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Renal/Urology > Lecture 15 - Chronic Kidney Disease > Flashcards

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
Q

What uraemic symptoms might someone with CKD present with?

A

Nausea, anorexia, vomiting
Pruritus
Wt loss
Fatigue, weakness, drowsiness

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26
Q

What investigations might you do in CKD to detect the underlying aetiology?

A

Bloods - UE, FBC, bicarb, total protein, albumin, Ca, phosp, LFTs, CK
Coagulation screen
Urine - dipstick, PCR/ACR 24h collection
Histology - renal biopsy
Radiology

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27
Q

Re: investigations in CKD to exclude active disease

What is a serum and urine electrophoresis used to check for?

A

Myeloma

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28
Q

Re: investigations in CKD to exclude active disease

What is a urine protein: creatinine ratio used to check for?

A

Intrinsic renal disease

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29
Q

Re: investigations in CKD to exclude active disease

What is a CK used to check for?

A

Rhabdomyolysis

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30
Q

Re: investigations in CKD to exclude active disease

What is an anti-GBM used to check for?

A

Anti-GBM disease

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31
Q

Re: investigations in CKD to exclude active disease

What are ANCA, ELISA for MPO or PR3 used to check for?

A

ANCA associated vasculitides

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32
Q

Re: investigations in CKD to exclude active disease

What are C3, C4, autoantibody screen used to check for?

A

Connective tissue disease, SLE, MCGN, cyroglobulinaemia, infection related glomerulonephritis

33
Q

What imaging might you need to use when trying to find the aetiology of CKD?

A

US
X-ray
CT
MRI

34
Q

When might you biopsy someone’s kidneys in CKD?

A

Unexplained renal failure with normal sized kidneys

35
Q

What things can be done to slow the rate of decline of CKD?

A 
BP control
Control proteinuria
Reversible contributing factors
Allopurinol
Dietary protein restriction 
Fish oils
Lipid lowering
Control acidosis
36
Q

What is associated with a faster decline in GFR?

37
Q

What investigations would you do to assess for acidosis as a complication of CKD?

A

Bicarbonate, pH

38
Q

What investigations would you do to assess for anaemia as a complication of CKD?

A

FBC, film, haematinics

39
Q

What investigations would you do to assess for bone disease as a complication of CKD?

A

Ca, Phosp, albumin, PTH

40
Q

What investigations would you do to assess for CV complications as a result of CKD?

A

BP, cholesterol

41
Q

What investigations would you do to assess for electrolyte imbalance as a complication of CKD?

42
Q

What investigations would you do to assess for fluid overload as a complication of CKD?

A

Ex - BP, oedema, JVP

CXR

43
Q

What investigations would you do to assess for gout as a complication of CKD?

44
Q

What investigations would you do to assess for HTN as a complication of CKD?

45
Q

At what GFR is metabolic acidosis due to CKD usually seen?

A

<20mls/min

46
Q

What electrolyte abnormality does metabolic acidosis worsen in CKD?

A

Hyperkalaemia

Also exacerbates bone disease

47
Q

How is metabolic acidosis in CKD treated?

A

Oral Na bicarb

48
Q

When does anaemia due to CKD usually manifest?

A

GFR <35mls/min

49
Q

What kind of anaemia do you see in CKD?

A

Normochromic normocytic

50
Q

What are the causes of anaemia in CKD?

A

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
Q

When should you treat anaemia in CKD?

A

If <10g/dl or symptomatic

52
Q

How is anaemia in CKD treated?

A

Iron replacement

ESA therapy

53
Q

What electrolyte abnormality results from increased GFR?

A

Hyperphosphataemia

54
Q

Why do you get bone disease in CKD?

A

Hyperphosphataemia + loss of renal tissue –> lack of activated vit D (as low Ca)

Secondary hyperparathyroidism

55
Q

What must happen to vitamin D to turn it into its active form?

A

Must be hydroxylated

56
Q

What enzyme catalyses the hydroxylation of vitamin D?

A

1a hydroxylase

57
Q

Why do you get a vitamin D deficiency in CKD?

A

Low 1a hydroxylase levels so low activation of vitamin D

58
Q

Why do you get secondary hyperparathyroidism in CKD?

A

Low ca and high phosphate stimulates parathyroids to produce more PTH to try and correct the imbalance

59
Q

What cardiovascular complication is hyperphosphataemia associated with?

A

Vascular and cardiac calcification

60
Q

Why are those with CKD at increased risk of fractures?

A

Increased PTH –> increased bone turn over

61
Q

How is renal bone disease managed?

A 
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
Q

What CV complications are associated with CKD?

A

HTN
Hyperlipidaemia
Uraemic pericarditis

63
Q

What K level may induce a fatal cardiac arrhythmia?

64
Q

What is involved in the management of chronic hyperkalaemia?

A

Diet

Drug modifications

65
Q

What does fluid overload lead to?

A

HTN

Oedema

66
Q

How is fluid overload in CKD managed?

A

Na restriction
Fluid restriction
Loop diuretics

67
Q

What should be the goal BP in CKD?

A

<125/75 in CKD with significant proteinuria or 130/80 if no proteinuria

68
Q

What drug can be used to treat HTN in CKD?

A

ACEi may offer additional advantage

69
Q

Which drugs commonly cause AKI on top of CKD?

A

Antibiotics

Contrast agents

70
Q

How can you manage CV complications of CKD?

A

BP control, aspirin, cholesterol reduction, exercise, wt loss

71
Q

What drugs should be avoided in renal failure?

A

Antibiotics - tetracycline, nitrofuratoin
NSAIDs
Lithium
Metformin

72
Q

What drugs are likely to accumulate in CKD and may require dose adjustment?

A 
Most antibiotics incl. penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
Digoxin, atenolol
Methotrexate
SUs
Furosemide
Opioids
73
Q

What drugs are considered safe to use in CKD?

A

Antibiotics - erythromycin, rifampicin
Diazepam
Warfarin

74
Q

What antihypertensive may be useful in CKD when GFR falls <45ml/min?

A

Furosemide (as it lowers K)

75
Q

Anaemia in CKD prediposes to what?

A

Development of LVH

76
Q

What does ESA stand for?

A

Erythropoiesis stimulating agents

77
Q

Give e.g.s of ESAs

A

Erythropoetin

Darbepoetin

78
Q

How may renal bone disease manifest?

A

Osteitis fibrosa cystica (hyperparathyroid bone disease)
Adynamic (reduction in osteoblasts + osteoclasts)
Osteomalacia
Osteosclerosis
Osteoporosis

Renal/Urology (29 decks)

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