Chronic Kidney Disease

Question 1

How would you define CKD?

Answer 1

CKD implies longstanding (more than 3 months), and usually progressive, impairment in renal function. In many instances, no effective means are available to reverse the primary disease process

Question 2

What ethnic groups are more likely to develop CKD?

Answer 2

African, Hispanics, and South Asians, particularly those from Pakistan, Sri Lanka, Bangladesh, and India, are at high risk of developing CKD

Question 3

How does treatment efficacy differ between ethnic groups?

Answer 3

Administration of antihypertensive drugs generally halts disease progression in white populations but has little effect in slowing kidney disease among black people, and additional treatment such as bicarbonate therapy is often required

Question 4

How does renal perfusion relate to cell injury?

Answer 4

The rate of renal blood flow of approximately 400 ml/100g of tissue per minute is much greater than that observed in other well perfused vascular beds such as heart, liver and brain.

As a consequence, renal tissue might be exposed to a significant quantity of any potentially harmful circulating agents or substances.

Question 5

How does disruption of the electrostatic barrier relate to kidney damage?

Answer 5

The glomerular filtration membrane has negatively charged molecules which serve as a barrier retarding anionic macromolecules. With disruption in this electrostatic barrier, as is the case in many forms of glomerular injury, plasma protein gains access to the glomerular filtrate

Question 6

What are the three main causes of CKD?

Answer 6

Diabetes, hypertension, atherosclerosis

Question 7

What are non-main causes of CKD?

Answer 7

• glomerulonephritis
• pyelonephritis
• polycystic kidney disease
• Long term use of NSAIDs or lithium
• Interstitial Nephritis

Question 8

What are risk factors for CKD?

Answer 8

• Diabetes
• High blood pressure
• Heart (cardiovascular) disease
• Smoking
• Obesity
• Being Black, Native American or Asian American
• Family history of kidney disease
• Abnormal kidney structure
• Older age
• Frequent use of medications that can damage the kidneys

Question 9

What is the clinical presentation for someone with early CKD?

Answer 9

The early stages of CKD are often completely asymptomatic, despite the accumulation of numerous metabolites

Question 10

When do symptoms of CKD present?

Answer 10

Urea > 40 mmol/L

Question 11

What are the symptoms of CKD?

Answer 11

1. Malaise and lethargy
2. Loss of appetite
3. Insomnia
4. Nocturia and polyuria due to impaired concentrating ability
5. Itching
6. Nausea, vomiting, diarrhoea
7. Paraesthesiae due to polyneuropathy
8. Restless legs syndrome
9. Bone pain due to metabolic bone disease
10. Paraesthesiae and tetany due to hypocalcaemia
11. Peripheral and pulmonary oedema
12. Symptoms of anaemia
13. Amenorrhoea in women; erectile dysfunction in men

Question 12

What are the symptoms in severe/late-stage CKD?

Answer 12

1. Mental slowing, clouding of consciousness and seizures

2. Myoclonic twitching.

Question 13

How is CKD diagnoses?

Answer 13

Diagnosis of CKD is largely based on history serum creatinine level and urine dipstick.

Question 14

How do you differentiate between CKD and AKI?

Answer 14

• One diagnostic clue that helps differentiate CKD from AKI is a gradual rise in serum creatinine (over several months or years) as opposed to a sudden increase in the serum creatinine (several days to weeks).
• In many people with CKD, previous kidney disease or other underlying diseases are already known.

Question 15

What investigations would you do for CKD?

Answer 15

Urea and creatinine (eGFR)

Albumin

Question 16

What are the 5 stages of kidney damage?

Answer 16

Stage 1 - Slightly diminished function; kidney damage with normal or relatively high GFR and persistent albuminuria

Stage 2 - Mild reduction in GFR with kidney damage

Stage 3 - Moderate reduction in GFR (30–59 ml/min/1.73 m2)
- UK guidelines distinguish between stage 3A (GFR 45–59) and stage 3B (GFR 30–44) for purposes of screening and referral

Stage 4 - Severe reduction in GFR. Preparation for kidney replacement therapy

Stage 5 - Established kidney failure, permanent kidney replacement therapy, or end-stage kidney disease

Question 17

What does ACR in CKD stand for and what does it relate to?

Answer 17

ACR = albumin/creatinine ratio

Increased ACR is associated with increased risk of adverse outcomes

Question 18

What are the GFRs for different stages of CKD?

Answer 18

Stage 1 > 90
Stage 2 60-89
Stage 3 30-59
Stage 4 15-29
Stage 5 < 15

Question 19

What are complications that can occur due to CKD?

Answer 19

1. Anaemia
2. Bone disease
3. Pruritis (itching) due to high nitrogenous waste
4. Nephrogenic systemic fibrosis (NSF)
5. Gastrointestinal complications
6. Gout
7. Cardiovascular disease

Question 20

How would you treat CKD?

Answer 20

Treatment is with the control of risk factors as well as the treatment of hypercalcaemia and hyperparathyroidism

Question 21

What is the prognosis for CKD?

Answer 21

CKD tends to progress inexorably to ESKD, although the rate of progression may depend upon the underlying nephropathy. Patients with chronic glomerular diseases tend to deteriorate more quickly than those with chronic tubulointerstitial nephropathies.

Hypertension and heavy proteinuria are bad prognostic indicators.

Question 22

What is the leading cause of death in CKD?

Answer 22

The leading cause of death in chronic kidney disease is cardiovascular disease, regardless of whether there is progression to stage 5