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MBCHB3 RBF > Lecture 19: Clinical renal failure > Flashcards

Lecture 19: Clinical renal failure Flashcards

1
Q

What is kidney failure?

A
  • A reduction in GFR

(Normally 100ml/min)

Acute Kidney Disease
vs
Chronic Kidney injury

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2
Q

What are the signs of renal failure?

A

Blood test:
- Elevated creatinine
- Elevated urea as renal failure continues

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3
Q

What is the staging for AKI based on serum creatinine or urine output?

Must know

A

Stage 1: Serum creatinine 1.5->1.9x baseline. OP <0.5ml/kg/hr urine 6-12hrs

Stage 2: 2.0->2.9x baseline. OP <0.5ml/kg/hr urine >12hrs

Stage 3: 3x baseline. OP <0.3ml/kg/hr urine >24hrs or 12hrs anuria.

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4
Q

What are the patient risk factors for AKI??

Must know

A
  • Elderly (65+)
  • CKD
  • Long term conditions i.e CKD, DM, CHF
  • Polypharmacy
  • Specific meds i.e
    -> Diuretic
    -> NSAIDS
    -> ACEi/BP meds
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5
Q

Why does creatinine elevate in renal failure?

A

Creatinine is a surrogate measure for:
- How much muscle waste product is produced
- How well the kidneys get rid of the waste product

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6
Q

What is the gold standard of GFR measurement?

A
  • Insulin clearance (injected)
  • Using an isotope Cr-EDTA clearance

But these are impractical for everyday clinical use

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7
Q

What is eGFR and what does it use?

A

eGFR = estiamted GFR and blood test measures creatinine as an indicator of renal function. Many formula exist for this.

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8
Q

What confounds the interpretation of GFR?

A
  • Creatinine is secreted in small amounts by the tubules so adds to overestimates of creatinine clearance.
  • Serum creatinine also reflects body size and muscle mass.
  • Moderate to severe CKD confounds interpretation. b/c as GFR declines extrarenal excretion increases (also pts have declining muscle mass)
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9
Q

What factors influence eGFR?

A
  • Weight i.e enhanced muscles mass vs fat b/c muscle mass will increase creatinine
  • Age, muscle mass declines with age
  • Age, GFR declines naturally with age
  • Gender, females have less muscle mass
  • Race, different ethnicities have different muscle mass
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10
Q

How does eGFR compare with GFR?

A

Two people with the same creatinine can have completely different GFRs… so eGFR is largely dependant on creatinine and muscle mass

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11
Q

So what two factors are examined when it comes to kidney function?

A
  • GFR (other methods of being calculated) and Creatinine
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12
Q

What are the two types of renal failure and what do they have in common?

A

Acute Kidney injury
Chronic kidney disease

Both have high creatinine and low GFR

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13
Q

What is acute kidney injury?

A
  • Sudden rapid reduction in GFR
  • Happens over days/weeks
  • Usually reversible

70% due to non-renal causes

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14
Q

What are the potential aetiologies of AKI?

A
  • Pre-renal (insufficient blood)
  • Renal
  • Post renal (Obstructions)
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15
Q

What are the causes of prerenal failure?

A
  • Low BP
  • Not enough blood to kidneys
    • Dehydration, septic shock, haemorrhage, cardiogenic shock , severe renal art. stenosis
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16
Q

What is found on a blood test for pre-renal AKI?

A
  • High creatinine
  • K = Hyperkalemia
  • Phosphate = High (itchy skin)
  • Ca: May be low
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17
Q

Whats the treatment for pre-renal AKI?

A

Fix underlying problem
- Rehydrate
- Treat bleeding
- Fix heart
- Antibiotics for sepsis
- ICU treatment for persistent low BP

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18
Q

What happens to pre-renal AKI if it doesnt get better?

A

Potentially leads to acute tubular necrosis

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19
Q

Whats acute tubular necrosis (ATN)?

A
  • Mainly due to pre-renal causes
  • Persistant oliguria (low urine) and renal failure after correction of underlying pre-renal condition

-> High creatinine
-> Low urine output
-> High potassium

Necrosis of the tissues, suspected from lack of blood

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20
Q

Whats the treatment for ATN?

A
  • Maintain normal BP
  • Treat underlying problem…
  • If kidney keeps getting worse then dialysis (not a cure just keeps people alive)
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21
Q

Whats recovery like for ATN?

A
  • 95% get better

Polyuric phase in recovery
- Tubules cant concentrate
- Up to 20L urine per day
- Need IV fluids to recover

22
Q

What are the renal causes of renal failure?

A

ATN:
- Pre-renal (as listed earlier)
- Drugs i.e aminoglycosides
- Toxins

Glomerulonephritis

23
Q

What causes rapidly progressive glomerulonephritis (RPGN)?

A
  • Acute renal failure due to glomerular disease (not drug related)
  • Usually presents with blood and or protein in the urine
  • AKI
  • Diagnosis requires a renal biopsy
24
Q

What are the causes of post renal AKI?

A
  • Kidney stones
  • Tumour
  • Prostate hypertrophy
  • Urinary retention
25
Q

What is chronic kidney disease?

A
  • Happens over months/years
  • Gradual decline in renal function
  • Irreversible (scarring on kindeys)
26
Q

What is seen with CKD?

A
  • Elevated creatinine
  • Elevated urea
  • Usually NORMAL urine ouput
27
Q

What are the markers of kidney damage?

A
  • Structural abnormalities
  • Abnormal urine sediment
  • Electrolyte abnormality
  • Decrease GFR <60ml/min
28
Q

What are the causes of CKD?

A
  • Diabetes
  • Glomerulonephritis
  • Hypertension
29
Q

What happens in CKD?

A
  • Gradual increase in creatinine due to underlying disease
  • Scarring of glomeruli and interstitium
30
Q

What are the patient symptoms of CKD?

A
  • None in early stages
  • Usually found on blood tests
  • Urine output normal
  • Uraemia: Symptom of kidney failure (Not till GFR has got low)
31
Q

What does uraemia result in?

A
  • Anorexia (B/c so sick doesnt eat)
  • Nausea
  • Vomiting
  • Itchiness
  • SOB
  • Swelling
  • Cold intolerance
  • Seizures
  • Coma
32
Q

What are the signs of CKD?

A
  • No consistent signs early on
  • Most common is hypertension
  • Oedema
  • Pulmonary oedema
  • Raised JVP
33
Q

How is CKD diagnosed?

A

Usually on a routine blood test
- Urea: Increased
- Creatinine: Increased
- eGFR: Decreased

34
Q

What are the stages of CKD and what are some consequences?

Recreate this slide with the appropriate values for each staage……. check nothing else has been missed.

A

Stage 1: Normal
Stage 2: Early (Increased PTH)
Stage 3: Moderate (decreased Ca, anaemia, low EPO)
Stage 4: Severe (High phosphate, acidosis, K may rise, malnutrition)
ESRF: Uraemia

35
Q

Why does phosphate rise in Kidney failure?

A

Body has a high turn over of phosphate
- Thus most of what is absorbed in excreted in the kidney.
- This in kidney failure, less is excreted and serum phosphate increases.

36
Q

What happens to Potassium in CKD?

A

Often high b/c proximal tubule issues

= Arrhythmias

37
Q

What can you do in CKD?

A

Aims of therapy:
- Prevent disease progression
- Control complications of renal failure

Chronic -> control of BP (tends to be the aim)

38
Q

What are the secondary factors likely to contribute to the progression of CKD?

A

VIP Diabetes!!! Hypertension!!

  • intra-glomerular hypertension
  • Glomerular hypertrophy
  • Ca and Ph
  • Dyslipidaemia
  • Proteinuria
  • Tubulointerstiital fibrosis
  • Toxcitiy of iron/NH4
39
Q

Whats a treatment found to improve all renal outcomes?

VIP

A

SGLT2i

improves all renal outcomes. Osmotic diuretic? MoA unsure.

Reducing blood pressure…

40
Q

How is blood pressure suggested to be tackled to improve renal outcomes?

A

Lifestyle changes

Salt, weight, exercise, smoking

Drugs:
- Diuretics
- SNS, RAAS

41
Q

Whats the importance of proteinuria?

A
  • An important prognostic factor
  • Wide range of GN outcome is determined by the degree of of proteinuria
  • Reduction in proteinuria is assc with improved outcomes
42
Q

How can proteinuria be modified?

A
  • Weight loss
  • ACEi + AIIRB
  • Aldo antagonists
  • Statins
  • Moderate protein restrict
  • Lowering BP
43
Q

Whats smoking assocaited with?

A

Associated with progression of both non-diabetic and diabetic kidney disease.

44
Q

What happens to Ca and P in CKD?

A

They are asssociated with progressive renal impairment and decline in renal function.

Improvement in Ca/P product is associated with reduction in rate of decline

45
Q

How can Ca/P be managed?

A
  1. Limit P in diet
  2. Phosphate binders i.e CaCO4
46
Q

How does CKD effect water balance?

A

CKD patients are more prone to both dehydration and volume overload.

47
Q

How is the kidney an endocrine organ?

A
  • EPO
  • Vit D
  • BMP
  • RAAS
  • Bradykinin
48
Q

What else can happen in CKD?

A
  • Normochromic normocytic anaemia
  • Electrolyte abnromalities
  • Metabolic acidosis due to lack of excretion
  • Uraemia
49
Q

How do you manage CKD?

A
  • Treat Primary and secondary disease
  • Avoid nephrotoxins
  • Optomise fluid balance / avoid dehydration
  • Correct abnormalities
  • Renal replacement therapy
50
Q

What are the ESKD treatment options?

A
  • Conservative
  • Dialysis; Peritoneal, heamodialysis
  • Renal transplant

MBCHB3 RBF (39 decks)

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