Renal System Disorders II - CKD Flashcards
What’s Chronic Kidney Disease ?
Chronic kidney disease is a longstanding and usually progressive impairment of renal function characterised by:
-GFR<60mL/min/1.73㎡
-or Urinary albumin to creatine ratio (UA/CR)>30mg/g
-or Protein-Creatinine Ratio (PCR)>100mg/mmol
with or without kidney evidence of kidney damage for more than 3 months.
The classification of CKD was established by _______ in the USA in 2002 and endorsed by ________ in 2004.
- Established by Kidney Disease Outcomes Quality Initiative (KDOQI) of the National Kidney Foundation.
- Endorsed by Kidney Disease: Improving Global Outcomes (KDIGO)
Classify CKD.
Stage 1: GFR ≥ 90mL/min/1.73㎡. Normal GFR
Stage 2: GFR = 60-89mL/min/1.73㎡. Slight decrease in GFR.
Stage 3a: GFR = 45-59mL/min/1.73㎡. Mild decrease in GFR.
Stage 3b: GFR = 30-44mL/min/1.73㎡. Moderate decrease in GFR.
Stage 4: GFR = 15-29mL/min/1.73㎡. Severe decrease in GFR.
Stage 5: GFR<15mL/min/1.73㎡. End stage kidney disease.
Patients with stages 1-2 CKD are frequently asymptomatic. Clinical manifestations typically appear from stage 3-5.
True or False?
True
Mention 7 causes of CKD.
- Poor glycemic control
- Uncontrolled hypertension
- Vascular disease e.g. renal artery stenosis
- Glomerular disease
- Cystic kidney disease
- Tubuloinstertitial disease
- Urinary tract obstruction
- Recurrent kidney stone disease
- Nephrotoxins e.g NSAIDS, corticosteroids
- Unrecovered AKI
- Congenital kidney or bladder defects.
Mention 7 symptoms of CKD.
- Malaise
- Loss of appetite
- Insomnia
- Pruritus
- Paresthesia due to polyneuropathy
- Bone pain
- Endocrine symptoms:- amenorrhoea in women, ED in men.
- Anemia symptoms e.g. pallor, lethargy, breathlessness on exercise.
- CNS Symptoms (CKD stage 5):- clouding of consciousness, seizure, myoclonic twitching, encephalopathy which may progress to coma or death.
- Peripheral or pulmonary oedema due to water and sodium retention (volume overload)
What are the complications of CKD?
- Anemia:- PCV<20%, Ferritin<100mg/mL, Hb<10g/L
2: Bone Mineral Disease (Renal osteodystrophy):- The various bone mineral diseases that may develop alone or in combination in CKD e.g osteomalacia, osteosclerosis, adynamic bone disease. - Skin Disease:- due to nitrogen retention e.g. pruritus, dry skin
- Metabolic abnormalities e.g. gout, insulin resistance, hypercholesterolemia, hypertriglyceridemia.
- Hyperkalemia:- (K+ > 5.0mEq/L) elevated K+ levels due to its reduced renal excretion, excessive intake or leakage of K+ from intracellular spaces.
- Hyperphosphatemia (Serum phosphate > 4.5mg/dL)
- Hypocalcemia (serum Ca2+ < 8.8mg/dL)
- Hypertension:- due to volume expansion.
**insulin is catabolised and excreted via the kidney. In CKD, impaired renal function may lead to reduced clearance of insulin from the bloodstream. Prolonged exposure to elevated insulin levels can contribute to insulin resistance.
The medical care of patients with CKD usually focuses on:
- Delaying or halting the progression of CKD
- Diagnosing and treating the pathological manifestations of CKD
- Timely planning for long-term dialysis or renal transplant.
The delaying or halting the progression of CKD involves treatment of the underlying conditions. What are the measures taken to achieve this?
- Aggressive BP control:- Using supratherapeutic doses of CCBs, ARBs or ACEIs to BP < 130/80 mmHg or <120 mmHg (according to SPRINT trial)
- Treatment of hyperlipidemia to target levels using statins e.g. Atorvastatin, Rosuvastatin
- Aggressive glycemic control:- target HbA1C<7%
- Avoid nephrotoxins e.g. NSAIDS, aminoglycosides
5.Use of RAAS blockers e.g. ACEIs and ARBs among patients with Diabetic Kidney Disease and proteinuria.
According to SPRINT trials, systolic BP of _____ mmHg is associated with decreased cardiovascular incidence and mortality in CKD patients.
<120 mmHg
Which common anti-hypertensive drugs are considered reno-protective?
ACEIs and ARBs.
What are the drugs used to achieve glycemic control?
- Biguanides e.g. Metformin
- Glibenclamides
- SGLT II inhibitors e.g. dapaglifloxin, empaglifloxin
What are SGLT II inhibitors?
Sodium-Glucose Co-transporter II inhibitors are a class of anti-diabetic medications that are not insulin-dependent.
They work on glucose transporters in the kidney, preventing the reabsorption of glucose, causing the kidneys to excrete more glucose.
How do you treat the pathological manifestations of CKD?
- Anemia(Hb<10g/dL):- treat with ESA
- Hyperphosphatemia:- treat with dietary phosphate binders and dietary restriction.
- Hypocalcemia:- treat with calcium supplements with or without calcitriol.
- Hyperparathyroidism:- due to decreased serum calcium. Treat with calcitriol, vitamin D analogues or calcimimetics (e.g. cinacalcet)
- Volume overload:- Treat with loop diuretics (e.g. torsemide, furosemide) or nonsteroidal mineralocorticoid receptor antagonists (nsMRA) e.g Finerenone
- Metabolic acidosis:- Treat with oral alkali supplementation–Calcium bicarbonate tablets.
- Uremic manifestations:- treat with long-term dialysis or transplantation
- Cardiovascular complications:- treat as appropriate.
- Growth failure in children:- treat with growth hormone.
What are phosphate binders? Give 2 examples.
They bind with dietary phosphate in the GIT which is then eliminated in faeces.
i. Sevelamer carbonate
ii. Lanthanum carbonate
