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SA urinary > S12) Chronic Kidney Disease > Flashcards

S12) Chronic Kidney Disease Flashcards

1
Q

What is adult polycystic kidney disease?

A
  • APCKD is an autosomal dominant disease due to a mutation in either PKD1 gene (~85%) or PKD 2 gene
  • Cysts grow with age, it generally presents in adulthood and is diagnosed with ultrasound and genetic testing
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2
Q

What are the secondary complications of APCKD?

A
  • Pain
  • Bleeding into cyst
  • Infection
  • Renal stones (stasis)
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3
Q

Identify three other co-morbidities of APCKD

A
  • Hypertension very common (before renal function changes)
  • Increased incidence of intra-cranial aneurysms
  • Increased incidence of heart valve abnormalities
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4
Q

What is Chronic Kidney Disease?

A
  • CKD is the irreversible and sometimes progressive loss of renal function over a period of months to years
  • Renal injury causes renal tissue to be replaced by extracellular matrix in response to tissue damage
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5
Q

Describe the aetiology of chronic kidney disease

A
  • Diabetes
  • Hypertension
  • Immunological e.g. glomerulonephritis
  • Infection e.g. pyelonephritis
  • Genetic e.g. APCKD, Alport’s
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6
Q

Which groups of patients have an increased incidence of CKD?

A
  • Elderly
  • Multi-morbid
  • Ethnic minorities
  • Socially disadvantaged
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7
Q

Classify the different stages of CKD in terms of GFR

A
  • G1 – normal/high GFR ( ≥ 90)
  • G2 – midly decreased (60-90)
  • G3a – midly/moderately decreased (45-59)
  • G3b – moderately/severely decreased (30-44)
  • G4 – severely decreased (15-29)
  • G5 – kidney failure (< 15)
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8
Q

Classify the different stages of CKD according to proteinuria

A
  • A1 – normal/mildly increased (< 30 mg/g)
  • A2 – moderately increased (30 - 300 mg/g)
  • A3 – severely increased (>300 mg/g)
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9
Q

What investigations should one request for a patient with suspected CKD?

A
  • Blood pressure
  • Urine dipstick
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10
Q

Describe the usage of eGF (estimated glomerular filtration rate)

A
  • Only accurate in adults
  • Correction needed for black patients (not Asians)
  • Defines CKD but not useful in AKI
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11
Q

In 5 steps, outline the clinical approach for CKD

A

⇒ Define degree of renal impairment

⇒ Define cause of renal impairment

⇒ Provide patient with diagnosis and prognosis

⇒ Identify complications of CKD

⇒ Plan long term treatment (delay progression, plan for dialysis/transplantation)

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12
Q

Identify the 5 general blood tests performed for a patient with suspected CKD

A
  • Urea & Electrolytes
  • Bone biochemistry
  • Liver function tests (albumin)
  • Full blood count
  • C reactive protein
  • ± PTH / iron levels (ferritin, iron, reticulocyte haemoglobin)
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13
Q

Which other blood tests are performed for a patient with suspected CKD and when should they be performed?

A

Clincial suspicion of…

  • Auto-immune disease – auto-antibody screen, complement levels
  • Vasculitis – anti-neutrophil cytoplasmic antibody
  • Myeloma – serum immunoglobulin screen, protein electrophoresis
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14
Q

Which imaging techniques are used for a patient with suspected CKD, and why are they performed?

A
  • Ultrasound scan – kidney size, evidence of obstruction (hydronephrosis)
  • Kidney biopsy – cause unknown, haematuria, proteinuria (USS first)
  • Other investigations:

I. CT scan (stones / mass)

II. MRI scan (mass)

III. MR angiogram (renal artery stenosis)

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15
Q

Identify four modifiable risk factors for CKD

A
  • Lifestyle
  • Smoking
  • Obesity
  • Lack of exercise
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16
Q

Identify two non-modifiable risk factors for CKD

A
  • Uncontrolled diabetes
  • Hypertension
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17
Q

Identify three drugs which act as risk factors for CKD

A
  • Proton pump inhibitors
  • ACE-Inhibitors / Angiotensin Receptor Blockers (proteinuria - )
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18
Q

Explain the effect of CKD on water/salt handling by the kidney

A

⇒ Reduced GFR

⇒ Lose ability to maximally dilute and concentrate urine

⇒ Small glomerular filtrate but same solute load → osmotic diuresis (nocturia)

⇒ Low volume of filtrate reduces maximum ability to excrete urine → maximum urine volume is much smaller

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19
Q

Which structures / processes are affected by acidosis?

A
  • Muscle
  • Bone
  • Renal function progression
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20
Q

How does one treat acidosis?

A

Oral NaHCO3 tablets

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21
Q

Why does hyperkalaemia occur in CKD?

A
  • Can occur once eGFR < 20 mls / min
  • Less likely when good urine output maintained
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22
Q

How can hyperkalaemia be treated in CKD?

A
  • Stop ACEi / ARB
  • Avoidance of other drugs that can increase K+ (amiloride, spironolactone, trimethoprim)
  • Altering diet to avoid foods with high potassium
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23
Q

What are the four possible consequences of the accumulation of waste products in CKD?

A
  • Contributes to uraemic symptoms
  • Reduced appetite
  • Nausea and vomiting
  • Pruritus
24
Q

Lots of drugs require dosage alteration in CKD / ESRD.

Why is drug metabolism altered in CKD?

A
  • Due to reduced metabolism and /or elimination
  • Drug sensitivity can be increased even if elimination unimpaired (side effects more likely e.g. statins)
25
Q

Provide five reasons as to why anaemia occurs in CKD

A
  • Decreased EPO production
  • CKD mineral and bone disorder
  • Bone marrow suppresion by uraemia
  • Medication e.g. ACE inhibitors
  • Co-morbidities
26
Q

Why is it important to treat anaemia in CKD?

A
  • Improves exercise capacity
  • Improves cognitive function
  • Regulates LVH
  • Slows progression of renal disease
  • Reduces mortality
27
Q

In four steps, outline the clinical approach for treating anaemia in CKD

A

⇒ Check iron stores first

⇒ If iron low, replace iron first (oral/IV)

⇒ Once iron normalises, re-check haemoglobin

⇒ If haemoglobin low, start EPO stimulating agent (ESA)

28
Q

Outline the mechanism pathway through which mineral bone disease arises from CKD

A
29
Q

How can one treat bone mineral disease arising from CKD?

A
  • Reduce phosphate intake
  • Phosphate binders (many contain calcium)
  • 1-α-calcidol
  • Vitamin D)
30
Q

When does renal replacement therapy usually need to occur?

A
  • Required when native renal function declines to a level no longer adequate to support health
  • Usually when eGFR 8-10 ml/min (normal ~ 100 ml/min)
31
Q

Define established (end stage) renal failure

A

Established renal failure is when death is likely without renal replacement therapy (eGFR <15 mls/min)

32
Q

Identify some symptoms of ESRD / dialysis

A
  • Overwhelming fatigue
  • Difficulty sleeping
  • Difficulty concentrating
  • Nausea & vomiting / reduced appetite
  • Restless legs / cramps
  • Symptoms of volume overload (SOB, oedema)
33
Q

What are the four options to treat kidney failure?

A
  • Haemodialysis
  • Peritoneal dialysis
  • Conservative care
  • Transplant
34
Q

What is the duration of dialysis? (same as haemodialysis)

A

4 hours, 3 times per week (night time, designated slot)

35
Q

What are the advantages and disadvantages of dialysis?

A
  • Advantages: less responsibility, days off
  • Disadvantages: travel time / waiting, ‘tied’ to dialysis times, restriction on fluid/food intake
36
Q

What are the contra-indications of haemodialysis?

A
  • Failed vascular access
  • Heart failure
  • Coagulopathy
37
Q

What are the complications of haemodialysis?

A
  • Lines: infection, thrombosis, venous stenosis
  • AVF: thrombosis, bleeding
  • Feel chronically unwell
  • Accumulate morbidity (CVS, bone)
38
Q

What are the benefits of home HD/ nocturnal HD?

A
  • Allows more dialysis hours
  • Better large molecule clearance
  • Patients often feel better
  • Patients often need fewer medications
39
Q

What are the two types of peritoneal dialysis?

A
  • CAPD – 4-5 bags throughout day (30 min exchange)
  • APD – overnight dialysis
40
Q

What are the advantages and disadvantages if peritoneal dialysis?

A
  • Advantages: independence, less fluid/food restrictions, easy to travel with CAPD, renal function better preserved initially
  • Disadvantages: frequent daily exchanges or overnight, responsibility
41
Q

What are the contra-indications of peritoneal dialysis?

A
  • Failure of peritoneal membrane
  • Adhesions, previous abdo surgery, hernia, stoma
  • Patient (/carer) unable to connect / disconnect
  • Obese/ large muscle mass
42
Q

What are the complications of peritoneal dialysis?

A
  • Peritonitis (exit or tunnel site)
  • Ultrafiltration failure
  • Leaks (scrotal, diaphragmatic)
  • Development of herniae
43
Q

What are the advantages and disadvantages of kidney transplant?

A
  • Advantages: reduced mortality and morbidity, better QoL
  • Disadvantages: peri-operative risk, malignancy risk, infection risk, diabetes and hypertension risk from meds
44
Q

how do you stage a CKD

A
45
Q

stage proteinuria

A
  • Treat: Stop forcing proteins out blood so can give ACEinhibitor which can lower the glomerular filtrate pressure and
46
Q

how can diabetes type 2 be a risk factor for chronic kidney disease

A
  • damage to blood vessels and efferent arteriole gets thicker so increases pressure
  • If diabetes is poorly controlled:
  • hyperfiltration
  • glucose reabsorption and sodium follows
  • macula densa detects the drop in Na and reduction In Blood pressure
  • RAAS activated
  • vasoconstriction and Bp increases
  • causes damage to glomerular capillaries
47
Q

what are some primary causes of CKD

A
  • polycystic kidney disease
  • ATN
  • Recurrent pyelonephritis
  • glomerulo - nephritis
48
Q

what are some secondary causes of CKD

A
  • Diabetes Mellitus
  • HTN (hyper tension)
  • reno-vascular disease
  • Auto-immune
49
Q

what layer of the kidney goes through atrophy during CKD

A
  • layers of the cortex disappear
50
Q

why is HbA1c not a good marker during CKD

A
  • kidney is not healthy so isn’t producing healthy Haemoglobin
  • It is not producing EPO
  • so not a good

= so should use a fasting plasma glucose

51
Q

how to monitor diabetes in CKD

A
  • HbA1C (Glycosylated Haemoglobin)
  • usually its a good test (RBC lifespan is 120)
  • it wont be a good test if you have anemia
52
Q

calcium homeostasis

A
  1. impaired renal function
  2. low Phosphate excretion
  3. so higher phosphate in plasma
  4. parathyroid stimulated
  5. hyperplasia (enlargement of a tissue or organ)
  6. increased PTH
  7. Increased bone reabsorption
53
Q

what is non bone calcification

A
  • deposits of calcium phosphate = painful
  • Treat phosphate binders to limit phosphate
54
Q

what is dialysis

A
  • its a procedure to remove toxins from the body
55
Q
A

SA urinary (25 decks)

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