CKD

Question 1

What is CKD?

Answer 1

Abnormal kidney function and/or structure

Question 2

What will CKD commonly co-exist with?

Answer 2

CV disease
Diabetes 
AKI
Falls
Fragility

Question 3

What is the diagnostic criteria for CKD?

Answer 3

2 samples of raised creatinine and low eGFR for more than 90 days

Question 4

What does eGFR take into consideration?

Answer 4

Serum creatinine level
Age
Sex
Race

Question 5

What is stage G1 CKD?

Answer 5

eGFR more than 90 ml/min

Normal kidney function but urine findings or structural abnormalities or genetic trait to point to kidney disease

Question 6

What is stage G2 CKD?

Answer 6

eGFR of 60-90 ml/min
Mildly reduced kidney function but urine findings or structural abnormalities or genetic trait to point to kidney disease

Question 7

What is stage G3a CKD?

Answer 7

eGFR of 45-59
Moderately reduced kidney function - risk of endocrine and CV risks increased
Requires follow up

Question 8

What is stage G3b CKD?

Answer 8

30-44

Question 9

What is stage G4 CKD?

Answer 9

eGFR 15-29

Severely reduced kidney functin

Question 10

What is stage G5 CKS?

Answer 10

eGFR <15 ml/min

Established renal failure

Question 11

What is category A1 ACR (albumin creatinine ratio)?

Answer 11

<3 mg/mmol

Question 12

What is category A2 ACR?

Answer 12

3-30 mg/mmol

Question 13

What is category A3 ACR?

Answer 13

> 30 mg/mmol

Question 14

How long should someone be monitored after an AKI?

Answer 14

2-3 years after AKI even if serum creatinine has returned to baseline
Advise people who have had an AKI that they are at increased risk of CKD

Question 15

What else should you test for when testing for CKD using eGFR and ACR?

Answer 15

Diabetes
Hypertension
CV disease
Structural renal disease, recurrent renal calculi or prostatic hypertrophy
Multisystem disease with potential kidney involvement = SLE
Family history of end-stage renal kidney disease
Opportunistic detection of haematuria

Question 16

What is the definition of accelerated progression of CKD?

Answer 16

Sustained decreased in eGFR of 25% or more and a change in GFR category within 12 months
OR
sustained decrease in GFR of 15 ml/min/1.73m2 per year

Question 17

What are risk factors for CKD progression?

Answer 17

CV disease
Proteinuria
AKI
Hypertension
Diabetes
Smoking
African, afro-carribean or asian family origin
Chronic use of NSAIDs
Untreated urinary outflow tract obstruction

Question 18

When should people be referred to nephrology?

Answer 18

eGFR of less than 30 ml/min/1,72 m2 (G4 or 5) with or without diabetes
ACR 70 mg/mmol
ACR 30 mg/mol with haematuria
Sustained decreased in eGFR 25% or more
Poorly controlled hypertension despite the use of 4 antihypertensive drugs
Known of suspected rare or genetic causes of CKD
RAS

Question 19

What is the BP targets in those with CKD?

Answer 19

140/90 mmHg

Question 20

What is the BP target in those with CKD and diabetes?

Answer 20

130/80`

Question 21

When should the dose of an ACEI/ARB not be modified?

Answer 21

GFR decreased from pre-treatment baseline less than 25%

Serum creatinine increase from baseline less than 30%

Question 22

What drug should be offered to everyone with CKD?

Answer 22

Atorvastatin 20mg as primary or secondary prevention of CVD

Increase dose if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73m2

Question 23

What are the 2 commonest causes of CKD?

Answer 23

Diabetes mellitus

Hypertension

Question 24

What are the different types of glomerulonephritis?

Answer 24

Primary e.g membranous/IgA/ primary focal segmental glomerulosclerosis
Secondary: DM/SLE/FSGS due to HIV/ heroin/ obesity

Question 25

What are the vascular causes of CKD?

Answer 25

RAS Ischaemia/ hypertensive nephrosclerosis Microangiopathic: HUS/ TTP/ HELLP/ pre-eclampsia Small cell vasculitis : GPA, MPA, EGPA

Question 26

What are the tubulointerstitial causes of CKD?

Answer 26

Acute Interstitial Nephritis (AIN) Acute tubulointerstitial nephritis (TIN) Autosomal Dominant Polycystic Kidney Disease (ADPKD) Reflux nephropathy

Question 27

What are the post renal causes of CKD?

Answer 27

Calculi - renal, ureteric, bladder Prostatic - benign prostatic hyperplasia (BPH), cancer Bladder - malignancy, bladder wall thickening Urethral stricture

Question 28

What are the clinical signs of CKD?

Answer 28

Anaemia - conjunctival and palmer pallor Signs of weight loss Early morning nausea and vomiting Advanced uraemia: lemon yellow, uraemic frost, twitching, encephalopathic flap, confusion, pericardial rub or effusion, jussmal breathing

Question 29

What are the symptoms of anaemia related CKS?

Answer 29

Fatigue | Muscle pain

Question 30

What pain can be associated with CKD?

Answer 30

Bony Neuropathic Ischaemic Visceral

Question 31

What uraemic symptoms are associated with CKD?

Answer 31

``` N+V Anorexia Wt loss Fatigue Itch Altered taste Restless legs Muscle twitching Difficulties concentrating Confusion ```

Question 32

What are the renal consequences of CKD?

Answer 32

Local - pain/ haemorrhage/ infection/ stones Urinary - haematuria/ proteinuria (frothy urine)/ nocturia/ oliguria Impaired salt and water handling - oedema, dehydration Hypertension Electrolyte abnormalities Acid-base disturbance End stage renal disease (ESRD)

Question 33

What are the extra-renal consequences of CKD?

Answer 33

CVD Mineral and bone disease Anaemia Nutrition

Question 34

What are the renal replacement therapies available?

Answer 34

Hemodialysis Peritoneal dialysis Transplantation Conservative management

Question 35

What can be done to reduce the risk of CVD in those with CKD?

Answer 35

``` Smoking cessation Weight loss Aerobic exercise Limiting salt intake Control of hypertension Lipid lowering therapy Aspirin for secondary prevention - can increase risk of GI bleed ```

Question 36

What ions and minerals are important in bone health?

Answer 36

``` Calcium Phosphate PTH Vitamin D FGF-23 (responsible for vitamin D and phosphate metabolism in the bones) ```

Question 37

What are consequences of CKD mineral and bone disease?

Answer 37

``` Secondary/ tertiary HPT Vascular calcification Bone pain Fractures CV events Lower quality of life High morbidity and mortality ```

Question 38

What dietary advice can be given for management of CKD-MBD?

Answer 38

``` Phosphate restriction Salt reduction Potassium restriction Fluid restriction to 1-1.5L a day Correct metabolic acidosis ```

Question 39

What medications can be given in CKD-MBD?

Answer 39

Alfacalcidol Phosphate binders Calcimimetic

Question 40

What is the target Hb in CKD?

Answer 40

100-120 g/L

Question 41

What needs to be investigated in anaemia in CKD?

Answer 41

Other causes: exclude B12 and folate deficiency | Check ferritin and iron stores aiming for; ferritin > 100

Question 42

How is renal anaemia manged?

Answer 42

Iron therapy