Renal: CKD Flashcards
What is CKD?
Chronic kidney disease (CKD) is:
a reduction in kidney function or structural damage (or both) present for more than 3 months, with associated health implications.
What investigation results confirm diagnosis of CKD?
- Markers of kidney damage:
- Urinary albumin:creatinine ratio (ACR) >3mg/mmol
- urine sediment abnormalities
- histological abnormalities
- structural abnormalities (on imaging)
- electrolyte abnormalities due to tubular disorders
- Hx kidney transplant
and/or
* a persistent reduction in renal function eGFR <60
How is CKD classified?
- classified using a combination of estimated glomerular filtration rate (eGFR) and urinary albumin:creatinine ratio (ACR).
What are the causes and risk factors for CKD?
- conditions which cause intrinsic kidney damage: HTN, DM, glomerulonephritis
- current or previous AKI
- nephrotoxic drugs e.g. aminoglycosides, ACEI, ARBs. bisphosphonates, ciclosporin, tacrolimus, diuretics, lithium,mesalazine, NSAIDs
- obstructive uropathy: structural renal tract disease, BPH, calculi
- multisystem diseases: SLE, vasculitis, myeloma
- familial: PKD, Alport’s, GN
- CVD: HTN, HF,metabolic syndrome
- gout
- incidental haematuria/proteinuria (after UTI excluded)
If any of the above - test for CKD with eGFR and ACR at least annually.
Repeat test in <2wk if eGFR <60 and no previous test.
If CKD is suspected in primary care, which investigations should be done?
- CKD should be suspected in patients with any Risk Factors (see slide), incidental raised creatinine or eGFR <60, Urine ACR >3, persistent haematuria after UTI excluded, urine sediment abnormalities.
- Bloods - U&E, eGFR.
- Early morning urine ACR
- Urine dip for haematuria
- Repeat eGFR and ACR in 3 months - diagnose CKD if either remains abnormal.
- Check BMI, BP, HbA1c, lipids (CVS risk factors - don’t use QRISK tool)
- USS renal if suspected obstruction/stones/FHx PKD and age >20
Which patients should be referred to nephrologist?
- 5 year risk of needing RRT >5%
- Accelerated progression of CKD:
- sustained decrease in eGFR of >=25% within 12 months AND a change in CKD category
- sustained decrease in eGFR of >=15ml/min within 12 months
- urine ACR of >=30mg/mmol with persistent haematuria after UTI ruled out.
- urine ACR of >=70 (unless known due to DM and being managed appropriately already)
- Uncontrolled HTN despite 4 antihypertensives
- suspected rare/genetic cause (e.g. PKD)
- suspected Renal Artery Stenosis - should be suspected if:
->25% reduction in eGFR within 3 months of starting or increasing dose of ACEI/ARB, refractory HTN, pul oedema, bruit. - suspected complication of CKD - malnutrition, hyperkalaemia,renal anaemia, bone disorder, metabolic acidosis.
Which patients should be referred to a urologist?
- suspected urinary tract obstruction - hydronephrosis on USS, or palpable bladder
- emergency admission if acute urinary retention, severe hyperkalaemia, severe uraemia.
- 2ww if isolated persistent haematuria and cancer suspected.
How should Hypertension be managed in CKD, if the person does not have diabetes? What is the target BP?
- If their urine ACR is <30, then manage as for adults without CKD.
- If their urine ACR is >=30 give ACEI/ARB
- If urine ACR <70, target BP <140/90
- If urine ACR >=70, target BP <130/80
How should Hypertension be managed in CKD, if the person has diabetes? What is the target BP?
- If urine ACR <70, aim BP <140/90
- If urine ACR >=70, aim BP <130/80
- If aged >=80, whatever the ACR, aim BP <150/90
- Offer ACEI/ARB first line
If a person has a urine ACR >=70, which medication should be started (irrespective of BP or CVD)?
- ACEI / ARB
What medication should all those with CKD be offered for primary prevention of CVD?
- atorvastatin 20mg.
Which medication can be added in second line for CKD treatment?
- SGLT-2 inhibitors (dapagliflozin, empagliflozin).
- for those with proteinuric CKD with or without diabetes
All suspected glomerulonephritis should be urgently referred to renal. Which is the most common GN in children and how does it present?
GN is characterised by inflammation and damage to the glomeruli.
- minimal change GN
- underlying cause unknown
- Presents with nephrotic syndrome: proteinuria >3.5g/day, hypoalbuminaemia <30, oedema -swelling of eyelids and face, ascites, peripheral oedema, urine frothy. Urine ACR >220.
non-proliferative
All suspected glomerulonephritis should be urgently referred to renal. In which GN is there an underlying malignancy in 10% adults?
- Membranous GN
- Slowly progressive, primarily affects adults age 30-50
- causes 30% of adult nephrotic syndrome
- thickened glomerular basement membrane
- 1 in 3 gain remission
- 1 in 3 proteinuric
- 1 in 3 progress to ESRD
non-proliferative
All suspected glomerulonephritis should be urgently referred to renal. Which is the most common cause of nephrotic syndrome in adults?
- Focal segmental glomerulosclerosis
- can be primary or secondary (underlying HIV, lupus, reflux nephropathy)
- segmental scarring of some glomeruli
- present with proteinuria or nephrotic syndrome
- > 50% progress to CKD
non-proliferative
