
3) Lifestyle advice - weight loss, reducing cholesterol and salt in diet
4) Smoking cessation
5) BP CONTROL!!
What is the most abundant protein in urine?
Tamm-Horsfall glycoprotein (THP), also known as uromodulin, is a glycoprotein that is secreted by the renal tubules.
What is abnormal proteinuria?
> 150mg/day
What is an early feature of severe renal disease?
Microalbuminuria (30-300mg/day) is an early feature of several renal diseases
Which BP tablet is recommended in CKD and why?
ACE-I/ARBs. They are reno-protective.
What is the mechanism of damage in diabetic nephropathy? (3)
1) Increased glomerular pressure leading to hyperfiltration
2) Barotrauma of mesangial cells
3) Nephron ischaemia
What are the clinical findings in diabetic nephropathy? (3)
Increased GFR, detectable proteinuria, microhaematuria kidney failure (decreased urine output)
What investigations are carried out in diabetic nephropathy?
Urinanalysis
What is treatment of diabetic nephropathy? (2)
Anti-diabetic medication + ACE-I - stop RAS activation
What is CKD?
Evidence of damaged renal parenchyma as demonstrated by active urinary sediment and/or structural abnormality (this must be present for stages 1 and 2 CKD) and/or evidence of decreased kidney function as demonstrated by a reduced glomerular filtration rate (GFR) and chronicity to distinguish it from acute kidney injury (AKI).’
What is chronicity in terms of kidney disease?
confirmed by the presence of abnormal kidney function by eGFR or proteinuria for >3 months
What are the major causes of mild-to-moderate CKD? (2)
Diabetes and HTN
What are the most prevalent causes of severe CKD? (2)
younger patients with glomerulonephritis and genetic causes of CKD
What are the side effects of ACE-I? (4)
dry cough, angioedema, hyperkalaemia, hypotension
When must ACE-I and ARBs be stopped?
AKI
What is a commonly accepted increase in creatinine with ACEIs?
25-30% rise
What are the grounds for referral to nephrology? (6)
CKD stage 3-5, AKI, urine PCR >100, malignant hypertension, hyperkalaemia, macroscopic haematuria but urological tests (i.e. cystoscopy) negative
What are uACR stages?
A1 - <30mg/g
A2 - 30-300mg/g
A3 - >300 mg/g
What the stages of eGFR in CKD?
G1 - >90 - damage with normal G2 - 60-89 - damage with mild decrease G3 - 30-59 - moderate G4 - 15-29 - severe G5 - <15 - renal failure
What is Azoteamia?
Elevation of nitrogenous metabolic waste in the blood due to failure of clearance by the kidneys
What is uraemia?
Clinical syndrome resulting from failing kidneys and progressive azotaemia
What is the target BP in CKD?
130/80 or less
When do you stop ACE-I/ARBs in a CKD patient? (3)
Stop if K+>6mmol/L, reduced eGFR >25% or reduced creatinine >30%
What is the HbA1c target in CKD?
53mmol/mol (7.0%),
At what stage of CKD does anaemia occur?
usually in stage 3
What is treatment for Anaemia in CKD?
IV iron + EPO injections
What causes CKD bone-mineral disorders (BMD)?
Failure of hydroxylation of vitamin D by kidneys. This leads to lack of calcium absorption and hypocalcaemia which drives secondary hyperparathyroidism.
What is the treatment for CKD BMD?
Vitamin D supplements. if PTH persists, treat with activated via D analogues.
What blood tests do you measure in for CKD BMD?
Ca2+, Pi, ALP, PTH and 25-OH vit D if eGFR <30.
How do you manage fluid and electrolyte balance?
Restrict fluid and salt intake
How do you manage oedema?
High dose loop diuretics
How is acidosis treated?
HCO3- replacement
What are the treatment for increased CVD risk?
Atorvastatin, BP control, aspirin (atherosclerotic events)
When should prep for RRT begin?
CKD stage 4 or risk of renal failure is 10-20% within year
What are the options for CKD stage 5?
PD, HD, transplant, conservative management
What immunisations do CKD patients require?
pneumococcal, influenza, hep B
How is stage 1&2 managed?
- smoking cessation, exercise, cholesterol, BP, ACEI/ARB
How is stage 3 managed?
As in stage 1&2 +:
Immunise
Aspirin, EPO, alfacalcidol, bicarbonate, diuretic
How is stage 4 managed?
As for previous stages +:
prepare for RRT, treat any complications
How is stage 5 managed?
As in earlier stages+:
HD/PD, vascular access, transplant workup, living donor
At what eGFR should metformin be stopped?
Less than 30mL/minute/1.73m^2
What is the interaction between simvastatin and amlodipine?
Increased risk of myopathy and rhabdomyolysis
What are the indications for dialysis?
- pH <7.25
- K+ > 7 mmol
- Fluid overload
- Toxins - SLIME = salicylate, lithium, isopropanol, magnesium, ethanol glycol
- Creatinine >400
- Uraemic symptoms (N&V, cognitive impairment, pericarditis, pruritus)
How do the osmotic diuretics work?
Act at the PCT and thick descending limb to Increase solute concentration (osmolality) prevents the reabsorption of water which will reduce plasma volume
How do loop diuretics work?
Loop diuretics block the Na+/K+/2Cl- co-transporter by stopping chloride transport. Na+ reabsorption is also blocked, hence loss of countercurrent mechanism + loss of water reabsorption
How do thiazide diuretics work?
Act at the Na+/Cl- cotransporter at the DCT + increase water excretion
What is a side effect of thiazide diuretics?
Increases urea reabsorption at PCT –> increase plasma uric acid levels –> GOUT
How does spironolactone work?
It is a K+ sparer. It blocks aldosterone which stops Na+/K+ insertion at DCT + collecting ducts. This stops Na+ and water reabsorption.
What are the requirements for HD?
Creation of AV fistula or central (tesio) line, dietary changes
What needs to done before PD can start?
Tenckoff catheter insertion
What are problems with HD?
Access (fistula: stenosis, thrombosis, steel syndrome.
Tunnel line: infection, blockage,
Dialysis disequilibrium, hypotension, time-consuming, diet+fluid restriction, tiredness, hospital based small bleeding risk due to anti-coagulation
What are the problems with PD
Catheter site infection, PD peritonitis, hernia, loss of membrane function over time (6 years), regular laxatives to keep bowels open
What are main contraindications for HD?
Inability to achieve suitable vascular access
What the main contraindications for PD?
IBD, ischaemic bowel, acute diverticulitis, abdominal abscess, pregnancy 3rd trimester
What does bone biochemistry show in hyperparathyroidism?
1) Primary hyperparathyroidism - high PTH, low Pi, high Ca2+
2) Secondary - High PTH, low calcium, high Pi
3) Tertiary - high PTH, high Ca2+, high Pi
What are the advantages of renal transplant?
Independence, significant survival advantage, no diet/fluid restriction, few symptoms, less complications
What are the disadvantages of Renal transplant?
Immunosuppression SEs, infections, malignancy
What are the advantages of HD?
- 4 days a week dialysis free
- more healthcare pro support
- treatment can be given during dialysis
What are the advantages of PD?
- less fluid/food restrictions
- home based
- no blood, no needles
- more portable
- less time for permanent access placement
What 4 variables are used to in the MDRD equation to calculate eGFR?
Creatinine, Age, Gender, Ethnicity (CAGE)
How does acute graft rejection present? (2)
Acute rejection occurs within 6 months, typically presents with signs and symptoms of infection
How is acute graft rejection managed?
Increased steroid dose
What are RBCs and Red cell casts in urine suggestive off?
Urine sediment with red blood cells and red blood cell casts suggests proliferative glomerulonephritis.
What is the target BP for diabetics?
< 140/90
