Chronic kidney disease

Question 1

CKD - Definiation

Answer 1

eGFR <30 for >3months

AND/OR

Evidence of renal damage

• Haematuria (urological causes eliminated)
• Albuminuria
• Structural abnormality on imaging
• Pathological abnormality on biopsy

Question 2

CKD - Causes

Answer 2

Diabetes (38%)
Hypertension (12%)
Polycystic kidney disease (7%)
Glomerularnephritis (17%)
Other (26%)

Question 3

CKD risk factors and recommended screening

Answer 3

Screen - request

• eGFR
• Urine ACR
• BP

Diabetes, HTN -> screen annually
CVD, BMI >30, Family hx CKD, smokers -> screen 2nd yearly
-ATSI - age 18-29 - screen for risk factors regularly
-ATSI - age >30 - screen 2nd yearly

Other risk factors - no recommendation for screening

• Age >60
• Hx of HTN in pregnancy
• Hx of AKI

Question 4

CKD screening process and diagnosis

Answer 4

1. eGFR < 60
   - Repeat in 7 days.
   - If deterioration >20% - AKI - d/w renal
   - If stable - repeat again - three samples over three months

Urine ACR

• Elevated - W - >3.5, M >2.5
• Repeat twice over three months

2. Diagnosis
   -3 reduced eGFR over 3+ month
   AND / OR
   -2+/3 Urine ACR elevated over 3+ months.

Question 5

CKD Investigations

Answer 5

Everyone

• eGFR
• Urine ACR

-U&E 
(-CMP - my idea, not in the guidelines)
-FBC (?Aneamia)
-Fasting lipids
-Fasting glucose
-ESR, CRP

If systemic disease

• Connective tissue disorders
• Rashes / arthritis
• Pulmonary Sx
• Rapidly deteriorating renal function

-ANA, ENA, ANCA, Complement studies, Anti-glomerular basement membrane antibodies

If >40 yo and ?Myeloma (Ca++ elevated, particularly if >60)
-Serum and urine protein electrophoresis (looking for paraproteins)

If risk factors for HIV, HBV, HCV - serology

Question 6

CKD management group definitions - Yellow

Answer 6

Stage IIIa - eGFR 45-59

OR

Stage I, II - eGFR >60 + microalbuminuria (F 3.5-35, M 2.5 -25)

Question 7

CKD management group definition - Orange

Answer 7

Stage IIIb - eGFR 30-44

OR

Stage IIIa (eGFR 45-59 or b 30-44) + microalbuminuria (F 3.5-35, M 2.5-25)

Question 8

CKD management group definition - Red

Answer 8

Stage IV, eGFR 15-29 OR V - eGFR <15 or needing dialysis

OR

Macroalbuminuria regardless of eGFR

• F >35
• M >25

Question 9

CKD - review intervals per colour

Answer 9

Yellow - 12 monthly
Orange - 3-6 monthly
Red - 1-2 monthly

Question 10

CKD - clinical assessment at review (4)

Answer 10

• Blood pressure (target <130-80)
• BMI and waist cirumference
• Smoking status
• Oedema (red only)

Question 11

CKD Investigations - All colours (5)

Answer 11

eGFR
Urine ACR
U&E
Fasting lipids
HbA1c if diabetic or needing screening

Question 12

CKD investigations - Orange and Red (4)

Answer 12

FBC - Hb target 100-115

U&E - K+ target

Question 13

CKD investigations PRN

Answer 13

Albumin - target >35 - screen if ?malnutirion
Iron, B12, folate
TSH

Question 14

CKD - assessment

Answer 14

1. CVD risk
   - Hypertension mgt
   - Hyperlipidiaemia mgt
   - Consider anti-platelet (orange and red)
2. Diabetes risk / control
3. Medication review
   - Dose adjustment / cessation as required
4. Lifestyle modification
   - Basic - smoking, alcohol, exercise, weight, diet
   - Diet for anti-hypertension - low salt <6g, high veggies
   - > Protein >7.5mg/kg/day
   - > Low K+ if a problem
5. Assess for common problems (16)
6. Assess if needs renal input
   - eGFR <30 or persistent Urine ACR >30
   - Sustained decline in eGFR >25% or 15mL in 12 months
   - HTN not controlled by three drugs

Question 15

CKD - Common problems - 18

Answer 15

Everyone need to monitor

1. Increased CVD risk
2. HTN
3. Hyperlipidaemia
4. Albuminiuria

Consider

5. Haematuria
6. Anaemia
7. Hyperkalaemia
8. Low Ca++, high PTH
9. Osteoporosis
10. Ureamia
11. Oedema
12. Sleep apnoea
13. Restless leg
14. Muscle cramps
15. Pruritis
16. Malnutrition
17. Depression
18. Cognitive decline