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
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
3
Q
What is stage 2
A
GFR 60-89
Required evidence of damage as relatively normal
4
Q
What do stage 1+2 require
A
Condition or cause i.e. abnormal U+E or proteinuria
5
Q
What is stage 3a + 3b
A
A = GFR 45-60 B = GFR 30-45
6
Q
What is stage 4
A
GFR 15-29
7
Q
What is stage 5
A
End stage renal disease
Requires RRT
GFR <15
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
9
Q
What are exceptions
A
PCKD
DM
Amyloid
HIV neuropathy
10
Q
What are the main causes of CKD in adult and in children
A
DM
HTN
Glomerular disease
Stenosis from atherosclerosis / ischaemia
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
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
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
14
Q
What causes pruritus
A
Uraemia
High phophate
Low iron
15
Q
What puts you at high risk of decline
A
Age High BP DM Metabolic disturbance Volume depletion Infection NSAID Smoking
16
Q
What happens to insulin requirements in CKD
A
Drop as insulin metabolised by kidney so require less
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
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
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
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
21
Q
What tests in the urine
A
Urinanalysis
ACR
24 hour
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
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
24
Q
What should you aim for DM HbA1c to be
A
<53
25
Who is more likely to need prompt dialysis
Anuric as can't excrete
26
How d you monitor CKD
eGFR and ACR annual
27
When would you consider dialysis distinct from AKI
```
Advanced uraemia
- GFR<10
- Encephalopathy
- Percaridit s
Refractory evere acidosis
Refractory hyperkalaemia
Refractory pulmonary oeema
Certain drug overdose
Fluid and salt uncontrolled
```
28
When do you prepare and how for RRT
<1 year before needed
| PD, haemo or transplant
29
What are complications of CKD
```
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
```
30
What causes gout
Build up of urate
31
How do you treat
Allopurinol
32
What indicates a higher mortality
GFR
| Albuminuria
33
What do patients with CKD die of
CVD > RRT
34
What type of acidosis does CKD cause
High anion gap due to urate that kidney can't excrete
Also can't excrete H ions
Lose bicarb
35
What are the affects of acidosis
```
Worsens hyperkalaemia - anything that causes acidosis = hyperkalaemia
If improve acidosis will improve K
Exacerbates renal bone disease
Increases muscle metabolism = cachexia
Poor resp reserve
```
36
What are the causes of metabolic acidosis
```
MUDPILES
Methanol
Uraemia acid (CKD)
DKA
Paracetamol
Infection / sepsis
Lactate - metforin
Ethyne glyol
Salicylates
```
37
How do you treat acidosis
Diet restriction
Sodium bicarb replacement
Potassium citrate
Dialysis
38
When should you be careful with sodium bicarb
Fluid overload due to Na
Hypertension
CI in saline as can worsen acidosis
39
When can you not give potassium citrate
Hyperkalaemia
40
What causes anaemia in CKD
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
What type of anaemia
Usually normochromic normocitic if due to EPO
42
What should you o first
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
How do you treat anaemia
Iron
| EPO - if definitely due to this, EPO won't work if iron levels aren't normal
44
What do you want iron to be
Higher than normal <500
| Correct iron before add EPO
45
What do you want Hb to be
Don't normal
| Target 100-120 as CVD with any value greater
46
Complications of anaemia
LVH
47
What causes CVD disease in CKD
```
Calcifciation of vessels
Hypertension
Vascular stiffness
Hyperlipidaemia
DM
Proteinura
Endothelial dysfunction
Uraemic pericarditis
Smoking
```
48
Preventative measures of CVD in CKD
```
Anti-platelet - unless bleeding risk
Statin
Smoking cessation
BP control
Exercise
```
49
What is importance of knowing CKD in CVD
Can influence troponin levels
Look at GFR
Should not interfere with HF but monitor K and eGFR
50
What causes fluid overload
Na and water retention
51
What does this lead to
Oedema
Hypertension
SOB
CVS disease
52
How do you assess fluid balance if on dialysis or poor renal
Oedema - peripheral and pulmonary
Listen to lungs
RR, HR, BP
BCM - body composition monitor
53
How do you treat fluid overload
```
Na and fluid restriction
Diuretic if overload
Loop = 1st line
Thiazide
Monitor
```
54
How do you treat hypertension associated with fluid overload
ACEI - renoprotective
| Furosemide
55
What BP should you aim for if no proteinuria and if porteinuia
140 / 90 if no proteinuria
| 130 / 90 if proteinuria
56
What is proteinuria associated with
Higher mortality
| CVD risk
57
What should you not combine
ACEI and ARB as risk of hyperkalameia and AKI
| Monitor eGFR and U+E
58
What are uraemia symptoms
```
Fatigue
Headache
N+V
Cramps
Anorexia
Altered mental
Pruritus
Easily bruising
Unexplained GI bleed
Pericardiits
Encephalopathy
```
59
If patient presents with restless legs
Exclude iron / uraemia
Sleep hygiene
Gabapentin / dopamine agonist if severe
60
How does renal affect bone overview in CKD
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
Vitamin D role
Becomes activated in kidney calcitriol
Inhibits PTH
Increases Ca reabsorption in bowel and kidney
Excretes phosphate
62
In renal bone
Less vitamin D as kidney not working to produce
Decreased Ca
Lose inhibition on PTH
63
What does this result in
Secondary PTH due to low Ca and high phosphate
64
Calcium role
Inhibits PTH
65
Calcium in renal bone
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
What does high calcium cause
Vascular calcification
67
Phosphate
Stimulates PTH so increases Ca
68
Phosphate in renal
Can't excrete so increased levels
Leads to increased mortality
Drags calcium from bone causing osteomalacia
69
PTH
Issue with treatment
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
What is primary PTH due to
Malignancy
71
What is secondary PTH due to
Low Ca in renal
72
What is tertiary PTH due to
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
How do you reduce phosphate and PTH and how do you increase calcium
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
If PTH persists
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
What is calcitriol
1-25 dihydro
| Vitamin D
76
If calchiew taken with food
Phosphate binder
77
If taken outwit food
Calcium supplement as absorbed by blood
78
Complications of renal bone disease
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
Calcium acetate
Phosphate binder
| Cause hypercalcaeima and vascular calcification
80
What can be used to treat and prevent osteoporosis
Biphosphonates - Aledronic acid
81
Symptoms of hypercalcaemia
Bone
Stone
Groans
Psychic moans
82
When is selevamere CI
Bowel obstruction
83
When do you refer to a specialist
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
What is CKD an independent RF for
Cardiovascular disease
85
What is essential in any renal pathology
Urine dip
86
When do you biopsy
```
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
What are absolute CI
Clotting
Unctrolled HTN >180 due to bleeding risk
Skin site infection or any active infection
88
What are relative CI
Small kindey
SOlitary kidney
Anatomical abnormality
89
What is renal protection
Slowing progression by lowering BP
90
What are BP aims in CKD
<140 / 90
| <130/90 if DM or high protein ACR >70
91
What are indications for ACEI. / ARB independent of BP
HTN + ACR >30
DM and ACR >3
ACR >70
92
What do you do if put on ACEI
Monitor regularly
Stop in intercurrent illness / AKI
Stop if develop hyperkalaemia
93
If patient end stage renal and asking help what do you want to tell
```
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
SE of EPO
Flu like
Rash
Bone aches
Accelerated HTN - can cause encephalopathy / seizure
Pure red cell aplasia
Iron deficiency 2 to increased RBC formation
