2.08 - CKD and AKI

Question 1

How is CKD classified according to GFR

Answer 1

G1: GFR>90
G2: GFR 60-89
G3a: GFR 45-59
G3b: GFR 30-44
G4: GFR 15-29
G5: GFR <15

Question 2

How is CKD classified according to albumin : creatinine ratio

Answer 2

A1: ACR<3
A2: ACR 3-30
A3: ACR >30

Question 3

What are the major causes of CKD

Answer 3

Hypertensive/diabetic/ischaemic neuropathy
Glomerulopathies
Inherited kidney disorders
Obstructive uropathy
Tubulointerstitial diseases
Nephrotoxic medications

Question 4

What are the symptoms of CKD

Answer 4

Anorexia
Nausea
Fatigue + weakness
Muscle cramps
Pruitus
Dyspnoea
Oedema

Question 5

What are the clinical signs of CKD

Answer 5

Pallor (Anaemia)
Hypertension
Fluid overload (JVP, oedema)
Skin pigmentation
Excoriation marks
Peripheral neuropathy

Question 6

What are the indications for CKD testing

Answer 6

Diabetes
Hypertension
AKI
Obesity WITH metabolic syndrome
Cardiovascular disease
Structural renal tract disease
Proteinuria or persistent haematuria
Family history

Question 7

What urine tests should be done to investigate CKD

Answer 7

Urine dipstick
Urine microscopy
ACR spot test
ACR 24 hour collection
Electrophoresis

Question 8

What blood tests should be done to investigate CKD

Answer 8

FBC
U+E
Bone profile
PTH
Bicarbonate
LFT
Lipid profile
Autoimmune screen
Myeloma screen

Question 9

What imaging should be done to investigate CKD

Answer 9

Renal ultrasound
MRangio
Echo
ECG

Question 10

Why might a renal biopsy be performed in CKD

Answer 10

Identify intrinsic cause

Question 11

What is the aim of renoprotective therapy

Answer 11

Slow CKD progression
Independent of aetiology

Question 12

How is renoprotective therapy performed

Answer 12

Blood pressure control (<140/90)
Reduce proteinuria

Question 13

Which CKD patients should be offered a RAAS antagonist

Answer 13

Diabetic and have an ACR >= 3mg/mmol
Hypertensive and have an ACR >30mg/mmol
ACR>70mg/mmol

Question 14

Why are RAAS antagonists not routinely used in CKD

Answer 14

ACE inhibitors are nephrotoxic

Question 15

Why is dapagliflozin (SGL2 Inhib) used in CKD

Answer 15

Prevents reabsorption of filtered glucose in nephron
Reduces glucose in blood -> Reduces blood pressure
Inhibits RAAS -> Reduces blood pressure

Question 16

When is dapagliflozin (SGL2 Ihib) recommended in CKD

Answer 16

eGFR 25-75 AND
T2DM OR ACR > 22.6

Question 17

What other therapies are renoprotective

Answer 17

Statins
Smoking cessation
Antiplatelets (if secondary to CVS disease)

Question 18

What are the common complications of CKD

Answer 18

Anaemia
Mineral + Bone disorders
Fluid overload
Acidosis
Hyperkalaemia

Question 19

Why does CKD cause anaemia

Answer 19

Reduction in EPO production -> Decrease in erythropoiesis

Question 20

What is the management for CKD induced anaemia

Answer 20

Erythropoietin stimulating agents (ESA) such as epoetin alfa
Patient must have adequate iron for it to be effective

Question 21

Why should blood transfusions be avoided in CKD management

Answer 21

To minimise the risk of sensitisation to HLA in preparation for renal replacement therapy

Question 22

Which medications most commonly cause hyperkalaemia in CKD

Answer 22

Potassium sparing diuretics
NSAIDS

Question 23

What other CKD complication may worsen hyperkalaemia

Answer 23

Metabolic acidosis

Question 24

How is acute hyperkalaemia treated

Answer 24

Calcium gluconate -> stabilise myocardium
Insulin / dextrose -> drive insulin into intracellular compartment

Question 25

How is chronic hyperkalaemia managed

Answer 25

Low potassium diet Potassium-binding resins Correction of acidosis

Question 26

Do i even need to ask you how CKD causes fluid overload robin is this really necessary

Answer 26

kidney fucked blood not filtered right too much gunk in the goo fat legs

Question 27

How is fluid overload managed in CKD

Answer 27

Oral diuretics Reduced sodium intake Fluid restriction

Question 28

Why does CKD cause Acidosis

Answer 28

Retention of hydrogen ions due to abnormalities in acid-base homeostasis May also exacerbate hyperkalaemia

Question 29

How do you know someone has acidosis

Answer 29

Low pH and lo bicarb levels

Question 30

What are the 3 forms of Renal Replacement Therapy

Answer 30

Haemodialysis Peritoneal dialysis Renal transplant

Question 31

What is haemodyalisis

Answer 31

Blood passes through dialysis machine to filter it instead of the kidneys Requires IV access via arteriovenous fistula or artificial line

Question 32

What is peritoneal dialysis

Answer 32

The peritoneal cavity is used as the site of ultrafiltration A catheter is used to insert dialysate into the peritoneal cavity Peritoneum is used as semipermeable membrane Dialysate is removed after a certain amount of time and procedure repeated

Question 33

How often is haemodialysis performed

Answer 33

Multiple times per week for 3-4 hours

Question 34

What are the two types of peritoneal dialysis

Answer 34

Continuous ambulatory (CAPD) - exchanges are made each day Automated (APD) - exchange is done overnight while pt sleeps

Question 35

What are the three types of donors who are able to give kidneys for RRT

Answer 35

Living donors Donors after Cardiac Death (DCD) Donors after Brain Death (DBD)

Question 36

What must patients who receive renal transplants also be given

Answer 36

Long term immunosuppressive therapy to prevent rejection of donor tissue

Question 37

Define Acute Kidney Injury (AKI)

Answer 37

Sudden decline of renal function over hours or days

Question 38

What are the main causes of pre-renal AKI

Answer 38

Decreased circulating vol Decreased cardiac output Systemic vasodilation Arteriolar changes

Question 39

What are the main vascular causes of intrinsic renal AKI

Answer 39

Atherosclerotic disease Thromboembolism Renal artery stenosis Malignant HTN

Question 40

What are the two types of glomerular pathology associated with AKI

Answer 40

Primary - not associated with systemic disease, eg - glomerulopathy Secondary - associated with systemic disease

Question 41

What can cause tubulointerstitial pathology leading to AKI

Answer 41

Prolonged renal hypoperfusion Medications (NSAIDs, PPIs, Penicillin) Infections

Question 42

What is the most common cause of post-renal AKI

Answer 42

Obstruction of the urinary tract

Question 43

What are the risk factors for AKI

Answer 43

Age (>65) Hx of AKI, CKD, HF, DM, Urological issues (infection, stones), Sepsis Hypovolaemia Nephrotoxic drug use Contrast agents

Question 44

What are the clinical features of pre-renal AKI

Answer 44

Reduced cap refill Dehydration Thirst Dizziness Reduced UO Low BP HF signs

Question 45

What are the clinical features of intrinsic renal AKI

Answer 45

Depends on cause Glomerular -> Sx of nephritic or nephrotic syndromes Tubulointerstitial -> arthralgia, rashes, fever, eosinophilia

Question 46

What are the clinical features of post-renal AKI

Answer 46

Loin-to-groin pain Pain at site of obstruction Haematuria N+V Prostatic obstruction -> dysuria Bladder neck obstruction -> palpable bladder

Question 47

What blood tests should be done to investigate AKI

Answer 47

Creatinine kinase Vasculitis screen Clotting Blood film Complement Immunoglobulins Serum electrophoresis Virology (HepB and HepC)

Question 48

What imaging should be done to investigate AKI

Answer 48

CXR - Heart failure Renal dopplers - vascular assessment MRI - vascular assessment

Question 49

How is AKI managed

Answer 49

Stop nephrotoxic drugs Fix volume dysregulation Fix electrolyte abnormalities

Question 50

List the nephrotoxic drugs

Answer 50

O DAMN O - Opiates D - Diuretics A - ACEi + Antibiotics M - Metformin N - NSAIDs