Urinary: CKD

Question 1

What is done to investigate al renal diseases?

Answer 1

• Blood pressure

- Urine dipstick

Question 2

What is the aetiology of CKD?

Answer 2

• Diabetes
• Hypertension
• Immunologic
• Infection
• Genetic – APKD, Alport
• Obstruction and reflux nephropathy
• Vascular
• Systemic disease

Question 3

What are the risk factors of CKD?

Answer 3

• Elderly
• Multi-morbid
• Ethnic minorities
• Socially disadvantaged

Question 4

Describe the staging of CKD

Answer 4

G1 – normal or >90
G2 – 60-90
G3a – 45 - 59
G3b – 30-44
G4 – 15-29
G5 - <15

A1 - normal
A2 - microalbuminuria
A3 – proteinuria

Question 5

What are the general blood tests used for investigation of CKD?

Answer 5

• Urea & Electrolytes
• Bone chemistry
• Liver function tests (albumin for proteinuria)
• Full blood count
• CRP

+/- iron levels (check iron stores first before EPO treatment)
+/- parathyroid hormone

Question 6

What are blood tests used to determine the cause of the CKD?

Answer 6

• Autoantibody screen
• Complement levels
• Anti neutrophil cytoplasmic antibody
• Serum immunoglobulin

Question 7

What are other investigations done in CKD?

Answer 7

• Ultrasound scan (Kidney size, evidence of obstruction)
• Kidney biopsy (cause unknown, Haematuria, Proteinuria)
• Other for specific causes (CT scan, MRI scan, MR angiogram)

Question 8

What are methods used to manage CKD?

Answer 8

• Modifiable risk factors of CKD (Lifestyle, Smoking, Diet , Lack of Exercise)
• Stopping proton pump inhibitors/NSAIDS
• Uncontrolled diabetes
• Hypertension (antihypertensive, diuretics, fluid restriction)
• Proteinuria
• Lipids

Question 9

What are the effects of CKD on water/salt handling by the kidney?

Answer 9

• Reduced GFR
• Lose ability to maximally dilute and concentrate urine
• Small glomerular filtrate but same solute load cause osmotic diuresis and nocturia
• Low volume of filtrate reduced maximum ability to excrete urine therefore maximum urine volume is much smaller

Question 10

What are the effects of acidosis in CKD?

Answer 10

• Muscle (enzymes denature)
• Bone
• Renal function progression to worsen

Question 11

What is acidosis in CKD treated with?

Answer 11

Treat with NaHCO3 tablets

Question 12

How is hyperkalaemia managed in CKD?

Answer 12

May require

• Stopping ACE-ihibitor/ Angiotensin receptor blocker
• Avoidance of potassium
• Altering diet to avoid food with high potassium

Question 13

What are the effects of accumulation of waste products in CKD?

Answer 13

• Contribute to uraemic syndrome
• Reduce apetite
• Nausea and vomiting
• Pruritis

Question 14

What is the effect of CKD on drug management?

Answer 14

• Dose alteration in CKD/ERSD due to reduced metabolism and elimination
• Drug sensitivity increased even if elimination unimpaired meaning side effects more likely

Question 15

What are the causes of anaemia in CKD?

Answer 15

• Decreased EPO
• Absolute iron deficiency. High hepcidin so less iron absorbed from gut
• Blood loss
• Short red blood cell life span
• Bone marrow suppression
• Mineral and bone disorders
• ACE inhibitor can cause anaemia
• Deficiency in B12 and folate

Question 16

Why is treating anemia in CKD important for the patient?

Answer 16

• Improve exercise capacity
• Improve cognitive function
• Helps regulate left ventricular hypertrophy
• Helps slow progression of renal disease
• Reduces mortality

Question 17

How does mineral bone disease occur in CKD?

Answer 17

• Phosphate retention
• Leads to bone resistance to PTH and low Vitamin D levels
• Leads to Hypocalcaemia
• Parathyroid hormone is triggered
• Phosphate retention leads to less calcium sensors and less vitamin D sensors
• This leads to secondary parathyroidism

Question 18

What are the effects of mineral bone disease in CKD?

Answer 18

• Leads to bone loss
• Can cause bone cysts
• Non bone calcification (deposits in the skin which causes ulceration, deposits in joints)

Question 19

What are the treatment for mineral bone disease in CKD?

Answer 19

• Phosphate intake
• Phosphate binders
• 1 alpha calcidol
• Vitamin D

Question 20

What are the symptoms of CKD?

Answer 20

• Tiredness (Overwhelming fatigue, Guilt, physically and mentally incable)
• Difficulty sleeping
• Difficulty concentrating
• Volume overload
• Nausea vomiting
• Itching
• Restless legs
• Sexual dysfunction/ reduce fertility
• Increased risk of infections

Question 21

What are advantages and disadvantages of haemodyalysis?

Answer 21

Advantages

• Less responsibility
• Days off

Disadvantages

• Travel time/waiting
• Tied to dialysis times
• Big restriction on fluid/food intake

Question 22

What are the contraindications of haemodyalysis?

Answer 22

• Failed vascular access
• Heart failure a relative contraindication
• Coagulopathy a relative contraindication

Question 23

What are advantages and disadvantage of peritoneal dialysis?

Answer 23

Advantages

• Self sufficient/independence
• Generally less fluid/food restrictions
• Fairly easy to travel with CAPD
• Renal function may be better preserved initially

Disadvantages

• Frequent daily exchanges and overnight
• Responsibility

Question 24

What are the contradictions of peritoneal dialysis?

Answer 24

• Failure of peritoneal membrane (surface area)
• Adhesion, previous abdo surgery, hernia, stoma
• Patient unable to connect
• Obese or large muscle mass

Question 25

What are the complications of peritoneal dialysis?

Answer 25

• Peritonitis
• Ultrafiltration failure
• Leaks
• Development of a hernia