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Renal > CKD > Flashcards

CKD Flashcards

1
Q

What is the definition of CKD?

A

Chronic Kidney Disease - abnormal kidney structure or function, present for more than 3 months with implications for health - can also include those with just a reduced GFR of less than 60.
Irreversible.

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2
Q

Which things do we use to categorise CKD?

A

GFR
Albuminuria
Pathological cause

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3
Q

Describe the classification using GFR

A 
G1 = above 90
G2 = 60-89
G3a = 45-59 (mild)
G3b = 30-44 (moderate)
G4 = 15-29 (severe)
G5 = lower than 15 (failure)
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4
Q

Describe the classification of CKD with albuminuria

A

This is based on the ACR, and sometimes just use the Cr
A1 = 0-30
A2 = 30-300
A3 = above 300

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5
Q

What are the different types of renal pathology that can cause a CKD?

A 
Glomerular 
Tubulointerstitial
Vascular
Cystic/congenital
Transplant
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6
Q

What is the prognosis like for CKD?

A

This varies depending on the GFR and albuminuria.
If low GFR or high albuminuria, this is associated with a higher risk of:
mortality
CVD
ESRD
AKI

A1, G1/2 = low risk
A1, G3a = moderate risk
A1 G3b = high risk
A1 G4 = v high risk

A2 G1/2 = moderate risk
A2 G3a = high risk
A2 G3b = v high risk

A3 G1/2 = high risk
A3 G3-5 = v high risk

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7
Q

What are the most common causes of CKD in the UK?

A

Diabetes
Glomerulonephritis
Renovascular disease

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8
Q

What do you ask about in PMH to try to determine the cause of CKD?

A 
Previous UTI
Previous transplant
LRT symptoms
HTN
DM
IHD
Renal colic

DRUGS WHAT HAS BEEN RECENTLY STARTED

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9
Q

What do you ask about in the family to see what the risk of CKD is?

A

Renal disease

SAH

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10
Q

What sort of things cause vascular kidney disease?

A

Renal vasculitis
HF
TTP

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11
Q

What sorts of things cause glomerular CKD?

A

Membranous change

DM
Amyloidosis

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12
Q

What can cause tubulointerstitial CKD?

A

UTI
Pyelonephritis
Stones

Drugs
Toxins
Sarcoidosis

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13
Q

What can cause cystic/congenital CKD?

A

Renal dysplasia

Alport syndrome
Fabry disease

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14
Q

What can cause transplant CKD?

A

Recurrence of renal disease
Rejection
Calcineurin toxicity

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15
Q

What do we ask in a systems review for CKD?

A

Eyes, skin, join problems?

Malignancy signs

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16
Q

What are the symptoms of CKD?

A 
Fluid overload (SOB, PO, HTN)
Fatigue
Anorexia
Nausea/Vomiting
Pruritis

Bone pain
Arthralgia
Foamy or cola urine
Retinopathy

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17
Q

What are the risk factors of CKD?

A

Over 50
PMH of KD
DM
HTN

Male
Black/hispanic
FH
Smoking
Obesity
Long term analgesic/NSAIDs
AI
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18
Q

What peripheral signs indicate CKD?

A 
Vascular disease signs
Joint disease
Gouty tophi
Fistula
Bruising (steroids)
Encephalopic flap (high urea)
Anaemia
Xanthelasma
Uraemia (yellow tinge)
Jaundice (hepatorenal)
Gum hypertrophy (ciclosporin)
Cushingoid (steroids)
Periorbital oedema (nephrotic syndrome)
Taut skin (scleroderma)
Facial lipodystrophy (glomerulonephritis)

JVP (overload)
Parathyroidectomy scar
Lymphadenopathy

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19
Q

What signs from a CV exam can suggest potential kidney problems?

A

High BP
Sternotomy (recent mitral valve)
Cardiomegaly
Peripheral oedema

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20
Q

What signs from a resp exam indicate potential kidney problems?

A

Pulmonary oedema
Peripheral oedema
Pulmonary effusion

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21
Q

What signs from an abdo exam suggest potential kidney problems?

A

Ballotable kidneys
Palpable liver
Transplant scars
Catheter

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22
Q

What investigations do we do for CKD?

A 
FBC - ACD
Glc - DM
Serum Cr - raised
MSU - protein/blood/albumin/Bence Jones - Multiple myeloma/uPCR/uACR 
MCS
GFR

ANA, ANCA - AI
Low calcium - kidneys aren’t converting vit D so no Ca absorption
High phosphate - kidneys aren’t excreting
High PTH - stimulated by low Ca - renal osteodystrophy

Renal USS - usually small unless infiltrative disease (amyloid, myeloma), APKD and DM. Asymmetry in congenital and vascular diseases

Consider renal biopsy

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23
Q

What are ANA and ANCA?

A

Antinuclear antibodies
Anti-Neutrophilic Cytoplasmic Autoantibodies

Present in autoimmune disease

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24
Q

How often do we monitor those with CKD?

A

GFR and albuminuria:
Annually if low risk
6 monthly if moderate
3 monthly if high

Worry if eDFR drop >25%

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25
Q

What makes CKD worse?

A 
HTN
DM
Metabolic syndrome
Dehydration
Infection
NSAIDs
Smoking
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26
Q

Differentials of CKD?

A

Diabetic nephropathy
HTN nephrosclerosis
Ischaemic nephropathy
Glomerulonephritis

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27
Q

What is urea?

A

This is a waste product of protein which is filtered by the kidney

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28
Q

What is creatinine?

A

This is a waste of muscle breakdown which is filtered by the kidneys

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29
Q

Which is better? Urea or creatinine?

A

Creatinine because it is affected less by diet.

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30
Q

What is uACR?

A

Urine albumin creatinine ratio. This is urine albumin/urine creatinine from a random urine and shows us albumin excretion in mg/day. This is classed as albuminuria if more than 30mg per day. Used because shows amount of albumin over a longer period of time.

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31
Q

What is uPCR?

A

Urine protein creatinine ratio. This is the protein/creatinine in a random urine. Gives us estimated protein excretion in mg/day. We worry if this is above 150mg

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32
Q

What do PD and HD stand for?

A

Peritoneal dialysis and haemodialysis

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33
Q

How long does CKD last for?

A

Lifelong

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34
Q

Why is MSU, MS? and when is best to get it?

A

It is midstream because this reduces the chance of cross contamination from the bacteria around the urethral opening.
It is best to collect it in the morning because this is when the samples are most concentrated and abnormalities can be picked up more reliably.

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35
Q

What can cause proteinuria?

A 
UTI
CKD
Fever
HTN
Nephrotic syndrome
Pregnancy
Recent exercise
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36
Q

Which cause of CKD does proteinuria indicate?

A

Glomerular

Tubulointerstitial

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37
Q

What does pyuria or WCC indicate?

A

Interstitial nephritis or UTI

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38
Q

Which urinary white cells strongly indicate nephritis?

A

Eosinophils

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39
Q

What reduces the risk of CVD the most?

A

Having a good BP

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40
Q

Why is there normally protein in the urine?

A

Tamm-Horsfall protein, also known as uromodulin, is secreted by renal tubules.

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41
Q

Which blood pressure tablet would you use for someone with DM, renal problems and HTN?

A

ACE-i/ARB

These are considered renoproductive and have been shown to slow the damage to the kidney and reduce albuminuria.

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42
Q

What is GFR?

A

THIS IS JUST AN ESTIMATED VALUE.
Based on creatinine, age, sex and race.
It is prone to error so don’t take it as gospel.

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43
Q

How do ACEis and ARBs reduce proteinuria/albuminuria?

A

The efferent tubule is more vasodilated due to lack of RAS. This reduces the hydrostatic pressure in Bowman’s space, reducing protein/albuminuria

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44
Q

What are the side effects of ACEis?

A 
Dry cough, common
Hypotension - dizziness, headache
Angioedema
Hyperkalaemia
AKI
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45
Q

What is an acceptable rise of Creatinine after starting ACEi/ARBs?

A

25-30%

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46
Q

What would a significant rise of creatinine indicate?

A

Renovascular disease

Renal artery

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47
Q

What are the contraondications on ACEis and ARBs?

A

Pregnancy

AKI

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48
Q

When should you refer to renal?

A

If G5 refer immediately
If G4 refer urgently
If G3 refer routinely if other clinical signs such as anaemia, proteinuria, haematuria, abnormal salts or if recent fall in GFR

Refer in any:
AKI
Haematuria
Proteinuria
Hyperkalaemia
Malignant HTN
Nephrotic syndrome
Systemic illness
Outflow obstruction
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49
Q

What are the complications of CKD?

A 
Renal Anaemia (low EPO)
Oedema/hypervolaemia
CVD
CKDMBD (mineral bone disorder) low CA, HPT^
Metabolic acidosis (low HCO3)
Restless leg syndrome (uraemia)
Hyperkalaemia
Hyponatraemia
50
Q

What is a metabolic screen?

A

Blood tests that screen for metabolic complications, involving:

Glucose (HbA1c)
Calcium

Proteins: albumin and total protein

UEs: NA, K, Urea, Cr, Cl, CO2

LFTs: ALT, AST, ALP, Bilirubin

51
Q

How do we treat renal secondary hyperparathyroidism?

A

Calcitriol/alphacalcidol

52
Q

How do we treat renal anaemia?

A

EPO and IV iron

Target ferratin at above 200 in CKD

53
Q

How do we treat hyperkalaemia with CKD?

A

Dietary restriction and then ACEi if that doesn’t work.

54
Q

How do we treat the metabolic acidosis?

A

Oral alkali such as sodium bicarbonate

55
Q

How do we reduce the progression of CKD?

A

Treat HTN
Reduce cholesterol
Prevent/treat UTI
Treat the underlying cause e.g. diabetes

56
Q

What would you see in a urine dipstick in CKD?

A

Proteinuria
Haematuria
Glucosuria

57
Q

What is ESRD?

A

The point at which a person cannot live on their renal function and renal replacement therapy must occur - dialysis or transplant

58
Q

How big are the normal and abnormalities of a kidney?

A

Normal - 11cm
Atrophy - 7.5cm
Hypertrophic - 13.5cm
Polycystic - 18.4cm

59
Q

What does acute on chronic renal failure mean?

A

That an AKI has occured in someone who has CKD

60
Q

What is azotaemia?

A

Elevation of nitrogenous metabolic waste (urea) in the blood due to failure of clearance by the kidneys.

Urea in the blood

61
Q

What does uraemia mean?

A

This is a clinical syndrome, not just the presence of urea in the blood.
A result of azotaemia which is failure of the kidneys and progressive azotaemia.

62
Q

How can we assess kidney function?

A 
Renal blood flow
GFR
Reabsorption: Glu, aa, phosphates, Na, HCO3
Urine concentration
Excretion: K, H, Cr
Renin
EPO
Activation of Vit D (colecalciferol to vit D)
63
Q

What is the normal range for GFR?

A

100-130ml/min/1.73m2

64
Q

Urine is what percent of the total volume filtered by the blood?

A

1% :o

65
Q

How much filtrate gets absorbed in different parts of the tubules?

A

Proximal tubule - 80% reabsorbed
LoH - 6% H2O and salt conservation to regulate fluid status
Distal tubule - 9% reabsorbed and active secretion
Collecting tubule - 4% filtrate reabsorbed

66
Q

What are the different ways in which we can measure GFR?

A

Isotope GFR which is measured via radioactive Cr

eGFR

67
Q

Is a serum creatinine normal level the same for everyone?

A

Fuck no.
eGFR is a good way of taking creatinine and telling us if that is okay or not.
E.g. 110umol/L may be good for a young, strong man and very bad for a weaker old lady

68
Q

Which diseases can cause direct kidney damage to put someone at risk of CKD?

A 
Diabetes
HTN
AI
Systemic sepsis
UTI
U stone
U obstruction
Drug toxicity
69
Q

Which groups of people are at higher risk of CKD?

A 
Older age
FH
Smaller kidneys
Low birth weights
Ethnic minorities
Low income
70
Q

What is nephrotic syndrome?

A

Triad of peripheral oedema, heavy proteinuria (more than 3.5g/day) and hypoalbuminaemia

71
Q

What are some causes of nephrotic syndrome?

A

Diabetes
Focal glomerulonephritis
Membranous nephropathy
Pre-eclampsia in late pregnancy

72
Q

What sort of nutritional management do we use in CKD?

A 
Adequate calorie and protein intake. 
Salt restriction
Fluid management
Supplement
Lipid control
Weight management
73
Q

What do we aim for BP to be in those with CKD?

A

Threshold 140/90
Target 130/80
Target 125/75 if proteinuric states uPCR more than 100

74
Q

With patients in CKD, we use ACEi and ARB and diuretics. When might we stop diuretics?

A

If eGFR lower than 30ml

75
Q

When would we start preparing for renal replacements?

A

Stage 4 CKD

76
Q

What immunisations do we give before renal replacements?

A

Pneumococcal
Influenza
Hep B

77
Q

What are the symptoms of uraemia?

A

N/V
Itching
Pruritis
Weakness

78
Q

What are the options of treatment for renal replacement?

A

Peritoneal dialysis (CAPD, APD)
Haemodialysis (at home too)
Transplant
Conservative management (palliative)

79
Q

You stop diuretics at 30mL/min/1.73m2, what else do you stop?

A

Metformin and all diabetic drugs.

80
Q

What does CAPD stand for?

A

Continuous ambulatory peritoneal dialysis.

81
Q

What does CAPD involve?

A

A peritoneal tube inserted through the tummy, about the width of a pencil and 40cm long, 15cm of which remains outside. This is then connected to peritoneal dialysis bags 4 times a day in what is a called a PD cycle. The tube is changed every 6 months.

82
Q

What is a peritoneal dialysis cycle?

A 
This is PD done at home with CAPD and involves connecting a new and a drain bag.
Draining the old fluid. 
Filling the new fluid in.
Disconnecting the new bag.
Uses osmosis.
83
Q

What lifestyle changes do you advise in CKD?

A

Stop smoking
Exercise
Cholesterol

84
Q

How do we treat HTN with CKD?

A

Stage 1&2 CKD - ACEI/ARB

Stage 3 - add a diuretic

85
Q

How do we treat CVD risk with CKD?

A

Aspirin when Stage 3 & 4

86
Q

Which statin should be used to lower lipids in CKD?

A

Atorvastatin

Most clinical and cost effective

87
Q

Can you take amplodipine and simvastatin at the same time?

A

Yes, but if taking more than 20mg amlodipine then higher risk of myopathy and rhabdomyolysis

88
Q

Which consequences of CKD can cause breathlessness?

A

Anaemia
Fluid overload/PO
Metabolic acidosis
HF

89
Q

What are the indications to start dialysis?

A

Fluid overload
Refractory hyperkalaemia
Uraemic symptoms - N/V, w/l, neurological symptoms, uraemic pericarditis

90
Q

If a patient chooses PD, what then needs to be inserted?

A

Tenckhoff catheter

catheter to peritoneum

91
Q

If a patient chooses HD, what needs to be inserted?

A

AV fistula

92
Q

When do those with advanced renal disease start dialysis

A 
When they are symptomatic:
fatigue
nausea
SOB
decreased appetite
93
Q

How long does it take to make dialysis happen?

A

3-6 months

94
Q

What kind of donations can you have?

A

Deceased donor

Living donor

95
Q

What is HD?

A

When the blood is passed through an outside kidney called a dialyser. This is done for 4 hours, three times a week and can be done from an AV fistula (takes about 3 months for a fistula to be ready)

96
Q

What is dialysate?

A

The solution used in PD

97
Q

What does APD stand for?

A

Automated peritoneal dialysis

98
Q

What is APD?

A

This is peritoneal dialysis overnight (7-10 hours) so does it as you sleep

99
Q

What can make home dialysis hard?

A

Addiction
Mental Impairments
Abdominal surgeries
Too scared

100
Q

What are the different challenges of home dialysis can we help to overcome?

A

Limited vision/hearing
Learning problems
Physical limitation

We can have extra support or train family members and even start a mentorship scheme so you’re not alone

101
Q

If you can do what, you can do dialysis?

A

Manage an ATM
and
Button a shirt

102
Q

What restrictions are there on HD that there aren’t on PD?

A

Fluid restriction

Specific diet

103
Q

Why might some people pick home dialysis?

A 
Autonomy
Live away from hospital
Scared of needles
Caring for others
Travelling a lot
104
Q

Where and when does HD happen and what do I need to do?

A 
In a hospital, can be at home
4 hours
3x per week
Make dietary changes
Fluid restriction
105
Q

Where and when does PD happen and what do I need to do?

A 
CAPD - 30 minutes 4x day
APD - 7-10 hours per night
Portable
Plan
Don’t need to fluid restrict 
Helps preserve residual urine output 
Can have nurses sent out to help you set things up and run them until you are comfortable
106
Q

What are contraindications for HD?

A 
Absolute: no IV access
Relative:
Severe dementia
Severe HF
Severe psychotic disorder
Bleeding disorder
LBP
107
Q

What are the absolute contraindications for PD?

A 
IBD (active)
Ischaemic bowel
Diverticulitis
Abdo abscess
Pregnant in 3rd trimester
108
Q

What are the relative contraindications for PD?

A 
Abdo hernia
Stoma
Multiple abdo ops
Blind
Bad dexterity
Obesity
Poor hygiene
Severe dementia
Severe nephrotic proteinuria
Severe obstructive resp 
Severe psychotic disorder
109
Q

What are the absolute indications for transplant?

A

Active malignancy

Concurrent/recurrent infection

110
Q

Which blood tests do you do for ESRD?

A

FBC - anaemia for EPO, ACD, Fe low
UEs - hypercalcaemia, low bicarb
Ca, Pi, PTH -

111
Q

Why do you get iron deficient in ESRD?

A

Hepcitin helps absorb iron and allows it to store. It is secreted by the kidneys so if no kidneys, no hepcitin.

112
Q

Which types of anaemia can you get in ESRD?

A

EPO
Low Fe due to hepcitin
ACD

113
Q

What is PTHs main task?

A

Keep calcium in range 2.2-2.6

114
Q

What are the disadvantages of PD?

A

Increased risk of peritonitis

115
Q

How long do you continue on peritoneal dialysis?

A

About 5 or 6 years
Peritoneal membrane can be damaged form the glucose in the dialysate which can cause sclerosing peritonitis.
Risk after about 10 years

116
Q

What are the benefits of HD?

A

4 days a week without anything
Someone else does it for you.
Trained to do it at home
Treatment can be given during dialysis

117
Q

What are the negatives of HD?

A 
Fistulas are surgeries of the highest failure rate
Harder to travel 
Fluid restriction
Catheter ass infections
Predominantly hospital based
Makes you tired
Rapid fluid shifts can cause symptoms
Small bleeding risk ass with anticoagulants given to prevent clots in the dialysis process
118
Q

What are the advantages of PD?

A 
Less fluid restriction
Home based
 No needles
No blood
More portable 
Can start quicker than HD
119
Q

What are the disadvantages of PD?

A 
Impact on daily routine
Risk of peritonitis
Peritoneal sclerosis risk
Regular laxatives needed
Home considerations
Fails after 6 years
120
Q

Transplant advantage

A 
Independence 
Survival advantage
No restrictions dietary
Fewer symptoms
Less IDA, MBD
121
Q

Disadvantages of transplant?

A

Immunosuppressive side effects - malignancy, diabetes, weight gain, diarrhoea
Infections
Malignancy

Renal (8 decks)

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