3: Chronic kidney disease

Question 1

What is chronic kidney disease?

Answer 1

Abnormal kidney function AND/OR structure

U&Es may be normal

Question 2

CKD significantly increases your chances of ___ to other diseases.

Answer 2

mortality

Question 3

CKD is closely linked to which two other diseases?

Answer 3

Cardiovascular disease

Diabetes

Question 4

Your risk of developing CKD (increases / decreases) with age.

Answer 4

increases with age

Question 5

What is the difference between acute kidney injury and chronic kidney disease?

Answer 5

AKI has an onset of less than 48h

Prolonged - two samples indicating abnormal kidney function, 90 days apart

Question 6

How long does kidney function need to be abnormal for a patient to be given a diagnosis of chronic kidney disease?

Answer 6

90 days

Question 7

What is the difference between GFR and eGFR?

Answer 7

eGFR is modified based on creatinine, age, sex and race

Question 8

How is CKD staged?

Answer 8

Stages G1 to G5 (including G3a and G3b)

Learn the egfr thresholds and descriptions

Question 9

An eGFR of > ___ is normal.

Answer 9

> 90

average is 125

Question 10

An eGFR of < ___ is abnormal.

Answer 10

< 90

Question 11

How is proteinuria actually measured?

Answer 11

Albumin/creatinine ratio

ACR measured alongside eGFR to quantify degree of kidney disease

Question 12

How is ACR classified?

Answer 12

A1 to A3

>300 is nephrotic

Question 13

What two values are used to classify CKD?

Answer 13

eGFR

ACR

Question 14

Is eGFR used for AKI?

Answer 14

Only used for CKD

Question 15

What is measured to quantify the degree of an AKI?

Answer 15

Creatinine only

eGFR not useful

Question 16

People who have had an AKI need to be monitored for several years afterwards.

How?

Why?

Answer 16

eGFR

AKI massively increases CKD risk (loss of nephrons, remaining nephrons have to work really hard and burn out quicker)

Question 17

Why is eGFRcystatinC more accurate than eGFR?

Answer 17

eGFR value is modified by creatinine levels

Creatinine is cleared by kidneys AND bowels

So technically eGFR can OVERESTIMATE kidney function

Question 18

People with which particular diseases should have their CKD and ACR checked?

Answer 18

AKI

CKD

Cardiovascular disease

Diabetes

loads but existing renal disease, cvd and diabetes are the main ones

Question 19

How can you tell if haematuria has come from the kidneys or bladder?

Answer 19

Microscopy

Kidneys - red cells will be dysmorphic from being squeezed through tract

Bladder - red cells will be intact

Question 20

What is the definition of accelerated CKD progression?

Answer 20

eGFR decrease in 25% within a year

OR

Consistent decrease by 15 units per year

Question 21

What is the difference between ACR and PCR?

Answer 21

ACR picks up kidney damage due to extra-renal stuff e.g hypertension diabetes

PCR also factors in tubular damage and stuff

?!?!?!?!

Question 22

Which common drugs are nephrotoxic?

Answer 22

NSAIDs

Question 23

Elderly patients with advanced CKD and extensive co-morbidities (will / won’t) benefit from treatment.

Answer 23

probably won’t

Question 24

criteria for CKD referral for treatment

gfr < 30

ACR > 70 (>30 with haematuria)

resistant hypertension

genetic stuff

renal artery stenosis

Question 25

What are the blood pressure targets in CKD?

Answer 25

**140 / 90** if no proteinuria **130 / 80** if protein/haematuria

Question 26

Anti-hypertensives like ACE inhibitors are **nephrotoxic**, but also **reduce glomerular BP.** When should they be withdrawn?

Answer 26

Significant enough decrease in eGFR / ACR check slides

Question 27

What prevention drug should be offered to **all** patients with CKD?

Answer 27

**Statin** look up side effects of these

Question 28

2/3rds of CKD are caused by which diseases?

Answer 28

**Diabetes** **Hypertension** (i.e CVD)

Question 29

What are some **vascular** causes of CKD?

Answer 29

**Renal artery stenosis** (for a variety of reasons, fools kidney into thinking systemic BP is low, so produces renin, but no effect, vicious cycle, systemic hypertension damages OTHER kidney) **Small-vessel ​vasculitis** (like GWP, EGWP and microscopic polyangiitis)

Question 30

What are some **glomerular / tubular** causes of CKD?

Answer 30

**Glomerulonephritis** **Tubulonephritis** v complicated so come back to this

Question 31

What are some **urological** signs of CKD?

Answer 31

**Renal calculi**

Question 32

clinical signs of ckd produced by **anaemia** (haematuria plus kidneys can't produce erythropoietin) **weight loss** (nutrients filtered) and **uraemia** (build up of urea in the blood) - loads of these **kussmaul breathing** (caused by metabolic acidosis)

Question 33

Symptoms of CKD are produced by what blood abnormalities?

Answer 33

**Uraemia** **Anaemia** **Metabolic acidosis**

Question 34

People with CKD tend to be in ___ for a lot of different reasons.

Answer 34

**pain**

Question 35

How is end-stage **CKD** treated?

Answer 35

**Haemodialysis** **Peritoneal dialysis** (try and figure out how these work) **Kidney transplant** (put BACK in the iliac fossa, not retroperitoneal) - either deceased\* donors or live donors **Conservatively** - 20% of patients treated symptomatically, palliatively

Question 36

People with CKD are at greatly increased risk of ___ disease.

Answer 36

**cardiovascular**

Question 37

What eGFR level and urinary sign predicts greatly increased CVD risk in people with CKD?

Answer 37

**\< 50** **Microalbuminuria**

Question 38

What process drives the cardiovascular complications of CKD?

Answer 38

**Atherosclerosis**

Question 39

People on dialysis are at hugely increased risk of CVD - why?

Answer 39

Because they have end-stage CKD

Question 40

What are modifiable risk factors for cardiovascular disease?

Answer 40

**Smoking** **Alcohol** **Weight** **Exercise** **Diet** (particularly salt)

Question 41

What should be prescribed to reduce CVD risk in people with CKD?

Answer 41

**Antihypertensives if needed** **Statin**

Question 42

Why are people with CKD at risk of pathological fracture?

Answer 42

**Affects bone composition, causing** pain fracture CVD......

Question 43

What endocrine disease can be caused by disordered calcium metabolism in CKD?

Answer 43

**Hyperparathyroidism** either secondary - physiological due to hypocalaemia (it's all being filtered) or tertiary - prolonged secondary, glands don't respond anymore

Question 44

What nutrient should be restricted to prevent bone disease in people with CKD?

Answer 44

**Phosphate** hyperphosphataemia common in people with CKD

Question 45

What dietary supplement should be given to people with CKD?

Answer 45

**Vitamin D supplements**

Question 46

What distinct spinal appearance can be seen on X-ray in people with CKD? What causes it?

Answer 46

**Rugger-jersey spine** - sclerosis and lucency of consecutive vertebrae Caused by **hyperparathyroidism** - minerals stripped from bone

Question 47

What blood disorder can CKD cause?

Answer 47

**Anaemia**

Question 48

How is anaemia secondary to CKD treated?

Answer 48

**Check VitB12 and folic acid** **Iron supplements**

Question 49

amputations due to peripheral vascular disease calcium/po3/pth --\> calciphylaxis, skin death, can't be grafted because dermis wiped out sclerosis of peritoneum

Question 50

when i say cvd i mean cardiovascular disease not cerebrovascular disease