Ckd Flashcards
What is apckd
- Autosomal dominant (+ new mutations)
- ~ 1:1000 births
- Mutation in either:
- PKD 1 gene ( ~ 85%) mean age 53 (Causes earlier disease on average Established (end stage) renal disease)
- PKD 2 gene
- Cysts grow with age, generally presents in adulthood
- Diagnosed with ultrasound (can’t exclude if < 30 yrs old)
- Genetic testing (not widespread)
- Prognosis depends on rate of increase in kidney size and age
Describe the appearance of apckd
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Whar are the complications of apckd
• Cysts fluid filled and can cause secondary complications: – Pain – Bleeding into cyst – Infection – Renal stones (stasis)
- Hypertension very common (before renal function changes)
- Rate of decline in function variable even between families
- Increased incidence of intra-cranial aneurysms
- Increased incidence of heart valve abnormalities
Descrbe teh management of apckd
• Treat hypertension block RAAS • Diet – Drink plenty of fluid – Low salt – Normal but not excessive protein • Tolvaptan - Blocks ADH - use ift for patients with hyponatraemia. Also a relationship between how cyst grow • Others (somatostatin analogues)
Define ckd
The irreversible and sometimes progressive loss of renal function over a period of months to years
Renal injury causes renal tissue to be replaced by extracellular matrix in response to tissue damage
Why is early management important
- In some patients CKD inexorably worsens with progressive loss of renal function
- Associated with substantial cardiovascular morbidity and mortality even with mild CKD
Describe ckd stagng
Creatinine decline - go through stages
Most ppl in stage 3a - good prognosis
The ppl in g4+ will end up with esrd if they get that far
Relatively normal kidney unction but a lot of protein - risk of ckd??
Describe teh epidemiology of ckd
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Describ the life expectancy changes n ckd
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Descirb teh appearance of ckd
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Wha are the causes of ckd
• Diabetes • Hypertension • Immunologic glomerulonephritis • Infection – pyelonephritis • Genetic – Adult Polycystic Kidney Disease, Alport’s • Obstruction and reflux nephropathy (OU) • ATN • Vascular • Systemic diseases (– e.g. myeloma) • Cause unknown
Descrbe the investigations of ckd
Define degree of renal impairment
• Define cause of renal impairment
• Provide patient with diagnosis and prognosis
• Identify complications of CKD
• Plan long term treatment (delay progression and plan for dialysis
and transplantation)
What needs to be measured in ckd
Blood pressure, creatinine, dipstick
Describe egfr in ckd
Only accurate in adults
• Correction needed for black patients (not Asians)
• It defines CHRONIC kidney disease and is not useful in acute kidney injury (intercurrent illness or haemodynamic problems)
What are the blood tests done in ckd (general
• Urea & Electrolytes • Bone biochemistry • Liver function tests (albumin) • Full blood count • CRP
• +/- iron levels (ferritin, iron, reticulocyte haemoglobin) • +/- PTH
Ferritin, transferrin, reticulocyte
Descrbe blood tests to determine the cause of ckd
• If there is clinical suspicion of the following:
• Auto-antibody screen (auto-immune disease)
• Complement levels (auto-immune disease)
• Anti-neutrophil cytoplasmic antibody (vasculitis)
• Serum immunoglobulin screen (myeloma)
• Protein electrophoresis & serum free light chain measurement
(myeloma)
What are the other investigations
• Ultrasound scan – Kidney size – Evidence of obstruction (hydronephrosis) • Kidney biopsy (check kidney size first) – Cause unknown – Haematuria – Proteinuria Other investigations if specific causes considered: – CT scan (stones / mass) – MRI scan (mass) – MR angiogram (renal artery stenosis)
Describe the prevention/ delay progression of ckd
• Modifiable risk factors for CKD – Lifestyle – Smoking – Obesity – Lack of exercise
- Uncontrolled diabetes
- hypertension
- Proteinuria Blockers (ACE-Inhibitors / Angiotensin Receptor) - Ace I can make Kai worse bc of haemodynamic effect of AE. But they reduce proteinuria and reduce risk - so want them to be on aces. But if they have acute chance - want to stop it for a bit, but start it again
- Lipids
Describe regulation of water and salt in ckd in terms o treatment
• 80-85% CKD patients are hypertensive - 3 or 4 hypertensive agents, 1 not enough.
– Anti-hypertensives – Diuretics – Fluid restriction
Desribe the effect of ckd on water/salt handling my kidney
Reduced GFR:
Lose ability to maximally dilute and concentrate urine (200 – 300 mOsmol/kg – vs – 50 – 1200 mOsmol/kg)
Small glomerular filtrate but same solute load causes osmotic diuresis (reduces maximum concentrating ability and response to ADH)…nocturia
Low volume of filtrate reduces maximum ability to excrete urine therefore maximum urine volume much smaller
Describe hyperkalaemia in ckd
- Can occur once eGFR < 20 mls / min
- Less likely when good urine output maintained
May require:
• Stopping ACE-Inhibitor / Angiotensin receptor blocker
• Avoidance of other drugs that can increase K+ (amiloride, spironolactone, trimethoprim)
• Altering diet to avoid foods with high potassium
Descrbe acidosis in ckd
May affect:
- muscle https://anidonat.com/2013/12/03/acidosis-and-alkalosis/
- bone - renal function progression
Treat with oral NaHCO 3 tablets
Whar are causes of anaemia in ckd
Descreased epo production, absolute iron deficiency - dont clot as well, lose blood, short rbc life span, co -morbidities, Brown marrow suppression by uraemia, ck mineral and bone disorder, medications egi acei, b3 folate deficiency, high hepcidin level - inflammation infection- may contribute to functional iron deficiency nd impaired bm responsiveness to epo
What is treating anaemia important
- Improves exercise capacity • Improves cognitive function • Helps regulate left ventricular hypertrophy • Helps slow progression of renal disease • Reduces mortality
- Makes patients feel better
Describe the treatment of anaemia in ckd
• Always check iron stores first
• If iron low, replace iron first (oral or intravenous)
• When iron supplies ok, re-check haemoglobin
• If haemoglobin still low, start erythropoietin stimulating agent (ESA /
Epo)
• Aiming for haemoglobin of 100 g/L – 120 g/L
• Cost of Epo: minimum ~ £1000 / annum
Describe mineral bone disease
1-a-calcidol have a role. Holding onto phosphate when gfr <60. Early stages of ckd. At iris, body Compensated. Klotho and fibroblast growth factor 23 help to expels phosphate. But klotho recedes in ckd. Path increased can expel phosphate but not good if this is high. Vit d deficient. Secondary hyerparathyroidism - more pth to get everythign pack.
Describe the management of ckd-bmd
• Reduce phosphate intake (as much as is practical)
• Phosphate binders
– Many contain calcium – caution re: how much calcium patient given
• 1-α-calcidol
• (Vitamin D)
Describe altered drug metabolism in ckd
• Lots of drugs require dose alteration in CKD / ESRD due to reduced metabolism & / or elimination
• Drug sensitivity can be increased even if elimination unimpaired meaning side effects more likely e.g. statins
Statins - give to most patient with kid to help with lipids, but they are more sensitive to side effects
Desribe accusation o waste products in ckd
• Contribute to uraemic symptoms • Reduced appetite • Nausea and vomiting • Pruritus…
Describe esrd and renal replacement therapy
Definition: Established (End-Stage) Renal Failure
• When death is likely without renal replacement therapy
• eGFR <15 mls/min
Renal Replacement Therapy
• required when native renal function declines to a level no longer
adequate to support health
• usually when eGFR 8-10 ml/min (normal ~ 100 ml/min)
Descrbe the symptoms with esrd/dialysis
• Tiredness – Overwhelming fatigue – Physically and mentally incapacitated – Feelings of guilt & ineptitude at needing rest • Difficulty sleeping • Difficulty concentrating
- Symptoms and signs of volume overload (SoB, oedema)
- Nausea & vomiting / reduced appetite
- Restless legs / cramps
- Pruritus
- Sexual dysfunction / reduced fertility
- Increased infections (reduced cellular & humeral immunity)
What are the options when kidneys fail
- Haemodialysis
- Peritoneal dialysis
- Which would you choose?
- Conservative care
- Transplant - best solution for a hance a a more normal life
Describe unit based harmodalysis
• 4 hours, 3 times per
week
• Night-time
• Designated slot
Advantages
– Less responsibility
– Days off
Disadvantages – Travel time / waiting – ‘tied’ to dialysis times – Big restriction on fluid/food intake
What are the contraindications an complications of hd
HD contra-indications and complications
• Contra-indications
– Failed vascular access
– Heart failure a relative contraindication
– Coagulopathy a relative contraindication
• Complications
– Lines: infection, thrombosis, venous stenosis
– AVF: thrombosis, bleeding, access failure, steal syndrome
– CVS instability
– Feel chronically unwell
– Accumulate morbidity (CVS, Bone etc)
Describe bone hd/ nocturnal had
• Allows more dialysis hours • Better large molecule clearance • Patients often feel better
• Patients often need fewer medications (BP meds, phosphate
binders etc)
• Home HD requires someone at home with you
Describe peritoneal dialysis
• 2 options • CAPD : 4-5 bags throughout day
(30 min exchange)
• APD: overnight dialysis
• You are responsible for your care
• Advantages • Self-sufficient / independence • Generally less fluid/food restrictions • Fairly easy to travel with CAPD • Renal function may be better preserved initially
Disadvantages
• Frequent daily exchanges or overnight
• responsibility
What are the contraindications and complications of copd
• Contra-indications
– Failure of peritoneal membrane
– Adhesions, previous abdo surgery, hernia, stoma
– Patient (or carer) unable to connect / disconnect
– Obese or large muscle mass (relative CI)
• Complications – Peritonitis, exit or tunnel site infections – Ultrafiltration failure – Leaks (scrotal, diaphragmatic) – Development of herniae
Descrbe kidney transplant
- Reduced mortality and morbidity compared to dialysis
- Better quality of life
- Peri-operative risk (mortality risk greatest for first 3 months)
- Malignancy risk
- Infection risk
- Risk of diabetes, hypertension from meds
Describe transplant medication
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What are renal replacement therapy options
• Patients with ESRD have
– Reduced life expectancy
– Reduced quality of life
• Transplant is best for survival and QoL
• Nocturnal HD / Extended hours Home HD comes close
• Try understand what patients with long-term conditions have to put up with!
