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CCC > Primary care-CKD > Flashcards

Primary care-CKD Flashcards

1
Q

Define chronic kidney disease.

What is the diagnostic egfr and ACR?

A

Abnormal kidney structure or function present for >3 months with implications for health

  • egfr <60 or ACR>3 for more than 3 months and multiple readings is diagnostic of CKD (if stage 1 and 2 need ACR to back up egfr finding)
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2
Q

What can cause chronic kidney disease?

A

VITAMIN CDE surgical sieve

Vascular - HYPERTENSION, renal artery stenosis, heart failure

Infective/inflamation- glomerulonephritis, pyelonephritis, interstitial nephritis/HIV/ steric reflux in kids

Trauma

Autoimmune - SLE/rheumatoid

Metabolic - DIABETES (most common), renal stones, urinary tract obstruction, hypercalcaemia

Iatrogenic-NSAIDS

Neoplastic - renal cancer

Congenital - renal dysplasia, Alport syndrome, Fabry disease

Environment/endocrine - parathyroid disease, smoking,malnutrition

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3
Q

What are the most common causes of chronic kidney disease in the UK?

A
  1. Diabetes mellitus
  2. Glomerulonephritis
  3. Hypertension
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4
Q

When does CKD become symptomatic?

A

When eGFR<30 which is stage 4 CKD

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5
Q

What are some symptoms of CKD?

think about reduced excretion and reduced production

A 
REDUCED EXCRETION 
Less urea excreted
- Anorexia, nausea, vomiting
- Bleeding risk (affects platelet stickiness)
- Tremor/flap (encephalopathy) 
- Yellow tinge/uremic frost 
- Pericarditis 
-Gout (urate)

Less phosphate excreted
- Itchy skin (pruritis)

Less K+ excreted
-Palpatations (cardiac arrhythmias)

Fluid overload (salt and water retention)

  • SOB
  • swelling of legs oedema
  • high BP symptoms

Build up of beta2microglobulin
-Peripheral neuropathy

REDUCED PRODUCTION
Parathyroid hormone production (less vitamine D activation)
- Bone pain

Less EPO
-Anemia (normocytic, normochromic)

It affects hormones

  • Amenorrhoea
  • Impotence

*Restless leg syndrome and insomnia

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6
Q

What does FBC show in CKD? (be specific)

A

Normochromic normocytic anaemia i.e. anaemia of chronic disease; due to decreased erythropoietin production

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7
Q

What do U&Es show in CKD?

What would blood gas show in CKD?

A
  • Low calcium (vitamins D not activated-renal dystrophy)
  • High phosphate (not removed by kidney)
  • Low sodium (fluid overload-hypervolemic hyponatreamia)
  • High potassium (cant remove)
  • Low bicarb (produced by kidney)
  • High urea, high creatinine

Blood gas- Metabolic acidosis (because the kidney produces bicarb but begins to fail to do this)

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8
Q

What investigations would you do in CKD? What would you see?

A

Look at progression of the disease

  • SERUM Cr
  • U+Es
  • eGFR
  • Albumin: creatinine ratio (ACR). If 3-70 this is concerning, repeat in three months. 70+ refer to nephrology.
  • Urinalysis and microscopy (heamaturia and proteinuria)

Look for a cause

  • ESR-?inflammation (SLE/glomerulonephritis)
  • Glucose-?diabetes
  • Measure blood pressure
  • Urine culture to exclude UTI
  • Autoimmune tests
  • Electrophoresis (myeloma)

Look for complications

  • Calcium?hypocalceamia
  • Parathyroid hormone increase due to low calcium
  • Vitamine D low (less calcitriol/activated vita made in kidney)
  • Hb- ?anaemia

Imaging/ further tests

  • Imaging: Renal USS (structural problems/obstruction. Kidneys will be small)
  • Immunology (SLE/vasculitis)

BIOPSY - if indicated (e.g. if you think it is glomerulonephritis, or progressive CKD ) you will see sclerosis

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9
Q

What is the gold standard investigation for CKD?

A

Isotopic eGFR

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10
Q

What further investigations should you consider for progressive CKD or AKI without recovery?
When is it contraindicated

A

renal biopsy (contraindicated in skin infections/clotting abnormalities/unconrtolled HTN)

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11
Q

What should CKD patients BP target be?

What medications should they be on? (think CVD)

A

Control BP

  • ACE inhibitors
  • Target BP < 140/90; in diabetes target is less < 130/80

Prevent CVD

  • Statins (atorvastatin) 20mg
  • Antiplatelets e.g. aspirin
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12
Q

Which medications are nephrotoxic?

What other drugs should be avoided in CKD?

A

A DIAMOND ALi

Aminoglycosides

Diuretics (especially potassium sparing)
Iodine contrasts/immunosuppressants
Antihypertensives  (although in CKD, ACEi are used,)
Metformin
Opioids
NSAIDs
Digoxin

Acyclovir
Lithium

CKD patients also shouldn’t take drugs which increase potassium (spironlactone, K+ supplements, amiloride)

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13
Q

What are the stages of CKD? (egfr)

A

○ STAGE 1 - eGFR >90 - normal kidney function
○ STAGE 2 - eGFR 60-89 - Review 12 monthly

	○ STAGE 3A - eGFR 45-59 - Review 6 monthly 
	○ STAGE 3B - eGFR 30-44 - Review 6 monthly
	○ STAGE 4 - eGFR 15-29 - Review 3 monthly 
	○ STAGE 5 - eGFR <15 - Review 6 weekly  *** You only really become concerned when patients are in stage 3 onwards <60
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14
Q

What can cause a relatively low serum creatinine?

A

Low muscle mass:

  • Being elderly due to wasting of muscles
  • Female
  • Amputees
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15
Q

Whats normal urea? What sorts of things can increase/decrease your urea?

A 
Normal Urea 2.5 to 7.1 mmol/L
• Breakdown of amino acids can produce urea 
DISPROPORTIONALLY HIGH UREA 
-Glucocorticoids
-High protein intake 
-GI bleed 
-Heart failure 
-Dehydration

DISPROPORTIONALLY LOW UREA

  • Low protein intake
  • Liver failure (doesn’t make as many proteins)
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16
Q

Whats normal creatinine? What sorts of things can increase/decrease your creatinine?

A

Normal creatinine 0.5 to 1.1

• Larger muscle mass= more creatinine (males have more than female)

-Disproportionately low in patients with low muscle mass (Elderly, wasting, amputees, female)

17
Q

What is egfr based on?

A

Egfr based on creatinine, age and sex. (when you receive it back times egfr by 1.2 if patient is Afro-Caribbean

18
Q

clinical symptoms/signs of kidney failure?

A

RENAL-polyuria, nocturia due to retention
CARDIOVASCULAR- hypertension, pulmonary oedema, vascular disease, LVH/dysfuction, vascular calcifications
GI-reduced app, weight loss, nausea, GI ulcers

19
Q

What should you safe guard people about Ace inhibitors?

A

if you get ill (D and V) or infection. Stop taking it until better- can cause hypotension

20
Q

What is the treatment for end stage renal disease? When is it indicated?

A

Renal replacement therapy is indicated egfr<15 (think about way before because it takes time)

  1. Dialysis
    - Help with excretory-remove salt and water from patient
  2. Transplant
    - Best rehab and survival
    - Lifelong immunosuppression
    - May fail later on
    - Lots of patients aren’t fit for transplant-comorbidities
  3. Palliative
21
Q

Explain the 2 types of peritoneal dialysis?

Whats a complication of peritoneal dialysis?

A
  • CAPT (continuous ambulatory)- 3/4 bag changes in the day
  • APD (automated)-attach to machine at night

BOTH DONE AT HOME

Complication is peritonitis (can be life threatening)

22
Q

What are the two types of dialysis?

A
  • Heamodialysis 3x week (normally have radial cephalic fistula), mostly hospital can train to do it at home
  • Peritoneal- home treatment
23
Q

What do Bence Jones proteins indicate in urine?

A

Bence Jones proteins indicate multiple myeloma

24
Q

What are the stages of CKD? (ACR)

A

ACR measurements of CKD
A1 <3
A2 3-30
A3 30+

25
Q

What is the name of the scar in renal transplant? whats it look like?

A

Rutherford morrisons scar (hockey stick scar normally in LEFT iliac fossa)

26
Q

Neumononic to remember CKD symptoms?

A 
BIGBEAN 
Breathlessness 
Itching 
Gout 
Bone pain 
Energy reduced 
Anemia 
Neuropathy-peripheral (build up of beta2microglobulin)
27
Q

How should you manage CKD?

A
  1. IDENTIFY AND MANAGE CAUSE
  2. MANAGE PROGRESSION
  3. MANAGE COMPLICATIONS
  4. MANAGE COMORBIDITIES
    - lose weight
    - stop smoking
    - diet advise (and keep hydrated)
    - STOP NEPHROTOXIC DRUGS
  5. MANAGE MENTAL HEALTH
  6. SAFETY NET (cardio events, deterioration)
  7. FOLLOW UP
28
Q

How can you identify the cause of CKD?

A

IDENTIFY CAUSE of CKD

  • Hba1c (diabetes)
  • BP (hypertension) BP <140/90 unless diabetic (then 130/80)
  • Urine microscopy (red cell clasts- glomerulonephritis, lupus, goodpastures)
  • Immunology (SLE, vasculitis, amyloid, myeloma)
  • Inflamitory markers
  • Renal USS (obstruction, structural)
29
Q

How can you monitor the progression of CKD?

How often should they be followed up?

A

CKD -monitoring progression

  • Us+Es, egfr, creatinine
  • Urine dipstick (Heam and protein urea), A:C ratio (protein)
  • FBC (anemia)
  • Ca, PTH
  • Phosphate
  • BP

Follow up

  • yearly for stage 2
  • 6 monthly stage 3
  • 3 monthly stage 4 (refer to nephrology at stage 4+ or if egfr dropped 15+ in a year
30
Q

How can you manage the complications of CKD

A

Complications of CKD management
Anaemia (normally normocytic normochromic)
- treat any iron, folate, b12 deficiencies FIRST
- give erythropoietic stimulating agent if Hb<11g/dL (once iron corrected)

Acidosis - sodium bicarbonate supplements if eGFR < 30 (this will also help with hyerkaleamila)

Hyperkaleamia (in severe CKD) moniter ECG and treat as normal

Oedema - high dose loop diuretics (can be combined with thiazide). Restricting salt and fluids

Renal osteodystrophy - vitamin D supplements colecalciferol) If persists give vit D analogue (calcitriol). May need surgery for tertiary parathyroidism

High Phosphate (manage with diet/phosphate binding)

Restless legs/cramps

  • iron deficiency may be cause-check ferritin
  • sleep hygiene advice
  • gabapentin

-Cardiovascular disease (HTN, PVD, HF) (statin 20mg atorvastatin) and Neuropathy

31
Q

How might you know if a CKD patient had peritonitis?

What is the most likely organism?

What do you do?

A

Peritonitis
-CLOUDY BAG if fluid (send for culture)
+/- fever
+/- abdo pain

Most often caused by Coagulase-negative Staphylococcus (staph epidermis)

Continue, but give IV BS AB (Cipro, or Vancomycin if MSRA. Both if unsure)

32
Q

What type of diet should someone with CKD be on?

A

Diet in CKD

  • ↓phosphate (calcium+phosphate=stones. Also itchiness)
  • ↓ potassium (arrhythmias)
  • ↓ protein (protein>ammonia>urea)
  • ↓ salt (increases BP)
33
Q

When would you refer CKD patient to nephrology?

A

refer to nephrology at stage 4+ (egfr<30) or if egfr dropped 15+ in a year

CCC (15 decks)

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