Kidney Disease Flashcards

1
Q

What is GFR? How is it calculated?

A

GFR = volume filtered by glomeruli, per unit time - corresponds to the arterial blood volume entering the kidney and being filtered (hard to measure)

Instead we focus on a substance that is completely filtered into the urine in order to calculate GFR (amount in renal artery will correspond to the amount in the urine)

Creates the following relationship - relates the substances that we’re measuring e.g. creatinine.

GFR = (Conc. Urine x urine ouput)/(Conc. Plasma)

Looking at the ratio between creatinine in the urine and the plasma – provides an indication of the rate of filtration and thus a window into the level of functioning of the nephrons

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2
Q

What are the four requirements for the substance that is used to measure GFR?

A
  1. Must not alter GFR
  2. Freely filtered at glomerulus
  3. Not reabsorbed / actively secreted in nephron
  4. Not metabolised / produced by kidney
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3
Q

Why do we measure GFR in the first place?

A
  • Provides an assessment of global renal function
  • Pathology causing loss/damage to glomeruli affects kidney generally – GFR loss correlated with general loss of function
  • Guides management in chronic kidney disease (CKD)
  • Rate of decline predicts need for renal replacement therapy
  • Used to guide dosing of potentially toxic (renally cleared) drugs
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4
Q

What are examples of exogenous substances that can be used to calculate GFR?

A

As a whole, not commonly used.

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5
Q

What are two endogenous substances that are used to calculate GFR?

A

Creatinine - more commonly used
* Small molecule (113 Da)
* Produced at relatively constant rate (muscle metabolism)
* Some active tubular secretion
* Long established role in GFR measurement

Cystatin C
* Small protein (13kDa), inhibitor of proteases
* Produced by all nucleated cells
* No significant tubular secretion/absorption
* 10-20x more expensive to measure (than creatinine)
* Relatively new method of measuring GFR

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6
Q

Why is it challenging to calculate GFR by measuring urine Creatinine and volume?

A

Requires 24 hour urine collection

  • Inconvenient for patient
  • Inaccurate: may not be complete, may be mis-timed
  • Imprecise: involves combination of imprecision from 4 variables…

Futhermore… At very low GFR (advanced renal failure) there is further inaccuracy
* less creatinine filtered
* amount creatinine secreted becomes proportionally much larger

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7
Q

So if we don’t measure urine creatinine/volume, how can we measure GFR?

A

Use plasma creatinine to estimate GFR (eGFR)

Based on the assumption that there is a recipricol relationship between plasma creatinine and GFR

  • Low GFR means that there is more creatinine in the blood
  • Higher GFR will results in more clearance and thus a lower plasma creatinine concentration

Very large inter-individual differences caused by differences muscle mass (production of creatinine) so must be taken into consideration

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8
Q

What are some examples of different equations used to calculate eGFR?

A

Cockcroft‐Gault equation - plasma creatinine, weight, age, and sex - Often used to adjust dosing for renally excreted drugs with potential toxicity

MDRD eqaution - most commonly used - only really accurate for people with a certain level of GFR impairment – most useful for GFR is less than 60ml.

EPI equation - provides more reliable measurments - equation accurately estimates GFR up to 90ml - not commonly adopted across the UK

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9
Q

When do the eGFR equations lose applicability?

A
  1. Children
  2. Pregnancy
  3. Very elderly – neither study included these groups
  4. Muscle mass extremes (frail, amputee, heavily built)
  5. Rapidly ‐ changing renal function
  6. Very low GFR
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10
Q

How is CKD diagnosis made? How is the staging of CKD performed?

A

Diagnosis of CKD usually requires eGFR consistently to be less than 60 mL/min/1.73 m2

But can involve eGFR >60 if any of:
- Persistent proteinuria / microalbuminuria
- Haematuria - blood
- Renal anatomical/genetic abnormality e.g. biopsy - proven GN, or PKCD

Staging uses both eGFR and urinary albumin to creatinine ratio (ACR)

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11
Q

What is the definition of acute kidney injury?

A

An abrupt loss of renal function

Commonly characterised by acute:
* oliguria & increases in plasma urea & creatinine
* Often accompanied by a loss in ability to regulate water, electrolyte & acid-base balance.

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12
Q

Do we use eGFR to detect acute kidney injury? How do we stage it?

A

eGFR is not a good measure for acute kidney injury - eGFR is better for more longer term changes

To pick up on AKI…
* We look at plasma creatinine - requires establishing creatinine baseline - looking for a reduction of 50% or more from baseline
* Decreased urine output

If we don’t have previous baseline – we use reference ranges –high degree of error

Combine degree of creatinine rise (using lab-computer based algorithm) and clinical context to gauge the severity of AKI

Used table to stage – considers clinical context and creatinine rise

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13
Q

What are some important renal tubular functions that we can assess?

A
  1. Acid-base homeostasis
  2. Electrolyte homeostasis
  3. Fluid balance and sodium
  4. Urine concentrating ability
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14
Q

What is the pH of the urine normally? What condition is associated with the failure of acid-base homeostasis? How can we test for it?

A

Urine is usually significantly more acidic than plasma
pH urine less than 5.5 vs. pH plasma 7.35 ‐7.45

Renal Tubular Acidosis (RTA) type I can lead to pH urine more than 5.5
* Distal tubular cells unable to secrete H+ - leading to acidification of blood
* Many possible causes: autoimmune, paraproteinaemia, nephrocalcinosis etc.

Test - Ammonium chloride loading test (rarely used!)
* Used to confirm suspected RTA type I
* NH4Cl administration leads to metabolic acidosis
* If pHurine >5.5 persists then RTA type I confirmed

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15
Q

How could one examine whether hypokalaemia (electrolyte imbalance) was due to a renal problem?

A

Electrolyte homeostasis – key function of kidney

Many different sources of electrolyte disorders – GI, shifts into cell, renal etc. – need to investigate to figure where the problem is coming from

Example: Hypokalaemia, K+ less than 3.5 mmol/L

  • Spot urine K+ less than 20 mmol/L (no excess being excreted) usually excludes renal loss
  • Often a spot urine is not sufficient as concentrations vary throughout the day… so we either need a 24 hour urine collection and measure creatinine to correct for variability in urine conc e.g. fractional excretion of phosphate (FEP)
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16
Q

What are plasma and urine sodium used for? If the plasma is hyponatraemic, what do urine sodium values above and below 30mmol/L tell you?

A

Plasma sodium – more an indicator of fluid balance, rather than total body sodium - hypernatraemia tends to reflect water deficit, rather than sodium overload

Urine sodium can be used to determine if tubular function appropriate

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17
Q

How is the kidney’s urine concentrating ability measured?

A

Concentrating ability - Assessed by measuring urine osmolality (and plasma osmolality for comparison)

Loss of urine conc ability may be accompanied by polyuria

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18
Q

What do you expect will happen to urine vs. plasma osmolality in CKD, acute tubular necrosis, DM and diabetes inspidus?

A

Expect that the osmolality of the urine to be greater than the plasma given that the urine should be more concentrated.

Advanced renal failure and tubular necrosis – kidneys are unable to concentrate the urine – urine osmolality = plasma osmolality

Diabetes – urine osmolality is the same or greater plasma osmolality – osmotic diuresis – pulls water into urine (extra glucose exerts osmotic pull)

Diabetes insipidus – urine osmolality is lower than plasma - very dilute urine

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19
Q

How do we test for diabetes inspidus?

A

DI involves failure of action of vasopressin (or ADH)

May be cranial (hypothalamic/pituitary pathology), nephrogenic (tubular problem)

Involves withholding fluids over several hours
* Normal response: plasma osmolality static, urine osmolality rises i.e. kidney conc urine
* DI: plasma osmolality will rise… urine remains dilute

Cranial DI should be responsive to DDAVP (synthetic vasopressin)

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20
Q

What is dipstick urinanalysis used for?

A

Point of Care test - Rapid, simple, convenient, cheap

Can measure…
* Glucose (diabetes?)
* Ketones (ketoacidosis?)
* Protein (albumin) – not as sensitive as lab measurement
* Blood (detects Hb: calculi, bladder ca., glomerulonephritis)
* Leukocytes (UTI)
* Nitrites (produced by nitrate-­‐reducing UTI bacteria)
* Bilirubin (jaundice)
* Urobilinogen (absent in cholestatic jaundice)
* pH

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21
Q

Do proteins normally enter into the filtrate? Are they reabsorbed? What happens in pathological states?

A

Normal
* Glomeruli prevent passage of most large plasma proteins
* Tubules actively re‐absorb/catabolise low MW proteins

Renal pathology may lead to:
* Increased glomerular permeability – increasing urinary albumin, detectable levels of large MW proteins not normally found in urine
* Decreased tubular protein reabsorption – increased conc. of low MW proteins

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22
Q

How is proteinuria detected?

A
  • Dipstick tests – can’t quantify across time – this case we need protein lab measurements
  • Lab-based albumin/creatine ratio – protein:creatine ratio (PCR) or albumin:creatinine ratio (ACR - can be used to classify CKD)

Creatinine is used to adjust for urinary conc

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23
Q

What is microalbuminuria?

A

Microalbuminuria - albumin levels too low to be picked up by dipstick but can be detected in the lab

Note – these changes can occur transiently – so if this is present you need to take measurements across time to confirm diagnosis

Important for prevention of significant diabetic nephropathy

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24
Q

What are the functions of the glomeruli, tubules and interstitium?

A
  • Glomeruli (filtering units)
  • Tubules (reabsorption)
  • Interstitium (the ‘bit in between the tubules’). Mainly comprises microvascular capillaries in health)
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25
Q

Label the structures in the following diagram of a glomerulus.

A
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26
Q

How is acute kidney injury defined?

A

AKI is defined as any of the following:
* Increase in serum creatinine by > 26.5
μmols/L in 48 hours or,
* Increase in serum creatinine by > 1.5x baseline creatinine within last 7 days or
* Urine volume < 0.5ml/kg/hr for 6 hours - decreased

Mainly used creatinine - important for staging as shown in the attached image.

oliguric – little or anuric – no urine

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27
Q

Why is AKI important to study?

A

AKI is COMMON (affects 7% of hospital inpatients) and has adverse consequences:
* Increased length of stay in hospital
* Increased morbidity
* Increased hospital & post-discharge mortality
* Very costly (~£500 million/annum)

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28
Q

Is severe AKI independently associated with CKD and end-stage renal disease?

A

Severe AKI is independently associated with adverse renal outcomes:

  • Increased incidence of chronic kidney disease
  • Increased incidence of end-stage renal disease
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29
Q

Is AKI a diagnosis?

A

No! It is a syndrome - we need to think about what is causing the dysfunction.

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30
Q

How can we divide the causes of AKIs in three ways?

A

PRE-RENAL - reduced real or ‘effective’ blood volume

RENAL - glomerulus, tubules and interstitium

POST-RENAL - obstruction – multiple levels (e.g. ureter, bladder etc)

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31
Q

What are some pre-renal causes of AKI?

A

Hypovolaemia (low blood volume) - e.g. bleeding, 3rd space fluid losses, over-enthusiastic diuretic therapy!

Hypotension e.g. septic/cardiogenic shock, liver failure

Reduced renal blood supply secondary to severe renovascular disease (±ACEI) - stenosis, dissection of the abdominal aorta

ACEi blocks RAAS system - results in reduced renal perfusion - can be damaging therefore.

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32
Q

What are some post-renal causes of AKI?

A

Note - bilateral obstruction or obstruction of a single kidney (transplant) required for AKI – all kidneys need to be affected

Causes include:
* Prostate – hypertrophy (common), cancer
* Bladder lesions - tumour
* Ureter - calculi, tumour, extrinsic compression (retroperitoneal fibrosis, tumour)

33
Q

How can renal obstruction be investigated?

A

Imaging is used to investigate obstructions

Renal Ultrasound can detect obstruction

CT scan with contrast can also be used to examine accumulation of constrast in kidney - Hydronephrosis (accumulaiton of urine in the kidneys)

34
Q

What is a myeloma kidney?

A

Myeloma kidney - causes intrarenal obstruction

B-cell dysplasia – one antibody produced – antibody accumulation/precipitation in the kidney – leads to obstruction

Myeloma – silent condition that can take out kidneys quite quickly – think about this when other common signs aren’t present

35
Q

Do all patients with significant acute kidney injury need an ultrasound?

A

All patients with significant acute kidney injury MUST have an ultrasound scan to exclude or demonstrate obstruction to the renal tract - within 24 hours

36
Q

In renal AKIs, what are the 3 areas if affected that can cause an AKI?

A
  1. Tubulointerstitium (tubules and the bit ‘in between’)
  2. Glomerulus
  3. Blood vessels
37
Q

Renal AKI cause - what is acute tubular injury?

A

Acute tubular injury - Commonest cause of AKI in hospitals and can complicate everything previously discussed!

Caused by…
1. Tubular toxins, eg gentamicin, cisplatinum, NSAIDs, radio-contrast dye
2. Severe prolonged hypotension (sepsis, MI)
3. Renal hypoperfusion e.g. elderly patient on ACEI, diuretic who has diarrhea and vomiting - common cause due to low oxygen levels in the medulla!

Recovery from ATI - Initial oliguria then may exhibit polyuric recovery phase (watch electrolytes)

Histology - cell debris in granular casts - tubular cells dying and accumulating in the tubules.

38
Q

Renal AKI cause - What are some tubulointerstitial causes?

A

Interstitium – think allergy - Acute allergic interstitial nephritis

  • DRUG-RELATED e.g. PPIs, (omeprazole) antibiotics, diuretics, NSAIDs
  • May have an eosinophilia - no rash
  • Often respond well to steroids

Hard to diagnose – no rash or other sign – look at eosinophil level with no signs of any other allergic reaction

39
Q

Renal AKI causes - what is a glomerular cause of AKI?

A

Glomerular causes

Rapidly progressive glomerulonephritis (RPGN)

Immune driven and characteristized by glomerular crescents – space full of immune cells - characteristics

Loss nephrons cant make new ones

40
Q

What are some examples of cresentic RPGNs?

A

Goodpasture’s syndrome – rare – pulmonary

Wegner’s granulomatosis and microscopic polyarteritis – show signs across the body – types of ANCA vasculitis (inflammation of blood vessels) - signs: Proteinuria/hematuria in urine, renal impairment, systemic signs (achy joints) - good sign

SLE – lupus – young women with skin rashes

Immune driven – RPGN – think immune

41
Q

Renal AKI causes - what is a vascular cause of AKI?

A

Haemolytic uraemic syndrome (HUS) - can be..
* E coli related (E coli O157)
* Familial cases (genetic aetiology)

Characterisitc - Glomeruli full of thrombus

42
Q

When taking a history from a AKI patient, what should we be looking for?

A
  • Renal history – pre-existing renal disease, diabetes, family history
  • Urine volume - ?acute oliguria
  • Drug history – ? New drugs, nephrotoxic drugs (NSAIDs, ACEI, antibiotics)

Systemic symptoms – diarrhoea, rashes, joints, etc - think vasculitis

43
Q

When performing an examination on a AKI patient, what should we be looking for?

A
  1. Fluid status (JVP, postural BP) - dehydrated?
  2. Evidence of infection
  3. Rash, joint pathology - vasculitis
  4. Arterial bruits - underlying renovascular disease
  5. Palpable bladder (obstruction) - post-renal

Check drug chart!

44
Q

What investigations could we consider performing on an AKI patient?

A
  1. Urine dipstick – simple BUT important (blood, protein)
  2. Blood tests - shown in image
  3. Urine culture
  4. Renal Ultrasound - if obstructed then decompress
  5. Renal biopsy (AKI and normal sized kidneys)
  6. Angiography ± intervention
45
Q

What is rhabdomyolysis?

A

Muscle becomes injured and release myoglobin into the blood - this ultimately gets stuck in the kidneys.

46
Q

What immunlogical tests could we consider performing on an AKI patient?

A
  • IgGs and serum electrophoresis – test for myeloma
  • Complement levels (SLE, post strep GN)
  • Autoantibodies e.g.
    Anti-nuclear factor (ANA) - SLE
    Anti-neutrophil Ab (ANCA) - vasculitis
    Anti-GBM Ab - Goodpasture’s syndrome
47
Q

What are the general treatments for AKI?

A

No therapy - just optimisation

  • Optimise fluid balance and circulation
  • Stop exacerbating factors e.g. nephrotoxic drugs (check drug charts)
  • Appropriate prescribing (check BNF, discuss with pharmacist) e.g. opiates accumulate in AKI
  • Supportive treatment e.g. dialysis, nutrition
48
Q

What are the specific AKI treatments for obstruction, sepsis, RPGN, goodpastures and compartment syndrome?

A
  • Obstruction - drain renal tract
  • Sepsis - effective antibiotics
  • RPGN e.g. SLE – immunosuppression - steroid
  • Goodpasture’s syndrome - Plasma exchange (get rid of antibody)
  • Compartment syndrome – fasciotomy
49
Q

In the case of an AKI patient, when do we start dialysis?

A

Uraemia isa build up of toxins in your blood

Wait until dialysis is needed

When - Severe uremia:
- NO prospect of improvement
- Encephalopathy or seizures
- Pericarditis - inflammaiton of the lining of the heart
- Hyperkalameia >6.5

Also use dialysis when…
* There is fluid overload, especially pulmonary oedema, resistant to treatment with diuretics/fluid restriction
* Severe acidosis (results in myocardial depression and hypotension)

50
Q

What are some complications associated with dialysis for AKI?

A

Vascular access related complications -
* Pneumothorax
* Infection
* Bleeding

Anticoagulation required which may be problematic in patients with bleeding.

Hypotension may be troublesome in some patients (sepsis, IHD, diabetes)

51
Q

What is the definition of CKD? What are some causes and consequences of CKD?

A

Definition:
GFR of less than 60 ml/min for >90 days /3 months

Causes: Diabetes / Hypertension/ Glomerulonephritis/ Cystic kidney disease (APCKD)/ Renovascular disease

Consequences:
* Many of the problems caused by CKD start early
* Excretory / Endocrine effects
* Dialysis / Transplant / increased mortality and morbidity

52
Q

How do we estimate renal function?

A

Normal GFR - 125 ml/min/1.73m2

Normally we estimate GFR using serum creatinine (using formulas) - but this can be misleading and inaccurate

Alternatively…
1. Urine creatinine - urea and creatinine is more accurate
2. Isotope GFRs - too expensive

53
Q

What are some equations that are used to calculate eGFR?

A

MDRD or CKD-EPI normally used

CKD-EPI - serum creatinine, sex, age and race (also a version using cystatin C instead of creatinine) - race co-efficient removed in 2021

54
Q

What are the different stages of CKD?

A

90-120 - normal Kidney function or stage 1 kidney disease - differential between these two is an abnormal kidney radiology or biopsy or protein in urine

60-90 - Similar thing for stage 2 kidney disease – you are also looking for other markers - abnormal kidney radiology or biopsy or protein in urine

Different for Stage 3, 4 and 5 – no additional tests needed – enough for kidney disease diagnosis

From stage 3 onwards – patient normally gets a referral

ESRD – end stage renal disease – stage I – transplant or dialysis (dialysis normally started when we reach an eGFR of 6-10)

55
Q

How common is CKD?

A

6.2 % population have CKD 3 (US/UK)

Given elderly population have more CKD, up to >25% of elderly pts may be expected to have Stage 3 CKD or worse

56
Q

What are some strategies to prevent CKD?

A

Main strategy – control blood pressure (RAS inhibition), reduce proteinuria (RAS inhibition) and optimize glucose control (if diabetes is present)

Main drug – RAAS inhibition (ACEi or ARBs) + control glucose (glycemic control)

SGLT2 inhibitors becoming more popular – diabetic medications that increases glucose excretion – patients on these had better heart, vascular, diabetic and renal outcomes

Proteinuria a marker and a cause or progressive renal disease - why we want to prevent it.

57
Q

How is CKD staged?

A

Consider both GFR and proteinuria to determine which patients require treatment.

Both proteinuria and GFR is a marker and cause of kidney disease

58
Q

How does proteinuria cause kidney disease?

A

How proteinuria can cause kidney disease…

Proteinuria – cells that take up protein in filtrate become overworked – causing inflammation, cell death and fibrosis – replacement of cells - chronic interstitial fibrosis

Use RAAS – opens efferent arteriole – reducing glomerular pressure - less protein going through

59
Q

What are two important considerations to make when thinking about drugs and CKD?

A

Some drugs can damage kidneys – NSAIDS (ibuprofen – cause vasoconstriction of arterioles), contrast (asked for CKD when getting a CT-scan for a patient), gentamicin (antimicrobial) and phosphate enemas (less common)

More importantly – drug dosing - lower drugs doses for patients with CKD – especially for chemotherapy and antibiotics – many toxic agents are contraindicated – make sure you check whether your patient has CKD

Start low and go slow!

60
Q

What are some examples of CKD complications associated with the excretory function of the kidney?

A

Excretory
* Salt and Hypertension
* Potassium
* Acidosis

61
Q

What are some examples of CKD complications associated with the endocrine function of the kidney?

A

Endocrine
* Anaemia
* Renal Osteodystropy- weakening of bones
* Cardiovascular risk
* Malnutrition

62
Q

What is the relationship between hypertension and CKD?

A

Hypertension is both a cause and a consequence of CKD - HTN causes renal disease & Renal disease results in hypertension

Complications of hypertension - Causes Left Ventricular Hypertrophy / Stroke / End-organ damage- eyes/ kidneys

BP treatment goals - adjusted for DM/proteinuria
- “normal” -130/80
- DM / Proteinuria - 125/75

Attached graph - shows relationship between GFR loss per year for different BP values

63
Q

Treatments for hypertension?

A

Treatment for Hypertension
* Low salt diet – DASH
* Lifestyle option – exercise, alcohol and smoking
* Blood pressure medications – ACEi, ARBs, CCB, thiazide diuretics, etc.

64
Q

Why is the associaiton between hyperkalaemia and CKD? What should we do to prevent it?

A

CKD – inability to excrete K+ - resulting in hyperkalaemia - important to monitor

  • Hyperkalaemia common as GFR declines < 25
  • Hyperkalaemia can occur if GFR >25 if diabetes + type 4 Renal tubularacidosis, ACE inhibitors (stops K+ excretion) or high K+ diet are present.

Prevention
* Dietary advice re High K foods
* Potassium binders – used in people that need to stay on ACEi in heart failure – binds to potassium – but expensive

65
Q

What is the relationship between acidosis and CKD? What do we to prevent it?

A

In CKD - Acidosis is due to animal protein in food (meat or dairy) and an inability to acidify the urine

Patient with weight loss and feeling unwell from eating protein – red flag

Prevention - Give sodium bicarbonate to maintain >22

66
Q

What type of anemia do we see in CKD patients?

A

Anemia - Hb < 12 in males/ < 11 in females

Normochromic normocytic pattern seen in anaemia of chronic disease / deficiency anaemia

Caused mainly by…
* Low EPO production
* CKD patients also have decreased RBC survival (50-60 day survival) - inflammatory state – bone marrow produces RBCs that are slightly premature/dysfunctional

But also due to…
* iron deficiency (GI blood loss or blood loss on dialysis etc.)
* Blood loss
* Other causes (aluminium toxicity, etc.)

67
Q

How to treat anemia associated with CKD?

A

Epo replacement therapy

All patients with low HB (less than 105) with adequate iron stores should be on Epo

Target Hb 100-120 (low target due to risk of malignancy, hypertension and thrombosis)

We see… Better Quality of life / less dyspnoea / reduced Left Ventricular hypertrophy

If poor response – check iron stores, CRP – C-reactive protein, B12 + folate, PTH and aluminium, malnutrition and malignancy

68
Q

What is renal osteodystrophy?

A

Weakness and loss of bone seen in CKD

69
Q
A
70
Q

How does renal osteodystrophy occur in CKD patients?

A

CKD – loss of Vitamin D activation – less Ca2+ uptake – PTH increases, which increases bone turnover increasing Ca2+ and PO4 - causes high bone turnover disease (secondary hyperparathyroidism)

71
Q

Apart from secondary hyperparathyroidism, what other ways does renal osteodystrophy present in CKD patients?

A
  • Osteoporosis
  • Adynamic bone disease (in response to treatment – abnormal response to Vit-D)
  • Aluminum bone D (related to dialysis)
72
Q

How do we treat renal osteodystrophy in CKD patients?

A
  1. Phosphate restrict – vegan diet and binders (phosphate binders) – reduce meat and dairy - Phosphate binds to Ca2+
  2. Vitamin D therapy – alfacacidol (already has hydroxylation) - increase Ca and decreased PO4
  3. Monitor PTH
  4. Parathyroidectomy – removal of parathyroid is an option
73
Q

What are the consequences of high phosphate levels (hyperphosphataemia)?

A

We see vessel calcification (medial calcification)- resulting in non-compliant vessels, systolic hypertension (L vent hypertrophy) and diastolic hypotension (myocardial ischaemia)

Calciphylaxis - calcium accumulates in small blood vessels of the fat and skin tissues - causing blood clots, painful skin ulcers and may cause serious infections that can lead to death

74
Q

What is the association between CKD and cardiovascular disease?

A

Increased risk of cardiovascular death and death from all causes as CKD progresses

List shows a range of cardiovascular risk factors that arise in response to CKD.

75
Q

What is the associaiton between CKD and malnutrition?

A

Malnutrition – common in CKD – patient reduce protein intake, decreased appetite and low albumin (due to ongoing chronic inflammation?)

No benefit of a low protein diet in ESRD patients – only results in malnourishment – advise moderate reductions in protein

76
Q

Which CKD patients should referred on to the renal clinic?

A
  • Any patient with rapid increase in creatinine/ hypertension
  • People with haematuria (blood) & rising creatinine/proteinuria and/or hypertension
  • Stage 3 CKD with hypertension/ proteinuria /haematuria/ rising creatinine
  • Any stage 4/5 CKD who is suitable for treatment

Late referral patients do considerably worse
Anaemia / renal bone disease / dialysis access

77
Q

What are the two main treatments for end stage renal disease?

A
  1. Dialysis
  2. Transplantation - usually only used for the less than 70 years old
78
Q

What are the two types of dialysis?

A

Haemodialysis - treatment to filter wastes and water from your blood

Peritoneal dialysis - At home method – peritoneal space filled with fluid (allows for exchange) and then waste fluid is removed

79
Q

When do you normally start dialysis?

A

Recommended start when Creatinine clearance (eGFR) 9-14

Consider conservative care in elderly patients where dialysis would be too stressful