Lecture 12 - Chronic Kidney Disease Flashcards
What is CKD?
A progressive deterioration of renal function over months to years
What is used to measure Chronic Kidney Disease (CKD)?
eGFR
Can see change in renal function over time
Why is CKD considered irreversible?
Renal tissue is replaced by extracellular matrix (scar tissue) in response to damage
What is the point of treatment of CKD if it cant be reversed?
Slows down the deterioration
What eGFR is considered normal/high?
Anything over 90ml/min
How many stages of CKD are there?
5
What are the 5 stages of kidney failure?
CKD S1: eGFR > 90 but other CKD symptoms
CKD S2: eGFR 60 - 89
CKD S3: eGFR 30 - 59
CKD S4: eGFR 15 - 29
CKD S5: eGFR <15
CKD S5 = Kidney failure
What may be suggestive of Chronic Renal Failure?
Small kidneys with thin cortices (small cortex)
What part of the kidney undergoes atrophy/shrinking in CKD?
Cortex
Go to the last slide and label the kidney:
1 = renal pelvis
2 = major calyces (calyx)
3 = minor calyces
4 = renal cortex
5 = renal medulla
6 = ureter
7 = renal pyramid
8 = renal column
9 = renal papilla
10 = renal lobe
What can causes Chronic Kidney Disease (CKD)?
Diabetes Mellitus
Hepatorenal syndrome (failing liver causes failing kidney)
Hypertension
Recurrent AKI
Chronic pyelonephritis
Chronic glomerulonephritis
Polycystic kidneys
What is meant by a primary cause of CKD?
The conditions directly affect the kidneys leading to CKD
What are some primary causes of CKD?
Polcystic Kidney disease
Acute tubular necrosis
Recurrent pyelonephritis
Glomeruloneprhitis
What are some secondary causes of CKD?
Diabetes Mellitus
Hypertension
Renovascular disease
Autoimmune
What is a key process that is thought to occur in Diabetic nephropathy that eventually leads to the CKD?
Hyperfilitration
Describe how the hyperfiltration DM leads to diabetic neuropathy (CKD):
High plasma glucose levels
Lots of glucose reabsorbed back into blood
Lots of Na+ reabsorbed as a result
Leads to levels of Na+ in filtrate being lower (detected by Macula densa cells in DCT)
RAAS activated to increase Na+ reabsorption and consequently increases BP ad therefore GFR
This increased BP/GFR means that damage to the glomerulus is likely causing CKD
What types of drugs /treatment can be given to regulate blood pressure reducing CKD detoriation?
Antihypertensives like ACEi and aldosterone receptor antagonists
Diuretics (furosemide)
Fluid restriction (prevents fluid overload)
What is the max blood pressure target for a patient with non diabetic CKD?
120 - 139/90 mmHg
What is the max blood pressure for patients with CKD with proteinuria or diabetes?
120 - 129/80 mmHG
Lower more strict target for diabetics with CKD
What are some indicators of CKD?
Microalbuminuria
Haemoturia
Albumin:creatinine ratio increased (since albumin levels in urine should be 0)
What are some complications of CKD?
Anaemia
Oedema
Bone mineral disease
Accelerated atherosclerosis/vascular disease
Metabolic acidosis
Why does CKD often lead to anaemia?
Kidney produces Erythropoietin (EPO)
CKD = reduced EPO production
Less EPO = less erythropoiesis
= less RBC cells made = anemia
How can CKD lead to oedma?
Decreased GFR may lead to not enough water being removed (fluid overload?)
Albumin escaping to be excreted in urine, plasma oncotic pressure low so fluid remains in interstitium
What important role does the kidney have in Calcium absorption/metabolism?
Converts inactive vitamin D to its active Vit D form
What is the function of active Vit D?
Stimulates Ca2+ absorption in the small intestine
Describe how CKD causes bone mineral diseases like non-bone calcification and weak fragile:
CKD means less active Vit D available and less phosphate removed by kidney
Les active Vit D = less Ca2+ absorbed by gut
Less Ca2+ means parathyroid makes more PTH
More PTH means increased osteoclast activity some more bone resorption
This leads to Ca2+ being released in blood which can then calcify with phosphate in non bony locations
Also lack of Active Vit D means impaired bone mineralisation
What are some symptoms of Uraemia?
Confusion
Palpitations
Anxiety
Depression
Leg swelling
High BP
Anaemia
SOB
Nausea
Muscle weakness
How may a patient present on blood investigations with CKD?
Anaemia
Hypocalcaemia
Hyperphosphatemia
Hyperparathyroidism
Hypertension
How could you treat a patient with Anaemia and hypertension in CKD?
Anemia = IV iron and EPO
Hypertension = ACEi, diuretics or B-blockers
What is an example of a ACE inhibitor that can be given for hypertension in CKD?
What about diuretic?
What about B-blocker?
ACEi = ramipril
Diuretic = furosemide
B-blocker = atenolol or bisoprolol
How is the Hyperphosphatemia managed in CKD?
How is the hypocalcaemia and hyperparathyroidism managed in CKD?
Hyperphosphatemia = phosphate binders and dietary advice
Hypocalcaemia and hypperparathyroidism = active Vitamin D
What is the end stage management for CKD?
Renal transplant
Dialysis
What is the eGFR value indicating End Stage renal failure?
eGFR < 15
Briefly outline the process of a renal transplant:
Healthy kidney removed with the renal artery, vein and ureter and its inserted into the Iliac artery’s of the patient
Unhealthy kidneys left in place
What are the 2 types of dialysis?
Haemodialysis
Peritoneal dialysis
How does a dialyser work in Haemodialysis?
Has a conc gradient so that the waste products in the blood are removed
Why are anticoagulants important in Haemodialysis?
Prevents the blood clotting
What are the advantages of Haemodialysis?
Go to hospital and professionals sort it
Days where you dont have to do it
Is effective
What a re the disadvantages of Haemodialysis?
Have to follow dialysis times
May struggle to insert Haemodialysis line into body
Food/fluid restrictions
What is peritoneal dialysis?
Where a catheter is inserted into he peritoneal cavity inserting fluid in cavity
Peritoneal membrane acts a semi permeable membrane filtering the waste contents of the blood into the fluid which is then drained into a bag
What are the advantages to peritoneal dialysis?
Do it at home (independance)
Less fluid/food restrictions than Haemodialysis
Easy to travel
May preserve renal function better at start
What are the disadvantages of Peritoneal dialysis?
Frequent daily exchanges/overnight
Responsibility of doing it yourself
May get peritonitis
Less long term survival data
What is the most commmon inherited nephropathy?
Polycystic kidney disease
What age does polycystic kidney disease present in?
30 - 40yrs
What complications do present with in Polycystic Kidney disease?
Hypertension
Acute loin pain
Haematuria
Bilateral palpable kidneys
Why can polycystic kidney disease lead to development of CKD?
The cysts can develop anywhere in the kidney compressing the parenchyma which impairs the renal function
What is meant by parenchyma?
Functional tissue
What type of inheritance is most common in Polycystic kidney disease?
Autosomal dominant
Where else can cysts develop in patients with polycystic kidney disease?
Liver
How do the kidneys appear on CT with polycystic kidney disease?
Very large kidneys
Many cysts
What can happen to the large yellow filled cysts in polycystic kidney disease if they get knocked?
Haemorrhaging into the cysts may occur
What cells line the cysts in poly cystic kidney disease?
Cuboidal epithelium
Why may a patient with Polycystic Kidney disease present with Haematuria?
Enlarged kidneys not protected by rib cage
Bash may occur
Leads to cysts rupturing so haemorrhage enters urine
What causes morbidity in polycycstic kidney disease?
The hypertension caused by reduced parenchyma in kidney (reduced fluid excretion)
Which can lead to MI and cerebrovascular disease
How is PKD treated that progresses to CKD?
Control BP
May need dialysis and renal translpmant if endstage renal failure develops
What are berry aneurysms?
When the walls of the blood vessels are weaker so the bulge outwards like a berry, blood collect here which can then lead to rupture /burst of the blood vessel
