CKD - Chronic Kidney Disease

Question 1

Define CKD

Answer 1

Kidney damage or reduced kidney function (GFR) for > 3 months

Question 2

GFR tends to decrease with age and is lower in women than men
What is the Normal GFR?
What would the GFR have to be to be considered CKD?

Answer 2

Normal = 100-120 ml/min/1.73
<60ml/min/1.73m2

Question 3

What are the main causes of CKD?

Answer 3

HTN
Diabetes
Systemic Diseases: SLE, RA
Chronic Analgesic use (NSAIDS)
Infections: HIV, Hepatitis B and C
Any AKI cause

Question 4

How does HTN cause CKD?

Answer 4

HTN causes endothelial injury which leads to the thickening of the afferent arteriole => narrowing => reduced blood flow => reduced GFR => Oliguria, azotemia, and hyperkalemia
The reduced blood flow also leads to ischemic injury. In response, mesangioblasts create matrix leading to !Glomerulosclerosis! and increased permeability => albuminurea and Oedema

Question 5

What is the most common cause of CKD?

Answer 5

Diabetes

Question 6

How does Diabetes lead to CKD?

Answer 6

It is the most common cause of CKD.
Hyperglycemia leads to glycation of Efferent arteriole which leads to stiffening and narrowing of lumen => reduced outflow causing increased pressure in glomerulus and afferent arteriole => HTN => Glomerulosclerosis, oliguria, azotemia, hyperkalemia, albuminurea and oedema

Question 7

CKD is defined as kidney damage or reduced kidney function for >3 months (GFR<60). What is defined as kidney damage?

Answer 7

This is the only imp one: Albuminurea with ACR (albumin creatinine ratio) >3.4mg/mol
Urinary sediment abnormalities (casts)
Biopsy/imaging abnormalities
Kidney transplant (assumed)

Question 8

What is the normal albumin:Creatinine ACR ratio?

Answer 8

<3.4 (a way to remember is that its the same # as proteinuria to qualify as nephrotic)

Question 9

Patients with CKD may be asymptomatic for a long time. What are complications of CKD?

Answer 9

Uremia: Nausea, vomiting, anorexia, pruritis, encephalitis, sleep disturbances
Increased Renin => HTN => Albuminurea => Pulmonary Oedema
Hyperkalemia => Arrhythmias (palpitations)
Reduced Vit D => hypocalcemia => !Mineral Bone Disease!
Reduced EPO => Anemia (pallor, lethargy)
Dyslipidemia => atherosclerosis
!Chronic metabolic acidosis!

Question 10

Patients with CKD may be asymptomatic for a long time. What symptoms might the patient present to you? (Think of quick history taking)

Answer 10

Uremic symptoms: Nausea, vomiting, anorexia, confusion, pruritis, sleep disturbances
Hyperkalemia: Palpitations
Vit D and hypocalcemia: Bone pain, fractures
!!!Orthostatic Hypotension!!!
LL swelling - Proteinuria => add foamy urine
Anemia: !Pallor!, fatigue, malaise, lethargy

Question 11

Patients with CKD may be asymptomatic for a long time. At around what eGFR level do symptoms typically begin to appear?

Answer 11

This varies widely from person to person but in general Stages 4 and 5 of KDIGO (GFR <30) but may begin to appear at stage 3B (30-45)

Question 12

What finding on examination would indicate Uremia?

Answer 12

Discoloration of skin (yellow/grey) or uremic frost
!Asterixis!
Pericardial rub (pericarditis)

Question 13

A patient with CKD is about to be discharged. In terms of modifiable RFs, what would you explain to the patient to improve outcomes?

Answer 13

Hypertention and dyslipidemia: Dietitian consult (reduced salt diet, increased protein), Increased exercise
Quit/reduce smoking
If Diabetic: Diabetes control, check compliance/issues
Influenza, PCV vaccinations
If on Dialysis: Hep B Vaccinations

Question 14

QUICK What are your differentials for CXR of pulmonary oedema?

Answer 14

Volume overload =>
CKD
Cardiac failure/CCF/RHF
Lymphoedema
Pleural Effusions
Exacerbation of Asthma/COPD

Question 15

QUICK What are your differentials for Uremic Encephalopathy?

Answer 15

Lactic acidosis (Sepsis)
DKA
Hepatic Encephalopathy

Question 16

What is the screening test used for diabetes? How does it work?

Answer 16

An Oral Glucose Tolerance Test (OGTT) involves drinking a glucose solution followed by multiple blood sugar measurements over several hours to evaluate how the body processes glucose. It helps diagnose diabetes, revealing how effectively the body manages glucose after a sugary drink and identifying impaired glucose tolerance or diabetes-related issues.

Question 17

A patient with Uremic encephalopathy enters the clinic? This is a known CKD patient. What investigations would you perform?

Answer 17

Bloods: FBC (anemia), U&E (GFR, Creatinine, potassium, Urea, Na), BUN, Calcium, LFTs, Glucose (OGTT), HBA1C, Triglycerides
Urinalysis: Dipstick (check leukocytes and nitrites), ACR, osmolality and sedimentation examination
!PTH! (Separate test) and Bone profile
ABG/VBG
Septic workup if fever or dysuria
Imaging: !CXR! (Renal ultrasound available)
!ECG! for hyperkalemia/arrhythmia

Question 18

What grading scale is used for CKD? How is it staged?

Answer 18

KDIGO: Based on the definition, there are 2 ways of identifying CKD and that is either through Kidney damage (ACR) or Reduced kidney function (eGFR)

ACR:
Normal <3.4
Moderately increased 3.4-34
Severely increased >34

eGFR:
Stage 1 = Normal = >90
Stage 2 = Mildly decreased = 60-90
Stage 3 = Moderately decreased: A = 45-60 and B = 30-45
Stage 4 = Severely decreased = 15-30
Stage 5 = ESKD (kidney failure) = <15

Question 19

A Diabetic patient at risk of needing dialysis presents to you. What prevention measures would you ensue to help the patient stay off dialysis?

Answer 19

Hypertension and dyslipidemia: Dietitian consult (reduced salt diet, increased protein), Increased exercise,
Quit/reduce smoking
Diabetes control, check compliance/issues
Influenza, PCV vaccinations
Hep B Vaccinations

Question 20

What are your therapeutic targets when managing CKD?

Answer 20

Proteinuria <1g/day or 50-60% reduction from baseline
BP: If proteinuria <0.5g/day then BP<140/90
If diabetic or proteinuria >0.5g/day then BP <130/80

Question 21

A patient with CKD ahs pulmonary oedema (volume overload). How would you manage this?

Answer 21

Furosemide and repeat CXR

Question 22

CKD patients typically have hypertension. How would you resolve this?
These patients tend to have another CVD risk factor? Why does this occur? How would you manage this?
Speaking of CVD risk, there is also one more drug that is prescribed to CKD patients for this. What is it? (give the dosage for this)

Answer 22

HTN is resolved via ARBs (Losartan, Valsartan) or ACE inhibitors (Enalapril, Lisinopril, ramipril)
Dyslipidemia. Why? Hypoalbuminemia due to proteinuria causes the liver to compensate by increasing production of both triglycerides and protein.
treated via Statin (atorvastatin, simvastatin)

Aspirin 75mg

Question 23

Give the full management with dosages for the treatment of Acute and Chronic Hyperkalemia

Answer 23

Acute:
1) IV Calcium Gluconate 10% 10ml (for cardioprotection)
2) IV 10 units of Insulin (Actrapid) in 50% 50ml Dextrose over 15-30 mins
3) Salbutamol 5mg nebulized

Chronic:
1) PO Calcium Resonium 15g TDS
2) Diuretics (if not anuric or ESKD) (Furosemide)
3) Hemodialysis

Question 24

What is an absolute contraindication to giving diuretics in CKD patients?

Answer 24

Anuric Patients
ESKD
Acute Hyperkalemia (although part of management of chronic hyperkalemia)
Acute Kidney injury (especially if prerenal as it is caused by hypovolemia and this will exacerbate it….
Hypovolemia! and Hyponatremia (water follows salt)

Question 25

The kidneys are responsible for Vit D activation. How is this affected in CKD and how would you manage it?

Answer 25

Vit D activation is important for the absorption of calcium. In CKD this causes hypocalcemia leading to increased PTH in response causing activation of osteoclasts => bone resorption => Mineral Bone Disease
This can be treated via the following
Restricting Phosphate diet
Phosphate binder
Calcichew D3 Forte (D3 = Calcitriol)
Calcitriol or Alphacalciferol (Vit D3 Analogue)
Cinacalcet (Calcimimetic)

Question 26

What type of drug is Calcitriol? Give another medication of the same type

Answer 26

Vit D Analogue.
Alpha-Calciferol

Question 27

Give an example of a calcimimetic

Answer 27

Cinacalcet

Question 28

Given reduced kidney function, you order an ABG. What is your expected result in someone with longstanding CKD? How would you treat it?

Answer 28

Chronic acidosis (metbaolic)
Bicarbonate

Question 29

Management of CKD is treating the underlying cause. Other than that, managing symptoms and complications. Assuming a patient is having the main complications and symptoms of CKD, what is your management plan?

Answer 29

1) Treat Underlying cause
2) Aim for Therapeutic Targets
(Proteinuria <1g/day or 50-60% reduction from baseline
BP: If proteinuria <0.5g/day then BP<140/90
If diabetic or proteinuria >0.5g/day then BP <130/80)
3) CVD: HTN (ARBs or ACEi), Dyslipidemia (statin) +!Aspirin 75mg!
4) Treat hyperkalemia chronic =>
a) PO Calcium Resonium 15g TDS
b) Diuretics (if not anuric or ESKD) (Furosemide)
c) Hemodialysis
5) Mineral Bone disease (2): Restrict phosphate, phosphate binder, Calcichew D3 forte, calcitriol, Cinacalcet
6) Chronic Acidosis => Bicarbonate
7) Dietitian Consult: reduced salt and increased (moderate) protein intake
8) Prepare for RRT

Question 30

What are the indications for Renal replacement therapy in CKD?

Answer 30

AEIOU applies to AKI
Here, the U or uremic symptoms apply regardless especially uremic encephalopathy
Also, CKD w/ eGFR <10ml/min/1.73m2

Question 31

What are the contraindications for Renal replacement therapy? (3)

Answer 31

Active malignancy
Severe comorbidities (cardioresp esp) must mention
Only in peritoneal dialysis, it is CI in abdominal infection or multiple abdominal surgeries + patient needs reasonable eyesight and dexterity

Question 32

What RRT would you prescribe to someone with abdominal infection or multiple abdominal surgeries? Why?

Answer 32

Hemodialysis or kidney transplant (esp in multiple abdo surgeries)
Why? With peritoneal dialysis, it uses the peritoneum as a natural filter for waste => may be compromised (abdo surgeries) and can lead to complications (in infections)

Question 33

What catheter is used in Peritoneal dialysis?

Answer 33

Techkoff Catheter