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JC WCS > Nephrology JC079: Chronic Kidney Disease And Its Complications > Flashcards

Nephrology JC079: Chronic Kidney Disease And Its Complications Flashcards

1
Q

Basic function of a nephron

A
  1. Get rid of nitrogenous waste products
  2. Conserve Na, H2O
  3. Maintaining electrolyte balance
  4. Maintaining acid-base balance

Structures:
- Bowman capsule
- Tubules
- LoH
- Collecting duct

Processes:
- Filtration
- Absorption
- Transport
- Secretion
- Concentration gradient
- Receptors / Channels
- Enzymes (Na/K-ATPase)

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2
Q

Albuminuria

A
  • Proteinuria (Dipstix) >300 mg/day —> associated with Chronic GN, Renal HT, Parenchymal disease

Urine Albumin-Creatinine ratio (ACR):
- >30 mg/mmol is considered “significant” in non-DM
- >3 mg/mmol is considered microalbuminuric in DM —> require ACEI / ARB

Causes:
1. **CKD
2. **HT
3. **High protein diet
4. **Exercise
5. Fever
6. ***UTI
7. CCF

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3
Q

Estimated GFR (eGFR)

A

How to estimate GFR:
1. 24 hour urine: measure urine Cr (U), plasma Cr (P), total urine volume (V) —> ***24 hour Cr clearance (UV / P)
2. Cockcroft and Gault CrCl = 88 x (145-age) / Serum Cr x weight / 70 - 3
3. MDRD equation (Modification of Diet in Renal disease study) per 1.73 m^2
- CKD-EPI (per 1.73 m^2)
- CKD-EPIcys

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4
Q

Chronic kidney disease (CKD)

A

Definition:
- **Slow **irreversible loss of renal function over time usually without symptoms until damage is advanced

記: 90, 60, 45, 30, 15
Staging of CKD (sustained for **>90 days (3個月)):
Stage 1: >90 (normal GFR with **another kidney abnormality)
Stage 2: 60-89 (mild ↓ GFR with ***another kidney abnormality)
Stage 3a: 45-59 (moderate ↓ GFR)
Stage 3b: 30-44 (moderate ↓ GFR)
Stage 4: 15-29 (severe ↓ GFR)
Stage 5: <15 / dialysis (ESRD)

KDIGO:
- Insert Albumin : Creatinine ratio (ACR) into CKD classification to make it predictable of progression (i.e. match Cr with ***Albuminuria level —> low eGFR + severe Albuminuria —> more likely to progress)

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5
Q

Role of Nephrologist

A
  1. Diagnosis of cause of CKD
  2. Management of complications of CKD
  3. Preparation for dialysis
  4. Preparation for kidney transplantation
  5. Palliative care for ESCKD
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6
Q

Patients journey of CKD

A

CKD diagnosis:
- Blood test, USG scans, Kidney biopsy

Stage 1-4 CKD:
- ***BP control

ESRD:
- Control renal **anaemia
- Control **acidosis
- Cardiac tests
- Live donor workup
- Fistula

Renal replacement therapy
1. Conservative / Palliative care
2. PD / HD
3. Transplantation

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7
Q

***Causes of CKD

A
  1. ***DM
  2. HT / Vascular
  3. Chronic GN (e.g. IgAN)
  4. Chronic pyelonephritis
  5. Polycystic kidney disease
  6. Drug induced, TIN, TCM
  7. Myeloma (CRAB), Vasculitis, SLE
  8. Obstruction, Kidney stones
  9. Alport syndrome / other hereditary diseases
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8
Q

Progressive CKD

A

Progression rate determined by:
1. **Causes
2. **Baseline Serum Cr, Proteinuria
3. **HT severity
4. **Renal fibrosis / Aging

Rate: 1-7 ml/min per year

Mild CKD:
- mild CKD / Albuminuria ↑ risk of CVS death
- finding + treating cause —> delaying progression + long-term follow-up + ***CVS protection are ALL important

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9
Q

Drug-induced kidney disease

A

Types:
1. Acute (<7 days)
2. Subacute (7-90 days)
3. Chronic (>90 days)

Mechanism:
1. Hypersensitivity
2. Vasoconstriction
3. Glomerular disease
4. Tubular toxicity
5. Nephrolithiasis
6. Crystalluria

Examples:
- Aminoglycosides —> AKI
- Aciclovir —> Nephrolithiasis
- Calcineurin inhibitor —> AKI-CKD
- Cisplatin —> Tubular
- Colistin —> AKI
- Protease inhibitor —> Nephrolithiasis, AKI

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10
Q

***S/S of CKD

A
  1. Fatigue
  2. Nocturia
  3. Thirst (∵ acidosis, hyperventilation, mouth-breathing)
  4. Fluid retention
  5. Itch

Clinical features:
1. **Acidosis
2. **HT, LVH
3. **CHF
4. **Anaemia (Normochromic normocytic ∵ lack of erythropoietin)
5. ***CKD-MBD (mineral bone disorder): high / low PTH, low turnover bone disease, bone biochemistry abnormality, vascular calcification

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11
Q

Kidney sizes on USG

A
  • Normal size 10-12cm + symmetrical

Small kidneys in CKD:
- Dyplastic
- **Scarred
- **Shrunken

Large kidneys:
- **Polycystic kidney disease
- **Infiltration (e.g. Amyloid)
- ***Obstruction

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12
Q

Other investigations

A
  1. Renal angiogram
  2. CT angiogram
  3. MRI of renal artery
    —> can be used to demonstrate renal artery stenosis
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13
Q

***Therapy aim for CKD

A
  1. ***Delay kidney failure, treat cardiac risk, treat CKD complications
  2. ***Control HT
  3. ***Reduce Albuminuria by ACEI / ARB
  4. Tackling ***glycaemic control HbA1c in DN
  5. Treat any ***acidosis, high K, Ca/P/PTH
  6. Control lipids
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14
Q

KDIGO 2021 guideline of Hypertension target

A

HT patients with CKD: Target ***<120 / 80

  1. ***ACEI / ARB
    - ↓ Albuminuria
    - Monitor U/E
  2. β-blocker
    - Cardioprotection
  3. CCB
    - SE: ankle edema
  4. Diuretics
    - ***Overdiuresis can lead to worsening renal function
  5. α-blocker
    - if have prostate symptoms
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15
Q

Dietary recommendation in CKD

A

HT patients:
- ↓ Na intake ***<2 g daily (<90 mmol)
- ↓ NaCl intake <5 g daily
- ∵ high salt intake —> more likely ↑ CVD events in CKD patients

CKD stage 3-5:
- moderate restriction of dietary protein
—> possibly ↓ uraemic toxins + hyperfiltration + ↓ clinical symptoms + delay maintenance dialysis

DN:
- daily protein recommendation: ***0.8 g/kg

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16
Q

Hyperlipidaemia in CKD

A

> 50 yo with CKD**3-5:
- >10% 10-year risk of coronary deaths regardless of cholesterol level
- **Statin / ***Statin + Ezetimibe recommended

17
Q

New + Old Diabetic drugs

A

Old drugs:
1. Metformin
2. Acarbose
3. Sulphonylureas
4. PPAR-γ agonists (Thiazolidinediones)

New drugs:
1. DPP4 inhibitors (Gliptins)
2. Repaglinide
3. GLP1 receptor agonists (Exenatide, Liraglutide)
4. Analogue insulin
5. ***SGLT2 inhibitor (Gliflozins) —> improve DM control + reduce kidney disease progression

18
Q

Diabetic kidney disease KDIGO guideline

A
  1. Lifestyle therapy
    - Physical activity
    - Nutrition
    - Weight loss
  2. Metformin / SGLT2 inhibitor / combination
    - **eGFR <45 —> ↓ Metformin dose
    - **    eGFR <30 —> Stop Metformin
    - ***do not initiate SGLT2 inhibitor if eGFR <30
    - discontinue SGLT2 inhibitor in dialysis patient
  3. Addition drug therapy for more severe CKD
    - GLP1 receptor agonists (preferred)
    - DPP4 inhibitor
    - Insulin
19
Q

Complications of CKD

A
  1. Fluid retention
  2. Metabolic acidosis
  3. HT
  4. Normochromic normocytic anaemia
  5. Secondary hyperparathyroidism
  6. Bone disease
20
Q

***Drug therapy for CKD

A
  1. Diuretic
  2. Anti-HT
  3. Oral NaHCO3 (for acidosis)
  4. Phosphate binder (for hyperPO4)
  5. Active Vit D analogues (alfacalcidol)
  6. Calcimimetics
  7. Erythropoiesis stimulating agents (ESAs)
21
Q

Renal Anaemia guideline

A

***Replenish Fe first before Hb

Fe saturation should be ***>20%
Fe supplement (aim Fe saturation >20%):
1. Oral Fe
2. Fe dextran
3. Fe sucrose (venofer)
4. Fe carboxymaltose (ferinject)

Best Hb level for renal patients: 10-11
—> ↓ EPO if Hb 12
1. ESA
- ↑ Hct
- injection form

  1. HIF-PH inhibitor (Roxadustat)
    - HIF (hypoxic-induced factor): stimulate erythropoiesis
    - HIF-PH (proline hydroxylase): enzyme degrading HIF
    —> HIF-PH inhibitor
    —> stop degradation of HIF
    —> more erythropoiesis

Causes of Resistance to ESA:
1. **Inflammation, neckline, failed allograft
2. HD vs PD
3. **Functional Fe deficiency (hypochromic RC)
4. Chemotherapy, IFN for Hep C
5. Bleeding
6. ***Marrow failure
7. Aluminium toxicity
8. Severe hyperparathyroidism

22
Q

Treatment of HyperK acidosis

A
  1. ***Low K diet
  2. ***Oral HCO3 (to control acidosis + slow down kidney deterioration)
  3. Adjust medication (e.g. ACEI, ARB)
  4. Other oral K lowering drugs
    - Exchange resins / Cation exchanges / K binder
    —> ***Calcium resonium, Patiromer, Sodium Zirconium Cyclosilicate
23
Q

***CKD-MBD (mineral bone disorder)

A

Clinical features:
1. **Hyperphosphataemia
2. **Vit D deficiency (1α-hydroxylase)
3. **Secondary hyperparathyroidism
4. **Osteitis fibrosa cystica (characterised by high bone turnover due to secondary hyperPTH (UpToDate))
5. ***Adynamic bone disease (i.e. low turnover bone dsease)
6. Osteoporosis (pelvic fracture)
7. Gout, Pseudogout

24
Q

Coronary artery calcifications ↑ with years of dialysis

A

***HyperCa

Mortality in dialysis patients (100x higher risk than general population)

Calciphylaxis:
- aka Calcific uraemic arteriolopathy (wiki)
- affect small blood vessels supplying skin —> painful skin ulcer

25
Q

***Treatment of MBD

A
  1. ***Dietary PO4 restriction
  2. Ca-based / Non-Ca-based PO4 binder (Sevelamer / ***Lanthanum)
    - Both: slight ↓ PTH
    - Ca-based: ↓ PO4, ↑ Ca, ↑ FGF23
    - Non-based: ↓ PO4 but no effect on Ca, ↓ FGF23
  3. ***Vit D
    - ↓ PTH
    - ↑ PO4, Ca
    - ↑ FGF23
  4. ***Calcimimetics (cinacalcet) but relatively expensive
    - ↓ PTH, PO4, Ca, FGF23
  5. Parathyroidectomy

(FGF23: ***prognostic indicator for survival of dialysis patients —> ↑ FGF23 —> higher risk of death)

26
Q

***Summary

A

CKD symptoms: Non-specific
CKD signs: may be related to cause / complication
Prognosis: depend on cause, renal pathology, serum Cr, proteinuria, HT

Complications:
- Renal HT
- MBD
- Renal anaemia

Investigation indicative of chronicity:
- **PTH
- **Normochromic normocytic anaemia
- ***Increased risk of CVS morbidity + mortality

Management (Delay progression + Treat complication + Treat CVS risk):
General:
1. Dietary
2. Fluid

Specific:
1. DM therapy (different choice in different CKD stages: caution if eGFR <30)
2. HT (target BP + treatment choices)
3. Renal anaemia therapy
- Fe
- EPO
- HIF-PH inhibitor

  1. HyperK acidosis
    - NaHCO3
    - Exchange resins / K binder
    - caution use of ACEI / MRA (mineralocorticoid receptor antagonist)
  2. CKD-MBD
    - Vit D
    - PO4 binder
    - Calcimimetics
    - Surgery

JC WCS (134 decks)

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