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Lecture 15 - Chronic Kidney Disease Flashcards

1
Q

What % of the population has CKD?

A

10%

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2
Q

How do we assess the excretory function of the kidneys?

A

GFR

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3
Q

What classification system is used to stage CKD?

A

NKF K?DOQI Classification System
Stage 1 - Kidney damage/normal/high GFR >90

Stage 2 - kidney damage/mild reduction GFR 60-89

Stage 3 - moderately impaired, a - GFR 45-49, b - 30-44

Stage 4 - severely impaired - GFR 15-29

Stage 5 - advanced or on dialysis - GFR <15

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4
Q

What is the relationship between GFR and serum creatinine?

A

As GFR reduces, serum cr increases

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5
Q

What can serum creatinine depend on apart from kidney function?

A

Muscle mass (age, ethnicity, gender, wt)

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6
Q

What formulae can be used to estimate GFR?

A

Cockcroft Gault

Modification of diet renal disease equation

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7
Q

What 4 variables does the MDRD equation look at?

A

Serum cr
Age
Gender
Ethnicity

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8
Q

Which factors may affect someone eGFR?

A

Pregnancy
Muscle mass
Eating red meat 12h before the sample was taken

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9
Q

What substances are allowed to cross the GBM?

A

Water, electrolytes, urea, creatinine

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10
Q

What substances can cross the GBM but are reabsorbed in the PCT?

A

Glucose

Low molecular weight proteins

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11
Q

What substances cannot cross the GBM in health?

A

Cells

High molecular wt proteins

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12
Q

How can we assess kidney filtering function?

A

Should be no protein/urine in urine - urinalysis (check for blood + protein)
May want to do protein quantification (protein creatinine ratio)

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13
Q

How might we assess the anatomy of the kidney in CKD?

A

Histology

Radiology

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14
Q

What is the current CKD definition?

A

Presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR <60ml/min/1.73m2 that is present >=3m

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15
Q

Why is CKD important?

A

Can lead to kidney failure –> dialysis and transplant
Complications
CKD death

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16
Q

What are complications of CKD?

A 
Acidosis
Anaemia
Bone disease
CV complications
Death, dialysis
Electrolyte imbalances
Fluid overload
Gout
HTN
Iatrogenic issues
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17
Q

Complications of CKD are more likely with worsening….

A

GFR

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18
Q

What does increased mortality in CKD correlate with?

A

Worsening renal function

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19
Q

What are causes of CKD?

A 
Diabetes
Polycystic kidney disease
Chronic pyelonephritis
Renovascular disease (renal artery stenosis from atherosclerosis or fibromuscular dysplasia --> ischaemic nephropathy)
HTN
GNs
Myeloma
IgA nephropathy
Sarcoidosis
Chronic exposure to nephrotoxins
Reflux nephropathy and scarring
Chronic obstructive nephropathy (e.g. prostatic disease, mets, retroperitoneal fibrosis, PUJ obstruction)
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20
Q

What is the clinical approach to managing CKD?

A

Detect underlying aetiology + treat
Slow rate of renal decline
Assess complications/prevent complications
Prepare for RRT

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21
Q

What may be some presenting features of CKD?

A 
Cognitive changes
Fatigue
Vomiting/nausea
Change in urine output
Haematuria/proteinuria (frothy urine/cola coloured urine)
Peripheral oedema
Itch and camps
HTN
SoB
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22
Q

What specific systemic diseases are good to ask about when taking a history of someone with CKD?

A

DM
Collagen vascular diseases, e.g. SLE, scleroderma, vasculitis
Malignancies - myeloma, breast, lung, lymphoma
HTN
Sickle cell disease
Amyloidosis

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23
Q

What drugs are good to ask about when taking a history from someone with CKD?

A 
NSAIDs
Penicillins/aminoglycosides
Chemotherapeutic agents
Narcotics
ACEi/ARBs
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24
Q

What pre/post renal factors should you ask about in your history when you’re assessing someone with CKD?

A 
CCF
Diuretic use
N/V/D
Cirrhosis
LUTS/pelvic disease
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25
What uraemic symptoms might someone with CKD present with?
Nausea, anorexia, vomiting Pruritus Wt loss Fatigue, weakness, drowsiness
26
What investigations might you do in CKD to detect the underlying aetiology?
Bloods - UE, FBC, bicarb, total protein, albumin, Ca, phosp, LFTs, CK Coagulation screen Urine - dipstick, PCR/ACR 24h collection Histology - renal biopsy Radiology
27
Re: investigations in CKD to exclude active disease | What is a serum and urine electrophoresis used to check for?
Myeloma
28
Re: investigations in CKD to exclude active disease | What is a urine protein: creatinine ratio used to check for?
Intrinsic renal disease
29
Re: investigations in CKD to exclude active disease | What is a CK used to check for?
Rhabdomyolysis
30
Re: investigations in CKD to exclude active disease | What is an anti-GBM used to check for?
Anti-GBM disease
31
Re: investigations in CKD to exclude active disease | What are ANCA, ELISA for MPO or PR3 used to check for?
ANCA associated vasculitides
32
Re: investigations in CKD to exclude active disease | What are C3, C4, autoantibody screen used to check for?
Connective tissue disease, SLE, MCGN, cyroglobulinaemia, infection related glomerulonephritis
33
What imaging might you need to use when trying to find the aetiology of CKD?
US X-ray CT MRI
34
When might you biopsy someone's kidneys in CKD?
Unexplained renal failure with normal sized kidneys
35
What things can be done to slow the rate of decline of CKD?
``` BP control Control proteinuria Reversible contributing factors Allopurinol Dietary protein restriction Fish oils Lipid lowering Control acidosis ```
36
What is associated with a faster decline in GFR?
High BP
37
What investigations would you do to assess for acidosis as a complication of CKD?
Bicarbonate, pH
38
What investigations would you do to assess for anaemia as a complication of CKD?
FBC, film, haematinics
39
What investigations would you do to assess for bone disease as a complication of CKD?
Ca, Phosp, albumin, PTH
40
What investigations would you do to assess for CV complications as a result of CKD?
BP, cholesterol
41
What investigations would you do to assess for electrolyte imbalance as a complication of CKD?
UE
42
What investigations would you do to assess for fluid overload as a complication of CKD?
Ex - BP, oedema, JVP | CXR
43
What investigations would you do to assess for gout as a complication of CKD?
Hx, Ex
44
What investigations would you do to assess for HTN as a complication of CKD?
BP
45
At what GFR is metabolic acidosis due to CKD usually seen?
<20mls/min
46
What electrolyte abnormality does metabolic acidosis worsen in CKD?
Hyperkalaemia | Also exacerbates bone disease
47
How is metabolic acidosis in CKD treated?
Oral Na bicarb
48
When does anaemia due to CKD usually manifest?
GFR <35mls/min
49
What kind of anaemia do you see in CKD?
Normochromic normocytic
50
What are the causes of anaemia in CKD?
Reduced EPO production (most important) Reduced erythropoiesis due to toxic effects of uraemia on bone marrow Reduced absorption of Fe Anorexia/nausea due to uraemia Reduced red cell survival (esp in haemodialysis) Blood loss due to capillary fragility and poor platelet function Stress ulceration --> chronic blood loss
51
When should you treat anaemia in CKD?
If <10g/dl or symptomatic
52
How is anaemia in CKD treated?
Iron replacement | ESA therapy
53
What electrolyte abnormality results from increased GFR?
Hyperphosphataemia
54
Why do you get bone disease in CKD?
Hyperphosphataemia + loss of renal tissue --> lack of activated vit D (as low Ca) Secondary hyperparathyroidism
55
What must happen to vitamin D to turn it into its active form?
Must be hydroxylated
56
What enzyme catalyses the hydroxylation of vitamin D?
1a hydroxylase
57
Why do you get a vitamin D deficiency in CKD?
Low 1a hydroxylase levels so low activation of vitamin D
58
Why do you get secondary hyperparathyroidism in CKD?
Low ca and high phosphate stimulates parathyroids to produce more PTH to try and correct the imbalance
59
What cardiovascular complication is hyperphosphataemia associated with?
Vascular and cardiac calcification
60
Why are those with CKD at increased risk of fractures?
Increased PTH --> increased bone turn over
61
How is renal bone disease managed?
``` Control phosphate (limit in diet) Phosphate binders (e.g. CaCO3, Ca acetate...) Normalise Ca and PTH (active vit D analogues (calcitriol) ``` If teritary hyperparathyroidism develops - parathyroidectomy + calcimetics
62
What CV complications are associated with CKD?
HTN Hyperlipidaemia Uraemic pericarditis
63
What K level may induce a fatal cardiac arrhythmia?
>7mmol/l
64
What is involved in the management of chronic hyperkalaemia?
Diet | Drug modifications
65
What does fluid overload lead to?
HTN | Oedema
66
How is fluid overload in CKD managed?
Na restriction Fluid restriction Loop diuretics
67
What should be the goal BP in CKD?
<125/75 in CKD with significant proteinuria or 130/80 if no proteinuria
68
What drug can be used to treat HTN in CKD?
ACEi may offer additional advantage
69
Which drugs commonly cause AKI on top of CKD?
Antibiotics | Contrast agents
70
How can you manage CV complications of CKD?
BP control, aspirin, cholesterol reduction, exercise, wt loss
71
What drugs should be avoided in renal failure?
Antibiotics - tetracycline, nitrofuratoin NSAIDs Lithium Metformin
72
What drugs are likely to accumulate in CKD and may require dose adjustment?
``` Most antibiotics incl. penicillins, cephalosporins, vancomycin, gentamicin, streptomycin Digoxin, atenolol Methotrexate SUs Furosemide Opioids ```
73
What drugs are considered safe to use in CKD?
Antibiotics - erythromycin, rifampicin Diazepam Warfarin
74
What antihypertensive may be useful in CKD when GFR falls <45ml/min?
Furosemide (as it lowers K)
75
Anaemia in CKD prediposes to what?
Development of LVH
76
What does ESA stand for?
Erythropoiesis stimulating agents
77
Give e.g.s of ESAs
Erythropoetin | Darbepoetin
78
How may renal bone disease manifest?
Osteitis fibrosa cystica (hyperparathyroid bone disease) Adynamic (reduction in osteoblasts + osteoclasts) Osteomalacia Osteosclerosis Osteoporosis

Renal/Urology (29 decks)

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