CKD - Assessment and management Flashcards
What is the definition of CKD?
- impaired renal function for >3months based on abnormal structure or function
- GFR 3months +/- kidney damage?
What are the 5 stages classifying renal impairment?
GFR
1. >90 - Normal or increased GFR with other evidence of renal damage
2. 60-89 - slight reduction in GFR with evidence of renal damage
3a. 45-59 - moderate reduction of GFR with OR without evidence of renal damage
3b. 30-44 - same as above
4. 15-29 - Severe reduction of GR with OR without evidence of renal damage
5.
When do symptoms typical occur in CKD?
Typically at stage 4
What are the causes?
- Diabetes!
- Glomerularnehpritis
- Unknown - up to 20%
- Hypertension or renovascular disease
- Pyelonephritis and reflux nephropathy
Who would you screen for CKD?
Any one with any one of these:
- Diabetes
- Hypertension
- Cardiovascular disease - IHD, PVD, CVD
- Structural renal disease, stones, BPH
- Recurrent UTIs
- Multisystem disorders that could involve the kidneys eg.SLE
- Family history of ESRF, polycystic kidney disease
- Haematuria / proteinuria
What must you include in your history?
- CAUSES - previous UTIs, lower-urinary tract symptoms, past history of HTN, DM, IHD, Systemic disorders. Drug and family history. Be on the look out for rarer causes + malignancy.
- CURRENT STATE - uraemic symptoms (anorexia, restless leg, vomiting, fatigue, weakness, pruritus, bone pain. Check for oliguria, dyspnoea, ankle swelling.
What must you include in an examination of a patient with suspected CKD?
Looking for:
1. Periphery - HTN, AV fistula, signs of previous transplant, bruising from steroids, skin malignancy and immunosuppression
- Face - Pallor (anaemia), yellow tinge (uraemia), gum hypertrophy (cyclosporin), cushioned appearance (steroids)
- Neck - Tunneled line insertions. Scar from parathyroidectomy
- Abdomen - PD catheter, signs of previous transplant, palpable kidneys and liver.
- Elsewhere - Signs of diabetes, cardiovascular or peripheral vascular disease.
In terms of monitoring renal function, why might eGFR decline faster than expected?
- Infection
- Dehydration
- Uncontrolled BP (poor compliance)
- Metabolic disturbance
- Obstruction
- Nephrotoxins
What tests would you order to investigate CKD?
Bloods - FBC (esp Hb), ESR, LFTs (ALP up), U+Es (Ca down, phosphate up), Glucose, Parathyroid hormone
Urine - Dip, MC&s, albumin:creatinine ratio or protein:creatinine ratio
Imaging - USS to check size (
When would you refer to a nephrologist?
- Stage 4/5 CKD
- Moderate proteinuria
- Proteinuria and haematuria
- Rapidly falling eGFR
- HTN poorly controlled despite 4 or more antihypertensives at therapeutic dose
- Known or suspected rare or genetic causes
- Suspected renal artery stenosis
What are the 4 main approaches to management?
- Investigation - identifying and treating reversible causes
- Limiting progression/complications:
BP - target
Which drugs are not safe to use in renal failure?
- antibiotics: tetracycline, nitrofurantoin
- NSAIDs
- lithium
- metformin
Which drugs are likely to accumulate in renal failure?
- most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
- digoxin, atenolol
- methotrexate
- sulphonylureas
- furosemide
- opioids
Need dose adjustment
Which drugs are mostly safe and require little adjustment in renal failure?
- antibiotics: erythromycin, rifampicin
- diazepam
- warfarin
