CKD

Question 1

definition

Answer 1

kidney structure/function abnorm

> 3 months

with health implications

Question 2

What are ckd pts most likely to die of ?

Answer 2

Heart disease

Question 3

who should be tested for CKD

Answer 3

People with risk factors

Incidental proteinuria

Persistent haematuria (not UTI)

eGFR <60

Question 4

How do you test for CKD

Answer 4

1. measure serum Cr to calculate eGFR

2. Take early morning urine to measure urinary ACR and dip for haematuria

Question 5

Why is urine taken in the early morning?

Answer 5

To stop the false positive of orthostatic proteinuria

Question 6

Persistent haematuria in the absence of UTI makes you suspect what?

Answer 6

Uro cancer

Question 7

How do you act on the eGFR result?

Answer 7

<90 but serum cr has increased by >20% indicates a decline in renal function

<60- repeat in 2w (exclude AKI), if still <60 repeat within 3mths. If it is then <60 then = CKD, if it is 45-59 and no proteinuria then confirm the diagonsis with eGFR cystatin C test

Question 8

How do you act on the ACR result

Answer 8

> 70- refer straight to nephrologist

3-70- repeat in 3 months. If still >3 then = CKD

Question 9

Does the diagnosis of CKD require both ACR and eGFR?

Answer 9

No is and/or

Question 10

How could you consider confirming the diagnosis

Answer 10

eGFR cystatin C test

Question 11

When is eGFR cystatin C test inaccurate

Answer 11

Uncontrolled thyroid disease

Question 12

What do you need to be mindful of in the eGFR test?

Answer 12

Don’t eat meat for 12h before

Interpret with caution in extremes of muscle mass, pregnancy, oedema, malnourished, asian/chinese (less well validated)

Question 13

What rate of eGFR is considered normal for a young adult?

Answer 13

125 ml/min/1.73m2

Question 14

An eGFR of <60 is associated with what

Answer 14

Higher risk for complications of CKD

Question 15

How is CKD staged?

Answer 15

Uses eGFR and ACR in a grid so e.g. G4A2

Question 16

Is an older person more or less likely to progress to end stage renal disease than a young person?

Answer 16

Less likely

Question 17

CKD can only be diagnosed on at least __ eGFR tests at least _____ apart

Answer 17

2

3mths

Question 18

How is ‘progressive’ CKD defined

Answer 18

Sustained fall in eGFR of >25% AND change in category in <12m

OR

Sustained fall in eGFR of 15 in <12m

Question 19

What extra investigations should you do in CKD if their eGFR is <45

Answer 19

Hb

Question 20

What extra investigations should you do in CKD if their eGFR is <30

Answer 20

Hb

calcium

phosphate

PTH

Vit D

Renal USS

Question 21

What extra investigations should you do in CKD if their ACR >=3

Answer 21

Dip for haematuria

If macroscopic or persistent (+1 on at least 2/3 occasions) then renal USS and r/o cancer if >50yo

Also need annual f/u of eGFR, ACR, BP, urine dip

Question 22

What extra investigations should you do in CKD if their ACR is >30 with haematuria or >70

Answer 22

Consider referral

Question 23

In what circumstances do you consider referral?

Answer 23

ACR is >30 with haematuria or >70

BP v poor control

Progressive

Outflow obstruction

Genetic or rare cause susp

Question 24

What is general CKD management?

Answer 24

Usual lifestyle advice

BP control- aim for 140/90 (but diabetics with ACR >70 aim for 130/80).

If ACR >70 alone/ACR >30 + HTN/ACR >3 + diabetes –> ACEi/ARB

Statin- atorvostatin 20mg

+manage anaemia, bone and metabolic disorders in severe disease

Question 25

Should you use Qrisk?

Answer 25

No

Question 26

What effect can CKD have on clotting?

Answer 26

Can = bleeding and thrombotic tendencies

Question 27

How should CKD be monitored?

Answer 27

Depends on pt and severity and stability of eGFR and ACR. There is a table in nice to guide (1-4 times per year)

Bear in mind that CKD is not progressive in many people

Question 28

What would you include in a CKD review?

Answer 28

Any symptoms (nb usually none)

Lifestyle advice

Compliance with HTN and statin meds

Test eGFR, ACR, BP and urine dip

if eGFR, ACR have decreased to certain thresholds then do the extra tests/consider referral etc.