CKD

Question 1

What readings will constitute chronic kidney disease?

Answer 1

The patient must have an eGFR of <60ml/min on two seperate occasions over three months with evidence of kidney damage

Question 2

What three ways can kidney damage be identified?

Answer 2

Ultrasound scan
Presence of protein or blood in urine
History of renal transplant

Question 3

Which populations are screened for CKD?

Answer 3

Patients with chronic diseases e.g. diabetes mellitus, hypertension, CVD, multisystem diseases
Long term history of nephrotoxic medications e.g. NSAIDs, calcineurin inhibitors, lithium
Family history
Strutural renal tract disease e.g. recurrent stones, BPH
AKI (follow up after 2-3 years)

Question 4

What are the CKD stages for eGFR?

Answer 4

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

Question 5

What are the stage of CKD by A:Cr ratio?

Answer 5

A1 - <3mg/mmol
A2 - 3-30mg/mmol
A3 - >30mg/mmol

Question 6

What sort of symptoms are present in severe CKD?

Answer 6

Anorexia, nausea, cramping, vomiting, fatigue, pruritis, peripheral odema, dyspnoea

Question 7

What are some typical signs that can be found on examination for CKD?

Answer 7

Bilateral palpaple kidneys would indicate polycycstic kidney disease
Hyperpigmentation, excoriation (picking at skin), conjunctival pallor, hypertension, left ventricular hypertrophy, pleural effusions

Question 8

What are some of the main causes of CKD to ask about in history?

Answer 8

Any history of UTI, CVD, DM, renal colic, systemic disorders
Check drug history for nephrotoxic drugs
Check family history for renal disorders and subarachnoid haemorrhage (polycycstic kidney disease patients often have berry aneurysms)
In systems review look for rare causes and indicators of systemic disease

Question 9

At what point does CKD become symptomatic?

Answer 9

When GFR falls below 30ml/min

Question 10

What peripheral signs should be looked for in CKD examination?

Answer 10

Peripheral oedema, Signs of peripheral vascular disease or neuropathy, vasculitic rash, gouty tophi, joint disease, AV fistula, signs of immunosupression, bruising from steroids, uraemic flap/encephalopathy

Question 11

What does a yellow tinge to the skin indicate?

Answer 11

Uraemia

Question 12

What does gum hypertrophy indicate?

Answer 12

Ciclosporin use

Question 13

What does periorbital oedema indicate?

Answer 13

It shows nephrotic syndrome

Question 14

What does facial lipodystrophy (abnormal distribution of fat) indicate?

Answer 14

Glomerulonephritis

Question 15

What blood tests should be done to investigate CKD?

Answer 15

U and E + bone profile - sodium, bicarb, potassium, calcium, phosphate
LFTs and albumin - hypoalbuminaemia and raised ALP
Serum lipids - dyslipidaemia
Plasma glucose
FBC - look for normocytic anaemia
Serology for autoantibodies - anti-GBM, ANCA, ANA, anti-dsDNA, hepatitis, myeloma screen

Question 16

What should be looked for on a CKD urine dip?

Answer 16

Look for blood and protein, get an A:Cr ratio done if possible, mid stream urine and culture to rule out infection

Question 17

What will ultrasound show for CKD?

Answer 17

Used to rule out obstruction, will show small bilateral kidneys in CKD unless inflitrative disorders (amyloid, myeloma) One kidney larger than other indicates renovascular disease

Question 18

How should CKD be monitored?

Answer 18

By looking at eGFR and albumin levels

Question 19

How should CKD be treated to slow disease progression?

Answer 19

Antagonism of RAAS with ACE-i or ARB but must closely monitor K+ (offer to over 3mg/mmol in DM and over 30mg/mmol in hypertension)
Blood glucose should aim for a target HbA1c of less than 7%
Lifestyle advise - excercise, smoking cessation, healthy weight, salt intake <5g per day
Think about statins for cardiovascular protection

Question 20

How is anaemia resulting from CKD treated?

Answer 20

Patients with eGFR<60 should have Hb checked. Any deficiencies should be treated e.g. iron, B12, folate. IV iron therapy can be given. Erythropoeitin stimulating agents (EPO) should be considered if Hb <110

Question 21

How is acidosis in CKD patients treated?

Answer 21

Can consider sodium bicarbonate supplements however caution should be taken in fluid overloaded patients due to sodium content

Question 22

How is odema treated in CKD patients?

Answer 22

Fluid restriction and sodium restriction. Combination of loop and thiazide diuretics have a powerful effect but not to be given if oligouric.

Question 23

How is chronic hyperkalaemia treated in patients with CKD?

Answer 23

Loop diuretics increase potassium excretion
ACE-i or ARB exacerbate so aim to reduce
Potassium restricted diet

Question 24

What is the pathophysiology and treatment of CKD bone mineral disorders?

Answer 24

There is less hydroyxlation of vitamin D in the kidneys which results in low serum calcium, this stimulates secondary hyperparathyroidism. This leads to bone demineralisation and fragility.
Treatment consists of vit D supplementation (Alfacalcidol), dietry phosphate restriction and phosphate binders (calcium acetate)