CKD

Question 1

Define CKD.

What’s the diagnostic criteria?

Answer 1

Chronic Kidney Disease

Abnormal kidney function or structure
Present for more than 3 months

All patients with:

• evidence of kidney damage
  OR
• GFR < 60ml/min/1.73m2

On at least 2 occasions separated by a period of 90+ days

Question 2

List some markers of kidney damage?

Answer 2

Persistent microalbuminuria
Persistent haematuria
Persistent proteinuria

Electrolyte abnormalities
Histological abnormalities
Structural abnormalities identified on scan

History of kidney transplant

Question 3

What’s a normal GFR?

Units?

Answer 3

Over 90ml/min/1.73m2 is normal

Question 4

What GFR indicates kidney failure?

Answer 4

GFR less than 15ml/min/1.73m2

Question 5

What markers should you use to classify CKD?

Answer 5

GFR

ACR (albumin:creatinine ratio)

Question 6

How is CKD classified?

Answer 6

Stage 1-5

Stage 1: normal: eGFR >90

Stage 2: mild: eGFR 60-89

Stage 3a: moderate: eGFR 45-59

Stage 3b: moderate eGFR 30-44

Stage 4: severe: eGFR 15-29

Stage 5: established renal failure: eGFR < 15 OR on dialysis

Question 7

Causes of CKD?

Answer 7

Genetic kidney abnormality (PKD)

Glomerulonephritic disease (nephritic and nephrotic syndrome)

Diabetes
Hypertension
Arteriopathic disease (atherosclerosis of kidney vessels, renal artery stenosis)

SLE

Infection
Urinary tract obstruction

Myeloma

Malignancy

Question 8

Risk factors for CKD?

Answer 8

Cardiovascular disease

• high BMI
• sedentary

Smoking
Hypertension
Diabetes

African, Afro-Car, Asian origin

AKI
Chronic use of NSAIDs

Question 9

Presentation of CKD?

Answer 9

Often incidental finding on routine bloods

In severe CKD:

• anorexia
• n+v
• pruritic
• lethargy
• weakness
• oedema
• muscle cramps
• pulmonary oedema
• sexual dysfunction

Question 10

What are some signs of severe CKD?

Answer 10

Increased skin pigmentation

Pallor

Hypertension + postural hypotension

Peripheral oedema

Pleural effusions

Peripheral neuropathy

Question 11

Investigations of suspected CKD?

Answer 11

BLOOD

• urea and creatinine aren’t brilliant
• eGFR
• electrolytes
• FBC to look for anaemia
• antibodies such as anti-GBM

URINE

Urine dip: look for proteinuria and haematuria

24hr collection for ACR (albumin creatinine ratio)

Urine electrophoresis: to look for Bence-Jones’ protein (monoclonal ab)

IMAGING

USS
XR
MRI
Biopsy

Question 12

How is ACR classified?

Units?

Answer 12

Units are mg/mmol

A1: Less than 3
A2: 3-30
A3: More than 30

Question 13

Management of CKD?

Answer 13

Treat reversible causes

Lifestyle changes

Manage risk factors like diabetes, hypertension, cardiovascular risk:

• ACEi etc
• Statin
• Metformin etc

Treat anaemia: EPO

Treat renal bone disease

Treat oedema: loop diuretics

Avoid nephrotoxins (NSAIDs, gent, contrast)

Immunise against influenza, pneumococcus

RRT

Question 14

How should patients with CKD be monitored?

Answer 14

Frequency depends on severity of impairment

ACR
eGFR
Proteinuria

Question 15

What is renal bone disease?

Management?

Answer 15

Renal osteodystrophy

The result of secondary hyperparathyroidism

Caused by hyperphosphataemia + hypocalcaema (which is a result of renal failure)

Hyperparathyroidism results in increased bone resorption rate, weakened bones, fractures

Management: diet rich in calcium, plus phosphate binding drugs (Ca carbonate, acetate)

Question 16

Complications of CKD?

Answer 16

Anaemia of chronic disease and due to reduced EPO

Coagulopathy

Hypertension

Renal osteodystrophy

Uraemia: encephalopathy,

Fluid overload: pulmonary oedema

Malnutrition: increased risk of infection

Glucose intolerance to peripheral insulin resistance

Question 17

In a CKD patient with hyperkalaemia, when would you start dialysis?

Answer 17

Above 7mmol/L

Persistent

Question 18

What is uraemia?

Answer 18

Azotaemia (high levels of N containing compounds like urea in the blood)

Caused by end stage renal disease, when GFR is less than 15

Question 19

Presentation of uraemia?

Signs?

Answer 19

Fatigue
Anorexia
Nausea + vomiting
Delirium
Seizures

Grey skin, pruritis
Dyspnoea
Hypertension
Uraemic frost
Pericardial rub
Bone pain, weakness, cramps, paraesthesia

Question 20

Complications of uraemia?

Answer 20

Uraemic encephalopathy

Uraemic pericarditis

Bleeding: because uraemic toxins cause abnormal platelets and dysfunction

Question 21

Management of uraemia?

Answer 21

Dialysis

Question 22

What are the indications for dialysis?

For AKI and CKD

Answer 22

CKD: stage 5, eGFR <15

Indications for AKI:

• uraemia
• pulmonary oedema
• hyperkalaemia (>6.5)
• severe hypo/hypernatraemia
• metabolic acidosis (less than pH 7)
• severe renal failure (urea>30)

Question 23

Types of renal replacement therapy and briefly explain?

Answer 23

Haemodialysis: blood comes out, filtered using semi-permeable membrane with dialysate (fluid) which brings excess water and toxins out of blood and good bits into blood, blood goes back into body

Peritoneal: dialysate goes into peritoneal cavity. The peritoneal membrane is rich with blood vessels, so blood gets filtered this way, dialysate emptied

Question 24

Regimen of haemodialysis?

Access?

Answer 24

3 days a week for 4 hours

Or at home, 5 days a week for 2-3 hours

AV fistula (which takes months to develop)

Or can use tunneled line (into RA) if needed urgently

Question 25

Regimen of peritoneal dialysis?

Access?

Answer 25

4 exchanges/day for 20 mins
Or overnight

A tube directly into peritoneal cavity