CKD and prescribing in renal disease

Question 1

CKD

Diagnosis

Answer 1

loss of renal function over time. Once half total number of nephrons lost, progresses similarly regardless of aetiology

Decline of kidney function for 3 months or more AND
Evidence of kidney damage (e.g. albuminuria or abnormal biopsy) OR
GFR <60 mL/min/1.73 m2

Question 2

CKD Classification

classify severity using: GFR and Albumin: Creatinine Ratios

Answer 2

Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2)
Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2)
Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m2)
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2)
Stage 5: Kidney failure (GFR <15 mL/min/1.73 m2 or dialysis

Question 3

Progression of CKD

Answer 3

Anaemia
Metabolic acidosis
Osteodystrophy
Hyperparathyroidism

NO cure, @stage 5 - dialysis or transplantation

Question 4

CKD causes

Answer 4

• Chronic damage -Glomerulonephritis, Chronic Interstitial nephritis, pyelonephritis
• Drugs
• Systemic diseases - Diabetes - diabetic nephropathy, HTN - nephrosclerosis, Hyperlipidaemia
• Autoimmune - SLE, Wegener’s granulomatosis, vasculitis, Goodpasture’s syndrome
• Genetic - polycystic kidney disease, posterior urethral valves, dysplastic kidneys

Question 5

Pathogenesis of CKD

Answer 5

Dec in nephron number - glomerular injury
adaptive hyperfiltration at glomerulus
Inc glomerular permeability - inc protein filtration and macromolecules (Proteinuria and dyslipidaemia)
Inc RAAS -
early ( inc SNGFR > adaptive hyperfiltration)
HTN

Nephtotoxic inflammation and remodelling

Later -
Tubulointerstitial Fibrosis and 2 FSGS

Dec GFR, Urine output
Systemic complications

Question 6

CVD in CKD

Answer 6

Uremic Cardiomyopathy
Uremic Arteriopathy

• MI
• CHF
• Sudden Cardiac Death
• Stroke

Question 7

Management goals

Answer 7

Goals
•Prevent progression to Kidney failure or ESRD
•Prevent CVD
•Prevent complications of CKD
•Prepare for dialysis/transplantation in a timely manner

Refer to specialist -
GFR<30ml/min with or w/out diabetes
sustained dec in GFR within 12 months
Suspected RAS
ACR 70mg/mmol or more - unless from diabetes and being treated
ACR 30mg/mmol with haematuria
Known or suspected genetic causes

Question 8

Complications of CKD and management

Answer 8

• Na retention and volume overload - Na restrictions, Diuretics
• Hyperkalaemia - Dietary restrictions, avoid nsaids
• Metabolic acidosis - Sodium bicarbonate
• Calcium/ phosphate imbalance/ Renal osteodystrophy - phosphate binders, calcimimetics, Vit D
• Anaemia (

Question 9

Kidney functions

Answer 9

• Sodium balance
• Potassium excretion
• Acid excretion
• Calcium/ phosphate balance
• Erythropoiesis

Question 10

Managing CKD in primary care

Answer 10

•Assess for and manage risk factors and co-morbidities
• Assess for HTN ; ACEi/ARBs(Not together!)
• Statins
• Antiplatelet for 2 prev of CVD
• Offer immunizations for Flu and pneumococcal
•Lifestyle - obesity, smoking, alcohol
- avoid NSAIDs and herbal remedies
Advise on increased risk of AKI
Provide sources of information, support and advise