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Renal / Urology > CKD > Flashcards

CKD Flashcards

1
Q

What is CKD

A

Irreversible and significant loss of renal function
Kidney damage or reduced function eGFR <60
Evidence of damage / structure
- Blood / protein loss
- Imaging / biopsy
- Hx transplant
>3 months

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2
Q

What is stage 1 and how is ACR also used for classification

A

GFR >90
Requires some evidence of damage to kidney

ACR = early and sensitive marker
A1 <3 i.e. no protein loss
A2 3-30
A3 >30 = significant protein / albumin loss

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3
Q

What is stage 2

A

GFR 60-89

Required evidence of damage as relatively normal

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4
Q

What do stage 1+2 require

A

Condition or cause i.e. abnormal U+E or proteinuria

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5
Q

What is stage 3a + 3b

A 
A = GFR 45-60 
B = GFR 30-45
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6
Q

What is stage 4

A

GFR 15-29

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7
Q

What is stage 5

A

End stage renal disease
Requires RRT
GFR <15

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8
Q

How do you differentiate CKD from AKI

A

CKD wil have bilateral small kidney due to long standing damage
CKD will have hypocalcaemia due to lack of vitamin D
CKD tends to have slow decrease in eGFR where as AKI = acute

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9
Q

What are exceptions

A

PCKD
DM
Amyloid
HIV neuropathy

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10
Q

What are the main causes of CKD in adult and in children

A

DM
HTN
Glomerular disease
Stenosis from atherosclerosis / ischaemia

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11
Q

What are other causes of CKD

A

Pre-renal

  • HF / liver failure as decrease perfusion
  • AKI accelerating as 85% pre-renal

Renal

  • Renal vascular due to HTN
  • Glomerular systemic - DM / amyloid / sarcoid
  • Primary glomerular disease (GN)
  • Interstitial renal disease - reflux in children / PCKD / chronic pyelonephritis / myeloma / chronic exposure to drugs e.g. NSAID / Alpot syndrome

Post

  • Prostatic
  • Malignancy
  • Retroperitoneal fibrosis = rare cause
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12
Q

What is the commonest cause of CKD in children

A

Congenital renal / fibromuscular dysplasia = most common
- Present with HTN and declining renal function
Reflux
PCKD
Obstructive stricture

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13
Q

What are symptoms of CKD

A 
Early stages = asymptomatic 
Fatigue
Pallor due to anaemia  
Insomina
Nausea
Headache  
Decreased appetite / anorexia
Taste disturbance 
Pain if capsule stretched  
Weakness / bone pain due to renal bone disease
Muscle cramps
Abdo cramp
Pruritus 
Fluid overload 
Peripheral + pulmonary oedema 
SOB 
Cognition 
Sexual dysfunction / impotence 
Amenorrhoea 
HTN  
Peripheral neuropathy 
Pleural effusion 
Calciflaxis 
Polyuria / oliguria
Haematuria
Proteinuria 
Electrolyte disturbance 
Uraemia - pruritus, N+V, cognition, bleeding as alters platelet, GI bleed, pericarditis due to irritating heart 
Electrolyte disturbance
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14
Q

What causes pruritus

A

Uraemia
High phophate
Low iron

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15
Q

What puts you at high risk of decline

A 
Age 
High BP
DM
Metabolic disturbance
Volume depletion
Infection
NSAID
Smoking
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16
Q

What happens to insulin requirements in CKD

A

Drop as insulin metabolised by kidney so require less

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17
Q

How do you investigate CKD in GP practice and what would you expect

A 
Same as AKI
FBC
U+E
Urinanalysis 
ACR 
Renal USS

Used to determine need for further investigation e.g. biopsy
If no blood / protein and Hx of HTN likely that

Possible anaemia 
Hyperkalaemia 
Hypoalbumin as leaking out 
Proteinuria 
Increased urea + creatinine
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18
Q

History and exam?

A 
Previous renal disease
FH
Systemic disease
Drugs
Uraemic / anaemia Sx
Vital signs- BP = very important 
General 
- Cachexia 
- Long term catheter
- Signs of overload/. SOB 
- Bruising / scratch marks - urea alters platelet so bleed more 
- Pallor of anaemia 
Volume status
Access
- Fistula / tunnelled line / catheter
CVS
-Murmur 
- Pericardial rub of pericaditis
- Scars suggesting IHD
Abdo 
- Scar from transplant - RIF
- Enlarged kidney 
- Tenderness suggest co-existing infection
- Renal bruit
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19
Q

What bloods / bedside tests should be done in hospital

A

Bedside

  • Obs inc BP always
  • Urine dip
  • Spot ACR
  • Can do 24 hours
  • Blood glucose
FBC - look for anaemia 
U+E- Dx and define CKD 
CRP - to see if infection worsening 
LFT 
Bicarb - low 
Glucose
Bone profile - Ca + phosphate + PTH 
- HypoCa
- Hyperphosphate and PTH = indicates chronic 
Clotting

Urinanalysis

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20
Q

What bloods / other tests to determine cause

A 
CK 
ANA / ANCA / Auto Ab
C3 for GN and SLE
Anti-GBM
Hepatitis
Myeloma screen 
- Protein electrophoresis 
- Bence Jones Protein - urine
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21
Q

What tests in the urine

A

Urinanalysis
ACR
24 hour

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22
Q

What other tests / imaging for complications

A 
Renal USS
- Good to look for obstruction and size
- Can do doppler to see thrombosis 
CT KUB non-contrast
- If suspect stone
MR angiography 
- Better to look for stenos 
ECHO / ECG
- See how heart
Vascular access
- If planning RRT
Biopsy
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23
Q

What are general measures / conservative in CKD

What are aims of Rx

  • General measures
  • Slow progression / renal protection with ACEI
  • Reduce risk of CVS disease
  • Manage complications
A 
Control BP
Control DM 
Exercise
Stop smoking
Weight loss 
Statin 20mg for primary prevention

Specific Rx of complications

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24
Q

What should you aim for DM HbA1c to be

A

<53

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25
Q

Who is more likely to need prompt dialysis

A

Anuric as can’t excrete

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26
Q

How d you monitor CKD

A

eGFR and ACR annual

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27
Q

When would you consider dialysis distinct from AKI

A 
Advanced uraemia 
- GFR<10
- Encephalopathy
- Percaridit s
Refractory evere acidosis
Refractory hyperkalaemia
Refractory pulmonary oeema
Certain drug overdose
Fluid and salt uncontrolled
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28
Q

When do you prepare and how for RRT

A

<1 year before needed

PD, haemo or transplant

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29
Q

What are complications of CKD

A 
Acidosis
Anaemia
Bone disease
CV risk
Electrolyte disturbance
Fluid overload
Other 
Gout 
Peripheral neuropathy 
Hypertension
Intoxincation
Dialysis 
Death
Poor growth in children due to CKD
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30
Q

What causes gout

A

Build up of urate

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31
Q

How do you treat

A

Allopurinol

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32
Q

What indicates a higher mortality

A

GFR

Albuminuria

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33
Q

What do patients with CKD die of

A

CVD > RRT

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34
Q

What type of acidosis does CKD cause

A

High anion gap due to urate that kidney can’t excrete
Also can’t excrete H ions
Lose bicarb

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35
Q

What are the affects of acidosis

A 
Worsens hyperkalaemia - anything that causes acidosis = hyperkalaemia
If improve acidosis will improve K 
Exacerbates renal bone disease
Increases muscle metabolism = cachexia
Poor resp reserve
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36
Q

What are the causes of metabolic acidosis

A 
MUDPILES
Methanol
Uraemia acid (CKD) 
DKA 
Paracetamol 
Infection / sepsis
Lactate - metforin
Ethyne glyol
Salicylates
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37
Q

How do you treat acidosis

A

Diet restriction
Sodium bicarb replacement
Potassium citrate
Dialysis

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38
Q

When should you be careful with sodium bicarb

A

Fluid overload due to Na
Hypertension
CI in saline as can worsen acidosis

39
Q

When can you not give potassium citrate

A

Hyperkalaemia

40
Q

What causes anaemia in CKD

A

Reduced EPO production in CKD as stimulate erythrocytes
- Usually around 3b

Can get other causes
Iron deficiency
Increased blood loss
Reduced RBC
Chronic disease 
Infections
41
Q

What type of anaemia

A

Usually normochromic normocitic if due to EPO

42
Q

What should you o first

A

Look for more common causes
Ferritin levels - will be low if iron deficient
Transferrin sat - do if normal as ferritin can rise in CKD due to inflammation

43
Q

How do you treat anaemia

A

Iron

EPO - if definitely due to this, EPO won’t work if iron levels aren’t normal

44
Q

What do you want iron to be

A

Higher than normal <500

Correct iron before add EPO

45
Q

What do you want Hb to be

A

Don’t normal

Target 100-120 as CVD with any value greater

46
Q

Complications of anaemia

47
Q

What causes CVD disease in CKD

A 
Calcifciation of vessels 
Hypertension
Vascular stiffness
Hyperlipidaemia
DM
Proteinura
Endothelial dysfunction
Uraemic pericarditis
Smoking
48
Q

Preventative measures of CVD in CKD

A 
Anti-platelet - unless bleeding risk
Statin
Smoking cessation
BP control 
Exercise
49
Q

What is importance of knowing CKD in CVD

A

Can influence troponin levels
Look at GFR
Should not interfere with HF but monitor K and eGFR

50
Q

What causes fluid overload

A

Na and water retention

51
Q

What does this lead to

A

Oedema
Hypertension
SOB
CVS disease

52
Q

How do you assess fluid balance if on dialysis or poor renal

A

Oedema - peripheral and pulmonary
Listen to lungs
RR, HR, BP
BCM - body composition monitor

53
Q

How do you treat fluid overload

A 
Na and fluid restriction
Diuretic if overload
Loop = 1st line
Thiazide
Monitor
54
Q

How do you treat hypertension associated with fluid overload

A

ACEI - renoprotective

Furosemide

55
Q

What BP should you aim for if no proteinuria and if porteinuia

A

140 / 90 if no proteinuria

130 / 90 if proteinuria

56
Q

What is proteinuria associated with

A

Higher mortality

CVD risk

57
Q

What should you not combine

A

ACEI and ARB as risk of hyperkalameia and AKI

Monitor eGFR and U+E

58
Q

What are uraemia symptoms

A 
Fatigue
Headache
N+V
Cramps
Anorexia
Altered mental
Pruritus
Easily bruising 
Unexplained GI bleed
Pericardiits
Encephalopathy
59
Q

If patient presents with restless legs

A

Exclude iron / uraemia
Sleep hygiene
Gabapentin / dopamine agonist if severe

60
Q

How does renal affect bone overview in CKD

A

Due to disturbance in calcium and phosphate
Less vit D as can’t be activated by the kidney
Less Ca - as no vit D
Increased phosphate - not excreted
Increased PTH - no inhibition / and low Ca

61
Q

Vitamin D role

A

Becomes activated in kidney calcitriol
Inhibits PTH
Increases Ca reabsorption in bowel and kidney
Excretes phosphate

62
Q

In renal bone

A

Less vitamin D as kidney not working to produce
Decreased Ca
Lose inhibition on PTH

63
Q

What does this result in

A

Secondary PTH due to low Ca and high phosphate

64
Q

Calcium role

A

Inhibits PTH

65
Q

Calcium in renal bone

A

No vitamin D to increase
Lose inhibition on PTH
Low Ca in CKD as no vitamin D
Hyper more common in AKI due to high PTH

66
Q

What does high calcium cause

A

Vascular calcification

67
Q

Phosphate

A

Stimulates PTH so increases Ca

68
Q

Phosphate in renal

A

Can’t excrete so increased levels
Leads to increased mortality
Drags calcium from bone causing osteomalacia

69
Q

PTH

Issue with treatment

A

Increases calcium by increasing bone turnover so if PTH is high chronic = problem
Fractures
Osteomalacia due to demineralisation
CVD risk

Other issue
- If suppress PTH too much with treatment then decrease bone turnover which also increases fracture risk

70
Q

What is primary PTH due to

A

Malignancy

71
Q

What is secondary PTH due to

A

Low Ca in renal

72
Q

What is tertiary PTH due to

A

PTH can’t be lowered with medical Rx
Occurs when PTH gland becomes autonomic after chronic activation e.g CKD and secretes without sensing calcium
Often if on dialysis
Require surgery

73
Q

How do you reduce phosphate and PTH and how do you increase calcium

A

Diet restriction - low phosphate
Non calcium based Phosphate binder - sevelamer
Calcium based phosphate binder but risk of hypercalcaemia - calcium acetate

Calcium diet
Vit D supplement -

74
Q

If PTH persists

A

Calcitriol - active vit D that doesn’t need kidney to activate
Calcitonin - not usually needed as CKD causes hypocalcaemia
Calcium minmeic to suppress PTH
Parathyroidetomy if all else fails

75
Q

What is calcitriol

A

1-25 dihydro

Vitamin D

76
Q

If calchiew taken with food

A

Phosphate binder

77
Q

If taken outwit food

A

Calcium supplement as absorbed by blood

78
Q

Complications of renal bone disease

A

Osteoporosis due to age / use of steroid
Osteomalacia due to increased bone turnover without Ca
Osteosclerosis as osteoblast try to produce new bone without Ca to mineralise

79
Q

Calcium acetate

A

Phosphate binder

Cause hypercalcaeima and vascular calcification

80
Q

What can be used to treat and prevent osteoporosis

A

Biphosphonates - Aledronic acid

81
Q

Symptoms of hypercalcaemia

A

Bone
Stone
Groans
Psychic moans

82
Q

When is selevamere CI

A

Bowel obstruction

83
Q

When do you refer to a specialist

A

Stage 4/5 / eGFR <30
ACR >70
Accelerated progression - >25% or >15 in 1 year
Uncontrolled hypertension despite >4 antihypertensives
Uncertain Dx
Suspect glomerulus disease - blood / urine
COmplications

84
Q

What is CKD an independent RF for

A

Cardiovascular disease

85
Q

What is essential in any renal pathology

86
Q

When do you biopsy

A 
Protein >1g / day
Unexplained proteinuria >1g/ day 
Unexplained haematuria
Decreased renal function / AKI but unknown cause 
Suspected RPGN / glomerular
Suspected multi-system disease e.g. RA
87
Q

What are absolute CI

A

Clotting
Unctrolled HTN >180 due to bleeding risk
Skin site infection or any active infection

88
Q

What are relative CI

A

Small kindey
SOlitary kidney
Anatomical abnormality

89
Q

What is renal protection

A

Slowing progression by lowering BP

90
Q

What are BP aims in CKD

A

<140 / 90

<130/90 if DM or high protein ACR >70

91
Q

What are indications for ACEI. / ARB independent of BP

A

HTN + ACR >30
DM and ACR >3
ACR >70

92
Q

What do you do if put on ACEI

A

Monitor regularly
Stop in intercurrent illness / AKI
Stop if develop hyperkalaemia

93
Q

If patient end stage renal and asking help what do you want to tell

A 
Aetiology of CKD 
Modality or plan - are the on dialysis / waiting for transplnat
Access available
Freuqnecy and last session of dialysis 
Unit being treated in
94
Q

SE of EPO

A

Flu like
Rash
Bone aches
Accelerated HTN - can cause encephalopathy / seizure
Pure red cell aplasia
Iron deficiency 2 to increased RBC formation

Renal / Urology (16 decks)

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