Session 10: Chronic Kidney Disease Flashcards
Define chronic kidney failure.
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.
How would CKD present on histology?
Gives rise to glomerulosclerosis and tubular interstitial fibrosis.
What are most glomerular diseases that lead to chronic renal failure characterised by?
Proteinuria and systemic hypertension
Why might incidence of CKD be difficult to define?
Because CKD is usually asymptomatic.
Global prevalence of CKD.
11-13%
What is CKD most commonly associated with in developed countries?
Old age
Diabetes
Hypertension
Obesity
CVD
Common causes of CKD.
Diabetes
Hypertension
CVD
Immunologic
Systemic like myeloma or lupus
Infection like pyelonephritis
Obstructive/reflux
Genetic like polycystic disease or Alport’s.
What is this?
Adult Polycystic kidney disease.
What is APCKD?
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.
Diagnosis of APCKD.
Ultrasound however this can’t exclude diagnosis if less than 30 years old as cysts might not have developed much by then.
Genetic testing
Complications of APCKD.
Pain
Bleeding into cysts
Infection
Renal stones
Hypertension
Intra-cranial aneurysms
Heart valve abnormalities
Management of CKD.
Treat the hypertension (most commonly by blocking RAAS)
Plenty of fluids
Low salt
Normal proteins
Tolvaptan
Stages of CKD.
1 - >90 GFR
2 - 60-89 GFR
3 - 30-59 GFR
4 - 15-29 GFR
5 - <15 GFR
Investigation of CKD.
Define degree of renal impairment
Define the cause of renal impairment
Diagnosis and prognosis
Identify complications
Long term treatment plan
eGFR
Give two investigations that are absolutely necessary and always done in CKD.
Blood pressure
Urine dipstick
How is eGFR used?
Only accurate in adults and needs to be corrected in black patients.
General bloods tests done in CKD.
U & E
Bone biochemistry
LFTs
FBC
CRP
Iron levels
PTH
Give example of blood tests done to determine the cause of CKD.
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.
Other investigations done in CKD.
USS for kidney size and obstruction.
Kidney biopsy
CT, MRI and MR angiogram.
Risk factors of CKD.
Any form of AKI from nephrotoxins or decreased perfusion.
Proteinuria
Hyperlipidaemia
General effects of CKD.
Increase in total body sodium and water
Acidosis
Hyperkalaemia
Lipid abnormalities
Anaemia
Renal osteodystrophy
Neuropathy, seizures, coma
Dyspepsia
Impotence and infertility
Pruritus
Atherosclerosis
Cardiomyopathy
How can CKD cause anaemia?
Decreased EPO
Absolute iron deficiency
Blood loss
Uraemia causing bone marrow suppression
ACE-inhibitors
High hepcidin levels due to inflammation and infection
Functions of the kidneys.
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.
Treatment in case of hyperkalaemia in CKD.
Stopping ACE-inhibs or ARBs
Avoid amiloride, spironolactone or trimethoprim
Avoid high potassium diet
Symptoms of CKD (may be diffuse).
Tiredness
Breathlessness
Restless legs
Sleep reversal
Aches and pains
Nausea
Vomiting
Itching
Chest pain
Seizures
Explain how mineral bone disease may arise in CKD.
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.
Definition of End Stage Renal Disease (ESRD)
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.
Symptoms of ESRD.
Tiredness
Difficulty sleeping
Difficulty concentrating
Oedema
Nausea and vomiting
Restless legs
Pruritus
Sexual dysfunction
Increased infections
What are the options in ESRD?
Haemodialysis
Peritoneal dialysis
Conservative care (elderly)
Transplant
What is dialysis?
A process where there is passage of molecules through a semi-permeable membrane down a concentration gradient.
What types of haemodialysis is there?
Unit-based HD
Home HD / Nocturnal HD
What is Unit-based HD?
4 hours, 3 times a week dialysis in hospital
Night-time
Designated slot
Advantages of unit-based HD.
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.
Disadvantages of Unit-based HD.
Travel time and waiting just to do the dialysis.
Tied to the dialysis.
Big restriction on food and fluid intake.
Cardiovascular instability
Hospital based
Advantage/disadvantage of Home HD / Nocturnal HD.
Allows more dialysis hourse
Better large molecule clearance
Patients often feel better
Fewer medications
However….
Requires someone at home with you
What is peritoneal dialysis?
CAPD and APD where CAPD you have 4-5 bags through the day.
APD is overnight.
You are responsible for your own care.
Advantages of PD
Independence
Less fluid and food restrictions
Easy to travel with CAPD
Renal function may be better preserved initially.
Can be done at home
Disadvantages of PD.
Frequent daily exchanges or overnight where you can’t have days off.
Frequent treatment failure
Responsibility of your own treatment
Advantages of transplant
Reduced mortality and morbidity compared to dialysis.
Better QOL
Restoration of near normal renal function
Cheap
Disadvantages of transplant.
Peri-operative risk
Malignancy risk
Infection risk
Risk of diabetes and hypertension.
Requires immunosuppression
Limited supply
