Primary care-CKD Flashcards
Define chronic kidney disease.
What is the diagnostic egfr and ACR?
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)
What can cause chronic kidney disease?
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
What are the most common causes of chronic kidney disease in the UK?
- Diabetes mellitus
- Glomerulonephritis
- Hypertension
When does CKD become symptomatic?
When eGFR<30 which is stage 4 CKD
What are some symptoms of CKD?
think about reduced excretion and reduced production
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
What does FBC show in CKD? (be specific)
Normochromic normocytic anaemia i.e. anaemia of chronic disease; due to decreased erythropoietin production
What do U&Es show in CKD?
What would blood gas show in CKD?
- 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)
What investigations would you do in CKD? What would you see?
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
What is the gold standard investigation for CKD?
Isotopic eGFR
What further investigations should you consider for progressive CKD or AKI without recovery?
When is it contraindicated
renal biopsy (contraindicated in skin infections/clotting abnormalities/unconrtolled HTN)
What should CKD patients BP target be?
What medications should they be on? (think CVD)
Control BP
- ACE inhibitors
- Target BP < 140/90; in diabetes target is less < 130/80
Prevent CVD
- Statins (atorvastatin) 20mg
- Antiplatelets e.g. aspirin
Which medications are nephrotoxic?
What other drugs should be avoided in CKD?
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)
What are the stages of CKD? (egfr)
○ 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
What can cause a relatively low serum creatinine?
Low muscle mass:
- Being elderly due to wasting of muscles
- Female
- Amputees
Whats normal urea? What sorts of things can increase/decrease your urea?
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)
Whats normal creatinine? What sorts of things can increase/decrease your creatinine?
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)
What is egfr based on?
Egfr based on creatinine, age and sex. (when you receive it back times egfr by 1.2 if patient is Afro-Caribbean
clinical symptoms/signs of kidney failure?
RENAL-polyuria, nocturia due to retention
CARDIOVASCULAR- hypertension, pulmonary oedema, vascular disease, LVH/dysfuction, vascular calcifications
GI-reduced app, weight loss, nausea, GI ulcers
What should you safe guard people about Ace inhibitors?
if you get ill (D and V) or infection. Stop taking it until better- can cause hypotension
What is the treatment for end stage renal disease? When is it indicated?
Renal replacement therapy is indicated egfr<15 (think about way before because it takes time)
- Dialysis
- Help with excretory-remove salt and water from patient - Transplant
- Best rehab and survival
- Lifelong immunosuppression
- May fail later on
- Lots of patients aren’t fit for transplant-comorbidities - Palliative
Explain the 2 types of peritoneal dialysis?
Whats a complication of peritoneal dialysis?
- 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)
What are the two types of dialysis?
- Heamodialysis 3x week (normally have radial cephalic fistula), mostly hospital can train to do it at home
- Peritoneal- home treatment
What do Bence Jones proteins indicate in urine?
Bence Jones proteins indicate multiple myeloma
What are the stages of CKD? (ACR)
ACR measurements of CKD
A1 <3
A2 3-30
A3 30+
What is the name of the scar in renal transplant? whats it look like?
Rutherford morrisons scar (hockey stick scar normally in LEFT iliac fossa)
Neumononic to remember CKD symptoms?
BIGBEAN Breathlessness Itching Gout Bone pain Energy reduced Anemia Neuropathy-peripheral (build up of beta2microglobulin)
How should you manage CKD?
- IDENTIFY AND MANAGE CAUSE
- MANAGE PROGRESSION
- MANAGE COMPLICATIONS
- MANAGE COMORBIDITIES
- lose weight
- stop smoking
- diet advise (and keep hydrated)
- STOP NEPHROTOXIC DRUGS - MANAGE MENTAL HEALTH
- SAFETY NET (cardio events, deterioration)
- FOLLOW UP
How can you identify the cause of CKD?
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)
How can you monitor the progression of CKD?
How often should they be followed up?
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
How can you manage the complications of CKD
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
How might you know if a CKD patient had peritonitis?
What is the most likely organism?
What do you do?
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)
What type of diet should someone with CKD be on?
Diet in CKD
- ↓phosphate (calcium+phosphate=stones. Also itchiness)
- ↓ potassium (arrhythmias)
- ↓ protein (protein>ammonia>urea)
- ↓ salt (increases BP)
When would you refer CKD patient to nephrology?
refer to nephrology at stage 4+ (egfr<30) or if egfr dropped 15+ in a year
