CKD Flashcards
What is the definition of CKD?
- Irreversible deterioration in renal function
- Develops over a period of years
- Manifests as biochemicala abnormality
How can CKD be classified?
- Based on:
- GFR category
- Albuminuria
- Aetiology
What are the problems with using formula to grade renal disease by eGFR?
- Large discrepancies between individuals
- Can be altered be eating a high protein meal
Why is GFR preferred over serum creatinine for indicating renal impairment?
People with low muscle mass (the elderly) can have normal serum creatinine despite a significant drop in GFR
Clinical features of CKD?
- Elevated urea and creatinine
- Nocturia
- Fatigue, dyspnoea
- Pruritis, N/V
- Kussmaul breathing (from metabolic acidosis)
Describe the classification system for CKD using GFR?
Describe the classification system for CKD using albuminuria?
Describe the classification system for CKD using the underlying disease?
What are the most common causes of CKD in the UK
- Diabetes
- Glomerulonephritis
- Hypertension/renovascular disease
What determines the prognosis in someone with CKD?
- Reduced GFR and albuminuria are independently associated with higher risk of:
- All cause Mortality
- CV mortality
- Progressive kidney disease and kidney failure
- AKI
Importance of trimethoprim in CKD?
- Trimethoprim alters creatinine concentration but not GFR
- Reversible increases serum creatinine, by inhibiting its renal tubular secretion
- Without a change in glomerular filtration rate
- Causes a decrease in calculated creatinine clearance
What are the investigations that can be performed for CKD?
- Blood:
- U&Es, Hb, glucose, Ca2+, PO43-, PTH, ANA, ANCA, antiphospholipi antibodies
- Paraprotein, complement, cryoglobulin, anti-GBM
- Urine:
- Dipstick, MC&S, A:CR, P:CR, Bence jones protein
- Imaging:
- US (small kidney exceptive amyloid & myeloma)
- Histology
Describe the monitoring which should be performed for someone with CKD?
- GFR & albuminuria annually
- If high risk, biannually
What are the risk factors for a decline in renal function in CKD?
- DIM(I)N(I)SSH
- DM
- Infection
- Metabolic disturbance
- (I)
- NSAIDs
- (I)
- Smoking
- Superimposed AKI
- Hypertension
What does managment of CKD require?
- Appropriate referral to nephrology
- Treatment to slow renal disease progression
- Treatment of renal complications of CKD
- Treatment of other complications of CKD
- Preparation for renal replacement therapy
When should a referral to nephrology be considered in someone with CKD?
- Stage G4 and G5 CKD
- Moderate proteinuria A:CR >70mg/mmol
- Proteinuria A:CR >30mg/mmol with haematuria
- Declining eGFR
- BP poorly controlled w/ >3 antihypertensives
- Known or suspected rate/genetic cause of CKD
Describe treatments to slow renal disease progression in CKD?
- Target BP < 140/90
- DM BP <130/80
- ACEi/ARB
- Do not combine drugs due to hyperkalaemia risk
- Low salt intake . (2g sodium)
- Target Hb1AC of around 53 mmol/mol
- Exercise, healthy weight and smoking cessation advice
Name some renal complications of CKD?
- Anaemia
- Acidosis
- Oedema
- Bone-mineral disorders
- Restless legs/cramps
- Diet
Describe the treatment of anaemia as a complication of CKD?
- Iron, B12 and folate therapy if required
- Do not miss chronic blood loss
- If Hb <110g/L
- Consider erythropoeitin stimulating agent
Describe the treatment of acidosis as a complication of CKD?
- If eGFR <30 and serum bicarbonate <20mmol/L
- Consider sodium bicarbonate supplements
- Caution in hypertensive and fluid overloaded patients due to sodium component
Describe the treatment of oedema as a complication of CKD?
- Restrict fluid and sodium intake
- High dose loop diuretics may be required
- +/- thiazide diuretic
How does CKD induce bone-mineral disorders?
- Two components:
- Impaired excretion of phosphate
- => Phosphate triggers PTH release
- Impaired ability to convert vitamin D to its active form
- => Impaired absorption of calcium
- Impaired excretion of phosphate
Describe the treatment of bone-mineral disorders as a complication of CKD?
- Dietary restrictions of phosphate containing foods
- Milk, cheese, eggs
- Phosphate binders
- Calcium carbonate
- Active vitamin D metabolites if hypocalcaemia occurs
Describe the treatment of restless legs/cramps as a complication of CKD?
- Exclude iron deficiency as exacerbating factor
- Give sleep hygiene advice
- Gabapentin/pregabalin/dopamine agonists for severe cases
- SEs: falls cognitive impairment, impulse-control disorder
Describe the treatment of diet as a complication of CKD?
- Dietician input
- Specifically protein intake, K+, phosphate restriction (dairy)
Describe the treatment of CVD as a complication of CKD?
- Higher CVD risk due to hypretension, inflammation, oxidative stress etc
- Antiplatelets: aspirin
- Atorvastatin 20mg for prevention of CVD
- End stage renal failure can influence troponin and BNP values
Describe the prearations for renal replacement therapy in CKD?
- Prep should begin when risk of renal failure is 10-20% within a year
- Referral to nephrology should be more than 1 year before RRT is required
- Suitable patients hsould be listed for a deceased donor transplantation
Name some drugs which are excreted renally therefore should have their administrations altered?
- Aminoglycosides
- Penicillins, cephalosporins
- Heparin
- Lithium
- Opiates
- Digoxin
- *Loading doses should not be changed*
Where do loop diuretics have their action?
- Inhibit sodium-potassium-chloride cotransporter in the thick ascending limb
- Transporter normally reabsorbs 25% of the sodium load
- More effective than thiazide diuretics
Where do thiazide diuretics have their action?
- Inhibit the sodium-chloride transporter in the distal tubule
- Normally reabsorbs 5% of filtered sodium
Where do potassium sparing diuretics have their action?
- Antagonize the actions of aldosterone at the distal segment of the distal tubule
- More sodium to pass into the collecting duct and excreted in urine
What is end-stage renal disease (ESRD)?
- When death is likely without RRT
- CKD stage 5
What can be used to manage proteinuria in CKD?
ACEi / ARBs
