Case 2 - CKD

Question 1

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Define CKD

Answer 1

• Presence of kidney damage
• Abnormal albumin excretion or decreased kidney function
• Quantified or measured by eGFR that persists for more than three months

Question 2

How is CKD staged?

Answer 2

eGFR with associated albumin (ACR) score

Question 3

eGFR CKD stage G1

Answer 3

• eGFR 90 or more but signs of kidney damage
• Normal and high

Question 4

eGFR stage G2

Answer 4

• 60-89 with markers of kidney damage
• Mild reduction related to normal range for young adult

Question 5

eGFR stage G3a

Answer 5

• 45-59
• Mild-moderate reduction

Question 6

eGFR stage 3b

Answer 6

• 30-44
• Moderate to severe reduction

Question 7

eGFR stage 4

Answer 7

• 15-29
• Severe reduction

Question 8

eGFR stage 5

Answer 8

• eGFR <15
• Kidney failure

Question 9

ACR score A1

Answer 9

• Less than 3 mg/mmol
• Normal to mildly increased

Question 10

ACR score A2

Answer 10

• 3-30mg/mmol
• Moderately increased

Question 11

ACR score A3

Answer 11

• More than 30mg/mmol
• Severely increased

Question 12

Causes of CKD

Answer 12

• Diabetes
• HTN
• Glomerulonephritis
• Renovascular disease
• PCKD
• Obstructive nephropathy - urological problems
• Chronic/recurrent pyelonephritis

Question 13

Complications of CKD

Answer 13

• Anaemia of chronic disease
• CKD mineral and bone disease
• Secondary and tertiary hyperparathyroidism
• HTN
• Cardiovascular disease - no1 cause of death
• Malnutrition/sarcopenia
• Dyslipidaemia

Question 14

Complications of CKD as it progressess

Answer 14

• Electrolyte distubances
• Fluid overload
• Metabolic acidosis
• Uraemic pericarditis
• Uraemic encephalopathy

Question 15

Who is involved in renal management?

Answer 15

MDT eg renal physicians, GPs, renal specialist nurse, dieticians, pharmacists, vascular surgeons

Question 16

Management of CKD - general

Answer 16

• Treat underlying disease
• Reduce CV risk
• Reduce progression of CKD
• Prevent complications
• Plan for future - RRT?

Question 17

How do we treat underlying disease in CKD?

Answer 17

• Treat and monitor diabetic control
• Treat HTN
• Treat infections promptly
• Tolvaptan if meeds criteria for PCKD
• Immunosupression for glomerulonephritis if needed

Question 18

How do we reduce CV risk to patients with CKD?

Answer 18

• Statin
• BP control -<130/80
• Improve diabetes control
• Weight loss
• Exercise
• Stop smoking

Question 19

How do we reduce progression of CKD

Answer 19

• Reduce proteinuria - ACEi/ARBs
• Monitor bloods
• Control BP

Question 20

How do we prevent/treat complications in management of CKD?

Answer 20

• Dietary advice re low phosphate and low K+ diet
• Phosphate binders
• IV iron/folate/Vit B12 replacement
• EPO
• Replace Vitamin D deficiency
• Calcimimetics for tertiery hyperparathyroidism
• Dietician help

Question 21

What do we discuss in plan for future for management of CKD?

Answer 21

• Options if reach end stage renal failure
• Home care team input
• Discuss advantages and disadvantages of types of RRT

Depending on choice:
* Fistula referal - venous mapping?
* Refer for PD tube insertion?
* Work up for transplant? - tests and transplant clinic

Question 22

Which diabetes causes diabetic nephropathy?

Answer 22

Type 1 DM or long duration of Type 2

Question 23

What is diabetic nephropathy often associated with?

Answer 23

Other microvascular diabetes complications eg
* Retinopathy
* Peripheral neuropathy

Question 24

How is diabetic nephropathy often diagnosed?

Answer 24

• Screening for it if have diabetes
• Raised urine albumin:creatinine ratio/PCR raised
• Evidence of long standing/poorly controlled DM
• Evidence of other microvascular disease

Question 25

Treatment of diabetic nephropathy

Answer 25

* ACEi/ARB - reduce proteinuria * Anti-hypertensives for BP control * CV risk modification * Continue screens for microvascular complications eg eye and foot checks

Question 26

What is hypertensive nephropathy?

Answer 26

* Chronic raised BP causes nephrosclerosis * Difficult to tell at advanced presentation whether HTN caused renal problems or the other way around

Question 27

Investigations to identify primary or secondary HTN

Answer 27

* 24hr metanephrines (Phaechromocytoma) * Aldosterone:renin ratio (primary aldosteronism) * Cortisol and dexamethasone supression test (Cushing syndrome) * TSH (hyperthyroidism) * MRA (renal artery stenosis)

Question 28

Treatment for hypertensive nephropathy

Answer 28

Anti-hypertensives

Question 29

What is polycystic kidney disease?

Answer 29

Autosomal dominant condition resulting in cysts within kidney which can rupture and/or become infected

Question 30

Two types of PCKD

Answer 30

* Type 1 - PDK1 mutation on chromosome 16 (85%) * Type 2 - PDK2 mutation on chromosome 4 (15%)

Question 31

Symptoms of PCKD

Answer 31

Related to size/infection of cysts eg * Flank pain * Haematuria * Fever * Or can be asymptomatic

Question 32

Diagnosis for PCKD

Answer 32

USS Family history is KEY

Question 33

Treatment for PCKD

Answer 33

* Control BP * Tolvaptan (vasopressin receptor 2 antagonist) available if slow progression of CKD * Genetic counselling and testing

Question 34

2 common complications of CKD

Answer 34

* Anaemia of chronic disease * Mineral bone disease

Question 35

What factors contribute to cause anaemia of chronic disease in CKD?

Answer 35

* Decreased EPO production * Absolute iron deficiency - poor absorption/malnutrition * Functional iron deficiency - inflammation/infection * Blood loss * Shortened RBC survival * Bone marrow supression - uraemia * Medication induced * VitB12/folate deficiency

Question 36

Managment of anaemia of CKD

Answer 36

* Measure haematinics - Vitamin B12, folate, folate, ferritin, iron, transferrin saturation, CHr * If deficient - replace first * IV iron may be better tolerated than PO * Discuss with renal team re starting ESA (erythropoesis stimulating agent) * Aim for Hb 100-120

Question 37

How can CKD mineral bone disease be diagnosed - criteria?

Answer 37

* Abnormalities of calcium, phosphate, alkaline phosphatase, PTH or Vit D metabolism * Vascular +/- soft tissue calcification * Abnormal bone turnover, metabolism, volume, linear growth/strength

Question 38

Low turnover bone states in CKD

Answer 38

* Adynamic bone disease * Osteomalacia - low Vit D usually

Question 39

High bone turnover states CKD

Answer 39

Osteitis Fibrosa - usually due to high PTH

Question 40

What does CKD lead to in terms of causing mineral bone disease?

Answer 40

* Increased fibroblast GF23 * Increased alkaline phosphatase and PTH * Increased phosphate * Decreased serum calcium * Decreased 1,25 Vitamin D

Question 41

What is tertiary hyperparathyroidism?

Answer 41

PTH is released despite raised Ca2+ levels (independently) As a result of PT gland nodular hyperplasia Consequence of advanced CKD

Question 42

Management of CKD mineral bone disease

Answer 42

* Reduce occurance and or severity of bone disease * Reduce CV morbidity and mortality caused by elevated PTH and high phosphate and calcium overload

Question 43

Signs of CKD

Answer 43

* Jaundice * Raised JVP * Pallor * Excoriation of pruiritis * Bruising * AV fistula for dialysis * Brown line pigmentation of nails * Central venous catheter for dialysis access * Scar of kidney transplant * Tenckoff catheter for peritoneal dialysis * Crackles lung bases - pulmonary oedema

Question 44

Tests to confirm cause of CKD

Answer 44

* Urine ACR * Urine dipstick - haematuria * BP * Serum HbA1C * Renal USS - PCKD? Obstruction? * Renal angiogram - renal artery stenosis? * Autoimmune screen - ANA/anti-dsDNA, C3, C4 (SLE), anti-GBM (goodpastures) ANCA (vasculitis) * CV disease - echo? lipids?