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Year 3 > Case 22 - Chronic Kidney Disease > Flashcards

Case 22 - Chronic Kidney Disease Flashcards

1
Q

Why is best to do a mid stream urine (MSU) sample in the morning when looking for protein?

A

Periods of prolonged standing can cause orthostatic proteinuria

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2
Q

What could protein in urine indicate?

A

Some kind of kidney disease

  • glomerular diseases (nephritic/nephrotic syndrome)
  • chronic kidney disease
  • tubulointerstitial disease
  • UTI
  • fever

It can also occur after physical exercise, and in pregnancy

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3
Q

What could blood in urine indicate?

A

Infection
Kidney or bladder cancer
Kidney disease

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4
Q

What are the normal levels of protein that are excreted in urine?

A

Up to 150mg/day of uromodulin (tamm-horsfall glycoprotein)

Up to 30mg/day of albumin

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5
Q

Define chronic kidney disease (CKD)?

A

Impaired renal function for >3 months

GFR <60 for greater than 3 months

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6
Q

What is the GFR level for end stage renal failure (ESRF)?

A

<15mL/min

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7
Q

What are the common causes for CKD?

A 
Diabetes (type II)
Glomerulonephritis - commonly IgA nephropathy 
Hypertension 
Polycystic kidney disease 
Renovascular disease 
Pyelonephritis
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8
Q

How is CKD staged?

A

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

On Albumin/Creatine Ratio: A1 <30, A2 30-300, A3 >300

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9
Q

At what CKD stage do symptoms start to occur?

A

Stage 4

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10
Q

What blood tests are done to assess renal function?

A 
FBC - assess Hb
ESR
U&amp;E
Glucose
Calcium 
Phosphate 
PTH
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11
Q

What happens to the size of the kidneys in CKD?

How can this be assessed?

A

Shrink in size (usually <9cm in CKD)

Using an ultrasound

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12
Q

What are the systemic complications of CKD?

A 
Renal anaemia 
Hyperkalaemia 
Hypertension 
Renal bone disease 
Cardiovascular complications 
Odema 
Urea toxicity
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13
Q

How does CKD lead to renal anaemia?

A

The kidney is responsible for producing erythropoietin, which in turn stimulates RBC production
If kidney is damaged there is less EPO produced therefore less RBCs produced
This leads to normochromic, normocytic anaemia

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14
Q

How is renal anaemia treated?

A

Oral or IV iron
Aim for target ferritin of >200
Recombinant human erythropoietin (darbepoetin)

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15
Q

How does CKD lead to hyperkalaemia?

A

The kidney is involved in electrolyte balance
When damaged it cannot excrete K+
This can lead to cardiac arrhythmias

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16
Q

How is hyperkalaemia treated in CKD?

A

Avoid high potassium foods in diet

Reduce ACEi dosage - ACEi block the production of aldosterone (aldosterone helps in K+ excretion)

17
Q

How does CKD lead to hypertension?

A

Less fluid is filtered by the kidneys
It is tricked into thinking BP is raised - activates RAAS system
This increases BP

18
Q

How does CKD lead to renal bone disease?

A

Kidneys are responsible for activating vitamin D which then helps to absorb calcium from the diet
Less activated VitD means less Ca absorbed causing hypocalcaemia
Hypocalcaemia causes PTH release
PTH activates osteoclasts to break down bone and release calcium

19
Q

How is renal bone disease treated?

A

Vit D analogues e.g, alfacalcidol
Restrict phosphate in diet - this helps to activate PTH further

Parathyroidectomy - if PTH levels are too high and unable to be controlled
Cinacalcet - drug used to treat secondary hyperparathyroidism

20
Q

How does CKD lead to metabolic acidosis?

A

The kidneys cannot reabsorb bicarbonate as well
Therefore too much bicarbonate is lost
This leads to metabolic acidosis

21
Q

How is metabolic acidosis treated in CKD?

A

Sodium bicarbonate supplements

22
Q

Why do you get oedema in CKD?

How do you treat it?

A

Due to build up of fluid as kidney isn’t filtering as well

Treat with diuretics e.g furosemide

23
Q

What are the effects of angiotensin II?

A

Causes vasoconstriction of the efferent blood vessels in kidneys - causing increased glomerular pressure
Acts on the adrenal gland to release aldosterone - aldosterone then acts on the kidneys to retain Na+ and water and excrete K+
Acts on the pituitary gland causing ADH secretion, which in turn causes H20 reabsoption in the kidneys

24
Q

When should you stop ACEi or ARBs?

A

AKI - as these drugs inhibit the RAAS system, which is responsible for maintaining GFR
If there is a large increase in creatinine following initiation of treatment (acceptable levels are 20-25% rise)
During pregnancy

25
Q

What are the indications for starting renal replacement therapy (RRT) (also known as dialysis)

A

Consider if ESRF (GFR <15)
Or if the patient has the following symptoms:
- signs of fluid overload
- refractory hyperkalaemia
- signs of urea toxicity e.g nausea, vomiting, weight loss, neurological symptoms

26
Q

What are the absolute contraindications to peritoneal dialysis?

A 
IBD (active)
Ischaemic bowel 
Acute diverticulitis 
Abdominal abcess
Pregnancy (3rd trimester)
27
Q

What are the absolute contraindications to haemodialysis?

A

Inability to achieve suitable vascular access

28
Q

What are the absolute contraindications to renal transplant?

A

Active infection

Cancer (if it is >5 years since and cured then may be considered)

29
Q

Why do renal transplants fail?

A

Acute rejection - due to surgical complications
Chronic rejection - this is more common, due to:
- Antibody response
- recurrence of primary disease in the transplanted kidney e.g IgA nephropathy
- tacrolimus/cyclosporine toxicity in the transplant

30
Q

At what level would you start thinking about treating hyperkalaemia?

A

If above 6

31
Q

What is the difference between primary, secondary and tertiary hyperparathyroidism?

A

Primary (due to excess PTH release) - high PTH, high calcium
Secondary (Low Ca triggers PTH release) - high PTH, low calcium
Tertiary (excess PTH release even when normal Ca has been corrected) - high PTH, normal calcium

32
Q

How are ACEi and ARBs considered renal protective?

A

They act to decrease the hydrostatic pressure in the glomeruli by inhibiting the action of angiotensin II on the extrinsic arterioles
Increased glomeruli pressure is associated in diabetic nephropathy

Therefore ACEi and ARBs reduce proteinuria/albuminuria

33
Q

At what stage would you refer a CKD patient to renal services?

A 
CKD 5 - immediate referral 
CKD 4 (15-29) - urgent referral (routine referral if stable)
CKD 3 (30-59) - routine referral if:
- microscopic haematuria 
- urinary PCR >45
- unexplained anaemia 
- systemic illness
- uncontrolled BP
- fall in GFR >5 in 12 months
- fall in GFR >15% after ACEi/ARB
34
Q

How do the causes of CKD differ between mild-moderate and severe CKD?

A

Mild-moderate: caused by diabetes and hypertension mainly

Severe: caused by glomerulonephritis (IgA nephropathy) and genetic causes e.g. Polycystic kidney disease

Year 3 (24 decks)

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