Session 10: Chronic Kidney Disease

Question 1

Define chronic kidney failure.

Answer 1

Progressive and irreversible loss of renal function renal function over a period of months to years.

This leads to renal tissue being replaced by extracellular matrix in the response to the damage.

Question 2

How would CKD present on histology?

Answer 2

Gives rise to glomerulosclerosis and tubular interstitial fibrosis.

Question 3

What are most glomerular diseases that lead to chronic renal failure characterised by?

Answer 3

Proteinuria and systemic hypertension

Question 4

Why might incidence of CKD be difficult to define?

Answer 4

Because CKD is usually asymptomatic.

Question 5

Global prevalence of CKD.

Answer 5

11-13%

Question 6

What is CKD most commonly associated with in developed countries?

Answer 6

Old age

Diabetes

Hypertension

Obesity

CVD

Question 7

Common causes of CKD.

Answer 7

Diabetes

Hypertension

CVD

Immunologic

Systemic like myeloma or lupus

Infection like pyelonephritis

Obstructive/reflux

Genetic like polycystic disease or Alport’s.

Question 8

What is this?

Answer 8

Adult Polycystic kidney disease.

Question 9

What is APCKD?

Answer 9

An autosomal dominant disease where there is most commonly a mutation in PKD 1 Gene.

Cysts in the kidneys grows with age and generally present in adulthood.

Question 10

Diagnosis of APCKD.

Answer 10

Ultrasound however this can’t exclude diagnosis if less than 30 years old as cysts might not have developed much by then.

Genetic testing

Question 11

Complications of APCKD.

Answer 11

Pain

Bleeding into cysts

Infection

Renal stones

Hypertension

Intra-cranial aneurysms

Heart valve abnormalities

Question 12

Management of CKD.

Answer 12

Treat the hypertension (most commonly by blocking RAAS)

Plenty of fluids

Low salt

Normal proteins

Tolvaptan

Question 13

Stages of CKD.

Answer 13

1 - >90 GFR

2 - 60-89 GFR

3 - 30-59 GFR

4 - 15-29 GFR

5 - <15 GFR

Question 14

Investigation of CKD.

Answer 14

Define degree of renal impairment

Define the cause of renal impairment

Diagnosis and prognosis

Identify complications

Long term treatment plan

eGFR

Question 15

Give two investigations that are absolutely necessary and always done in CKD.

Answer 15

Blood pressure

Urine dipstick

Question 16

How is eGFR used?

Answer 16

Only accurate in adults and needs to be corrected in black patients.

Question 17

General bloods tests done in CKD.

Answer 17

U & E

Bone biochemistry

LFTs

FBC

CRP

Iron levels

PTH

Question 18

Give example of blood tests done to determine the cause of CKD.

Answer 18

Auto-antibody screen and complement levels for auto-immune disease.

Anti-neutrophil cytoplasmic antibody for vasculitis

Serum immunoglobulin levels for myeloma.

Protein electrophoresis and serum free light chain measurement for myeloma.

Question 19

Other investigations done in CKD.

Answer 19

USS for kidney size and obstruction.

Kidney biopsy

CT, MRI and MR angiogram.

Question 20

Risk factors of CKD.

Answer 20

Any form of AKI from nephrotoxins or decreased perfusion.

Proteinuria

Hyperlipidaemia

Question 21

General effects of CKD.

Answer 21

Increase in total body sodium and water

Acidosis

Hyperkalaemia

Lipid abnormalities

Anaemia

Renal osteodystrophy

Neuropathy, seizures, coma

Dyspepsia

Impotence and infertility

Pruritus

Atherosclerosis

Cardiomyopathy

Question 22

How can CKD cause anaemia?

Answer 22

Decreased EPO

Absolute iron deficiency

Blood loss

Uraemia causing bone marrow suppression

ACE-inhibitors

High hepcidin levels due to inflammation and infection

Question 23

Functions of the kidneys.

Answer 23

Regulation of BP, blood volume, pH, electrolytes, osmolality.

Excretion of waste products and metabolism of drugs.

1-alpha calcidol

Renin

EPO

All of this can go wrong in CKD.

Question 24

Treatment in case of hyperkalaemia in CKD.

Answer 24

Stopping ACE-inhibs or ARBs

Avoid amiloride, spironolactone or trimethoprim

Avoid high potassium diet

Question 25

Symptoms of CKD (may be diffuse).

Answer 25

Tiredness Breathlessness Restless legs Sleep reversal Aches and pains Nausea Vomiting **Itching** Chest pain Seizures

Question 26

Explain how mineral bone disease may arise in CKD.

Answer 26

Impaired renal function can lead to decreased enzyme that converts vitamin D into its active form calcitriol. This leads to lower Ca2+ absorption in the intestines and impaired mineralisation of bone. This leads to less plasma Ca2+ and increase in PTH. This increase in PTH further more resorbs bone in order to increase Ca2+ levels and can lead to weak bones.

Question 27

Definition of End Stage Renal Disease (ESRD)

Answer 27

When death is likely without renal replacement therapy and eGFR \<15 ml/min This is associated with a reduced life expectancy and a reduced quality of life.

Question 28

Symptoms of ESRD.

Answer 28

Tiredness Difficulty sleeping Difficulty concentrating Oedema Nausea and vomiting Restless legs Pruritus Sexual dysfunction Increased infections

Question 29

What are the options in ESRD?

Answer 29

Haemodialysis Peritoneal dialysis Conservative care (elderly) Transplant

Question 30

What is dialysis?

Answer 30

A process where there is passage of molecules through a semi-permeable membrane down a concentration gradient.

Question 31

What types of haemodialysis is there?

Answer 31

Unit-based HD Home HD / Nocturnal HD

Question 32

What is Unit-based HD?

Answer 32

4 hours, 3 times a week dialysis in hospital Night-time Designated slot

Question 33

Advantages of unit-based HD.

Answer 33

Less responsibility as you don't have to care of the dialysis yourself. You also get days off where you don't have to be on dialysis. Can remain on it for years.

Question 34

Disadvantages of Unit-based HD.

Answer 34

Travel time and waiting just to do the dialysis. Tied to the dialysis. Big restriction on food and fluid intake. Cardiovascular instability Hospital based

Question 35

Advantage/disadvantage of Home HD / Nocturnal HD.

Answer 35

Allows more dialysis hourse Better large molecule clearance Patients often feel better Fewer medications However.... **Requires someone at home with you**

Question 36

What is peritoneal dialysis?

Answer 36

CAPD and APD where CAPD you have 4-5 bags through the day. APD is overnight. You are responsible for your own care.

Question 37

Advantages of PD

Answer 37

Independence Less fluid and food restrictions Easy to travel with CAPD Renal function may be better preserved **initially**. Can be done **at home**

Question 38

Disadvantages of PD.

Answer 38

Frequent daily exchanges or overnight where you can't have days off. Frequent treatment failure **Responsibility of your own treatment**

Question 39

Advantages of transplant

Answer 39

Reduced mortality and morbidity compared to dialysis. Better QOL Restoration of near normal renal function Cheap

Question 40

Disadvantages of transplant.

Answer 40

Peri-operative risk Malignancy risk Infection risk Risk of diabetes and hypertension. Requires immunosuppression **Limited supply**