Week 4 - F - Chronic Kidney disease - more depth

Question 1

What is chronic kidney disease?

Answer 1

It is a reduced glomerular filtration rate and/or kidney damage associated with decreased urine creatinine over a long time

Question 2

Why does creatinine overestimate the glomerular filtration rate?

Answer 2

This is because it is also secreted by the tubules

Question 3

Creatinine is a product of muscle breakdown What people will therefore produce more creatinine?

Answer 3

Muscular people will therefore produce more creatinine

Question 4

For white/Asian males: GFR = 186 x creatinine (mg/dl)-1.154 x Age-0.203 Correction factor for women, and for black race What is this equation known as?

Answer 4

This is knwon as the MDRD4 equation and allows you to calculate the glomerular filtration rate level

Question 5

What are the four factors taken into account in the MDRD4 equation?

Answer 5

Serum creatinine Age Race Sex

Question 6

Occasionally it is appropriate to measure the GFR instead of the eGFR What would be used to do this?

Answer 6

Would use inulin

Question 7

What are 3 things that can account for evidence of kidney damage?

Answer 7

This would be proteinuria, haematuria (in absence of lower tract urinary cause) and abnormal imaging

Question 8

What are the stages of chronic kidney disease? Also give the approximate prevalance of each stage?

Answer 8

https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/picture1jpggifjpg-15B3F937B40613F584F.png

Question 9

At what age does the glomerular filtration rate start to decrease and what is the rate at which it decreases?

Answer 9

• After the age of 40, GFR declines by about 0.75ml/min/year

Question 10

Patients with what in their urine are more likely to progress to worse stages of CKD?

Answer 10

Patinets with proteinuria

Question 11

What are common causes for chronic kidney disease?

Answer 11

Diabetes Hypertension Glomerulonephritis - commonly IgA

Question 12

Patient presents and on ultrasound has multiple fluid filled cysts and hypertension What is this disease that can predispose to chronic kidney disease?

Answer 12

Polycystic kidney disease

Question 13

When do symptoms of a reduced GFR actually begin to show?

Answer 13

Symptoms do not begin to show until late where the GFR reaches around 20ml/min

Question 14

What are some of the symptoms of chronic kidney disease?

Answer 14

• Non-specific – tiredness, poor appetite, itch, sleep disturbance • Impaired urinary concentrating ability – nocturia Also can have a uraemic tinge to the skin - slightly yellow

Question 15

Principlesof treating CKD: Slow progression Reduce cardiovascular risk Identify and treat complications of CKD Prepare for renal replacement therapy What drug is given to reduce cardiovascular risk and slow progression?

Answer 15

An ACEI is given to slow the progression - this reduces proteinuria and reduces the blood pressure

Question 16

Why is there hypertension in chronic kidney disease? What is the target blood pressure?

Answer 16

Hypertension due to salt and water retention as kidneys are not excreting at the rate they should be Target BP - 130/80

Question 17

What substances may increase in the blood due to a decreased filtration rate?

Answer 17

Hypernatraemia Hyperkalaemia Hyperphosphataemia Anaemia

Question 18

What is the condition known as whee there is damage to the bone secondary to chronic kidney disease?

Answer 18

Renal osteodystrophy - happens because the chronic kidney disease cause secondary hyperparathyroidsim increasing the turnover of bones to restore calcium levels and therefore bones become weak

Question 19

What are non pharmalogical factors in treating CKD? (ie what are the dietary controls)

Answer 19

Diet control, monitor blood glucose and stop smoking No salt diet, decrease intake of phosphate rich foods

Question 20

Apart from stopping smoking, how else are the cardiovascular risks treated?

Answer 20

By potentially giving a statin if cholesterol is high and STOP SMOKING

Question 21

How does anaemia arise in chronic kidney disease?

Answer 21

Anaemia arises as the kidneys are failing to produce erythropoeitin, this stops the stimulation of red blood cell formation in bone marrow leading to anaemia

Question 22

What do you have to make sure is not causing the anaemia in CKD?

Answer 22

Check the: Iron Vitamin B12 and folate deficiency

Question 23

What can be used to treat the anaemia in chronic kidney disease?

Answer 23

Intravenous iron - if this doesnt work Then give EPO (erythropoetin)

Question 24

Vitamin D hydroxylated in the kidney Impaired in CKD Leads to reduced calcium absorption, leading to secondary hyperparathyroidism In advanced CKD, serum phosphate rises – also increases PTH secretion What can the seconday hyperparathyroidism cause?

Answer 24

This can cause tertiary hyperthyroidism which will be autonomous PTH secretion even when calcium is normal so - high PTH, high calcium, weak bones

Question 25

What is the treatment for a hypocalcaemia and for the hyperphosphataemia??

Answer 25

Vitamin D analogues (alfacalcidol) and Ca supplements decrease bone disease and hyperparathyroidism. Can also try phosphate binders

Question 26

Patinets with chronic kidney disease can also become acidotic and have oedema What can be given for both?

Answer 26

Acidotic - give sodium bicarbonate - be careful in hypertension and giving sodium Oedema - give loop diuretics and remember to restrict sodium and fluid intake

Question 27

Principles: Slow progression Reduce cardiovascular risk Identify and treat complications of CKD What was the final prinicple for managing CKD if it needs to happen?

Answer 27

Prepare patient for renal replacement therapy

Question 28

Most patients are ‘medically’ suitable for haemodialysis or peritoneal dialysis What GFR roughly does this discussion come up at with patients and what is the step protocol?

Answer 28

When the GFR hits roughly 20ml/min Buckman six step protocol to give the patinet the bad news Make sure to inform the patinet properly

Question 29

What are the two types of dialysis available?

Answer 29

Hameodialysis and peritoneal dialysis

Question 30

How does the patinet get ready fr haemodialysis?

Answer 30

Arteriovenous fistula (AVF) is best form of access AVF needs 6 weeks to mature after formation Refer to vascular surgeons when GFR about 15ml/min

Actual dialysis starts arounds <5-10 eGFR (dialysis provides an actual eGFR of about 10-12 ml/min/1.73m2)

Question 31

What can be given for peritoneal dialysis?

Answer 31

Peritoneal dialysis – operation needed to insert catheter Catheter can be used after 1-2 weeks

Question 32

What is the treatment of choice for end stage renal failure?

Answer 32

Renal transplantation

Question 33

When can patinets with chronic kidney disease be listed on the cadaveric list for a kidney?

Answer 33

Patients can be listed for cadaveric transplantation when within 6 months of dialysis

Question 34

When is conservative managment usually chosen in a patient?

Answer 34

When they are elderly and choose not not to have dialysis Instead opt for symptom and control and erythropoetin for the anaemia

Question 35

What eGFR should NSAIDs be avoided in?

Answer 35

CKD 4 (Avoid if eGFR less than 30 mL/minute/1.73 m2)