CKD

Question 1

CKD definition

Answer 1

Impaired renal function for >3months based on abnormal structure or function, OR GFR<60mL/min/1.73m2 for >3months with or without evidence of kidney damage.

Question 2

CKD 5 stages and GFR

Answer 2

1= GFR> 90 Only CKD if other evidence of kidney damage: protein/haematuria

2= 60–89

3a= 45-59 mild-moderate

3b= 30-44

4= 15-29

5= <15 Kidney failure

Question 3

At what GFR do symptoms occur

Answer 3

<30

Question 4

Risk factors

Answer 4

• Diabetes mellitus
• Hypertension
• Age >50y
• Childhood kidney disease
• Smoking
• Obesity
• FH of CKD
• Autoimmune disorders

Question 5

Signs and symptoms CKD

Answer 5

1. Fatigue
2. Pallor – anaemia
3. Uraemic tinge to skin (yellowish)
4. Oedema – feet and ankles
5. Nausea with/without vomiting
6. Pruritus & excoriations
7. Restless legs
8. Anorexia
9. Nocturnal polyuria

Question 6

CKD investigations- bloods

Answer 6

Haemoglobin: for anaemia (normally low EPO causes normochromic, normocytic anaemia)

U&E: for low calcium, for high urea

Glucose: for diabetes mellitus

High phosphates

High alkaline phosphatase (ALP)

High PTH levels: means CKD stage 3+

Question 7

CKD investigations- urine

Answer 7

Dipstick: haematuria and/or proteinuria

MC&S (microscopy, culture and sensitivity) because rapid dec in GFR can be due to infection

High Albumin : creatinine ratio

High Protein : creatinine ratio

Question 8

CKD investigations- imaging

Answer 8

USS for size, symmetry, anatomy, corticomedullary diff erentiation, and
to exclude obstruction. In CKD kidneys may be small (<9cm)

If asymmetrical consider renovascular
disease. Scarring may be seen on USS but isotope scans are more sensitive.

Question 9

CKD- Identifying and Treating Reversible Causes

Answer 9

• Relieve obstruction
• Stop nephrotoxic drugs
• Deal w high Ca2+
• Lifestyle to lower cardiovascular risk: smoking cessation, achieve healthy weight
• Tight glucose control in DM

Question 10

CKD- Limiting Progression/Complications BLOOD PRESSURE

Answer 10

Target BP <130/80; diabetic <125/75; ACR >70

Renin-angiotensin system antagonist (first line: ACEi)

In Diabetic Kidney Disease, give ACEi or ARB EVEN with normal BP (ACEi are renoprotective in DKD)

Monitor eGFR and serum potassium
Furosemide can be used as antihypertensive

Question 11

CKD- Limiting Progression/Complications BONE DX

Answer 11

Treat any raised PTH (note: high phosphates increase PTH too)
Restrict diet of phosphates
Phosphate binders: usually calcium-based binders or sevelamer
Vit D analogues (e.g. alfacalcidol, calcitriol)
Calcium supplements to decrease bone disease and hyperparathyroidism (2ndary and tertiary)
Parathyroidectomy may be required

Question 12

CKD- Limiting Progression/Complications CARDIOVASCULAR MODIFICATION

Answer 12

Statins to patients w raised lipid profile

Aspirin

Question 13

CKD- Limiting Progression/Complications DIET

Answer 13

moderate protein diet, K+ restriction if hyperkalaemic, avoidance of high phosphate foods (e.g. milk, cheese, eggs)

Question 14

What ACR value indicates the need for ACEi ?

Answer 14

NICE guidelines recommend prescribing an angiotensin converting enzyme (ACE) inhibitor to all patients with chronic kidney disease (CKD) who have a urinary ACR or 70mg/mmol or more