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GERR > Lecture 45b: CKD Pathophysiology > Flashcards

Lecture 45b: CKD Pathophysiology Flashcards

1
Q

what is the clinical relevance of CKD

A
  • CKD is common (10% adults)
  • assc. w/ diabetes and hypertension
  • assc. w/ premature mortality
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2
Q

what is the most severe form of CKD

A

end stage renal disease or ESRD

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3
Q

what is CKD

A

chronic kidney disease

- dec in GFR which occurs over months or years and is usually irreversible

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4
Q

how is renal function measured

A
  • serum creatinine (from U&E)

- GFR from serum creatinine measurement

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5
Q

at what % of kidney function does serum creatinine rise outside of normal range

A

~ below 50% GFR

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6
Q

what is the normal GFR in adults

A

~100mL/min

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7
Q

what is eGFR used on

A
  • age
  • sex
  • ethnicity
  • serum creatinine
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8
Q

how is CKD classified

A 
stage 1 = eGFR >90 
stage 2 = eGFR 60-89 
stage 3 = eGFR 30-59
stage 4 = eGFR 15-29
stage 5 = eGFR <15
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9
Q

what CKD stages typically concern clinical medicine

A

stage 3-5

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10
Q

how common is CKD

A

5-6% have stage 1-2

~5% have stage 3-5

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11
Q

list symptoms of CKD

A
  • symptoms often occur very late when kidney function is poor
  • fatigue (anaemia 2nd to Epo deficiency)
  • SoB (fluid retention +/- acidosis)
  • leg oedema (fluid retention)
  • nausea, anorexia, weight loss (retained toxins)
  • itch (retained toxins)
  • bone pain (vit D defect)
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12
Q

why is fatigue a symptom of CKD

A

in CKD there is reduced Epo production by kidneys which leads to anaemia

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13
Q

give some signs of abnormal kidney function

A
  • pallor (anaemia)
  • oedema (salt and fluid retention)
  • hypertension ( salt and fluid retention)
  • proteinuria +/- haematuria
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14
Q

give some of the causes of CKD

A
  • diabetic kidney disease
  • hypertensive and/or atherosclerotic vascular disease of kidneys
  • glomerulonephritis
  • polycystic kidney disease
  • tubulointerstitial disease (chronic pyelonephritis/refluc nephropathy)
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15
Q

what are the risk factors for CKD

A
  • renal disease
  • diabetes
  • hypertension
  • smoking
  • dyslipidemia
  • age
  • male>female
  • family history
  • cardiac disease
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16
Q

what might be seen histologically in diabetes related CKD

A
  • diabetic glomerulus has expansion of messangial cells and messangial cell matrix
  • nodules –> nodular form of glomerular sclerosis
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17
Q

how does diabetes cause kidney disease

A
  • neuropathy in diabetes can cause development of nodules on the glomeruli
  • dec number of caps fo blood flow so GFR falls
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18
Q

describe the pathology of diabetic nephropathy

A
  • ^ intraglomerular hypertension
  • -> glomerular sclerosis
  • hyperglycaemia
  • -> messangial expansion
  • -> glom BM thickening
19
Q

how does albumin get into urine in diabetic kidney disease

A
  • BM is thickened but leaky

- ^ pressure in glomerulus

20
Q

what is the issue with albumin in urine

A

proteinuria is toxic to tubules

21
Q

what is the result of progressive diabetic kidney disease

A
  • tubular atrophy
  • cellular infiltrate
  • interstitial fibrosis
  • vasculopathy
22
Q

what meds are used to treat proteinuria renal disease and why

A

ACEi and ARBs

- block ang2 formation to allow efferent arteriole to dilate again and reduce glom cap pressure

23
Q

43 year old woman , type 1 diabetes. BP is 151/93 , urine albumin creatine ratio indicates albuminuria.

Which drug would be used to control her blood pressure to reduce risk of kidney disease

A

ramipril

  • ACEi that dec. BP, intraglomerular cap pressure, dec albuminuria and slow progression of diabetic kidney disease
24
Q

what are the consequences of reduced GFR

A
  • fluid retention
  • -> HF
  • -> tissue oedema (pitting oedema)
  • reduced metabolite excretion
  • -> uraemia
  • -> ^ serum creatinine
  • -> ^ serum urate ( can cause gout)
25
Q

what are the 2 key issues w/ drug prescribing in renal disease

A
  • kidney failure (low GFR) prolongs half life of many drugs –> ^ risk of drug toxicity
  • some drugs can make kidney failure worse by disturbing renal physiology e.g. NSAIDs
26
Q

consequences of reduced renal tubular filtration

A
  • reduced fluid reabsorption
  • -> polyuria
  • -> nocturia
  • reduced K+ excretion
  • -> hyperkalaemia
  • reduced acid secretion and reduced bicarb formation
  • -> Metabolic Acidosis
27
Q

is K+ mor ICF or ECF

A

ICF

28
Q

what are the primary issues in renal bone disease

A
  • reduced vit D activation because of kidney damage
  • dec Ca absorption from gut
  • decreased mineralisation of bone (osteomalacia)
  • reduced active vit D and low Ca stimulate release of PTH resulting in bone resorption (hyperparathyroidism)
29
Q

in normal health what other molecule in the body is calcium normally in balance w/

A

phosphate

30
Q

what happens to phosphate levels when calcium levels decrease

A

phosphate levels ^

31
Q

how does ^ PTH release (stimulated by low calcium and low active vit D) affect calcium and phosphate levels

A
  • ^ Ca levels
  • no change to phosphate levels
  • now have high Ca and high phosphate in the body
32
Q

name an issue that can arise as a result of high calcium and phosphate levels in the body

A

ectopic calcification of tissues (in Px w/ CKD)

33
Q

what cells are stimulated by PTH to release calcium

A

osteoclasts

34
Q

what cells require active vit D to carry out their function

A

osteoblasts

35
Q

explain how renal bone disease can arise as a result of CKD

A
  • CKD = damaged kidney
  • reduced vit D activation by kidney
  • dec Ca absorption from gut
  • dec mineralisation of bone
  • -> osteomalacia
  • reduced Ca and active vit D stimulate PTH release
  • -> hyperparathyroidism
  • PTH stimulates osteoclasts to resorb bone to release Ca
  • osteoblasts require active vit D to reverse bone resorption; no active vit D so no osteoblast action
36
Q

83yo man has stage 5 CKD. Clinical blood tests indicate his eGFR is 11mL/min/1.73m2.

Which of the following electrolyte disorders is most likely to be present in this man?

a) hyperkalaemia
b) hypokalaemia
c) hyponatraemia
d) hypernatraemia
e) hypocalcaemia

A

a) hyperkalaemia

- hyperkalaemia most likely b/c kidney excretion of K is significantly impaired by poor kidney function (very low eGFR)

37
Q

what is one of the most important signs and most easily modifiable risk factor for CKD

A

hypertension

38
Q

outline the management of CKD

A
  • treat hypertension
  • slow the progression of proteinuric renal diseases w/ ACEi or ARBs
  • reduce assc. CVD risks e.g. statin for hyperlipidaemia
  • treat any complications:
  • -> anaemia (Epo injections)
  • -> renal bone disease (activated vit D)
  • -> hyperphosphataemia (phosphate binding drugs)
  • -> hyperkalaemia (restrict dietary intake)
39
Q

outline some renal replacement therapies for ESRD

A
  • haemodialysis
  • -> vascular access e.g. arteriovenous fistula or central venous catheter
  • peritoneal dialysis
  • -> peritoneal dialysis catheter inserted into abdomen w/ incision below umbilicus to insert end exit site on right/left side of lower abdomen
  • kidney transplant
  • -> placed in left/right iliac fossa (palpable kidney underneath surgical scar)
40
Q

compare and contrast the two methods of chronic dialysis

A

haemodialysis

  • usually hospital based
  • nurse delivered
  • 3x per week
  • needs access to blood
  • very expensive
  • restricted to sites w/ dialysis machines

peritoneal dialysis

  • home based
  • patient performs dialysis
  • daily
  • uses abdominal cavity
  • cheaper
  • can be done virtually anywhere in the world
41
Q

what is the best form of renal replacement therapy for ESRD

A

kidney transplant

42
Q

why are kidney transplants preferred in ESRD if Px suitable

A
  • > 95% success rate
  • better quality of life for Px
  • much better survival for Px
  • much cheaper per year than dialysis
43
Q

what is the downside of having a kidney transplant

A
  • lifelong drug treatment to suppress immune system and prevent rejection of transplant
  • so increased risk of infection

GERR (46 decks)

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