Case 22 - CKD Flashcards
What is the definition of CKD?
Abnormalities of kidney structure/function over a period of 3 months with implications for health
Usually progressive and irreversible and leads to ESRD over time
What is azotaemia?
The build up of nitrogenous waste in the blood due to lack of excretion by the kidneys
What is uraemia?
A result of azotaemia due to failing kidneys
RFs for CKD
Age Smoking Increased CV risk Black/hispanic Male HTN Genetics Autoimmune Hx
Symptoms of CKD
Pruritus Lethargy Oedema N and V Anorexia Arthalgia
What are the main causes of CKD?
DM and HTN Can also be caused by: -Glomerulonephritis -Congenital abnormalities -Recurrent UTIs -PKD -Lupus
What is the Pathophysiology of diabetic nephropathy?
HTN resulting from diabetes affects afferent arteriole
RAAS is activated by hyperglycaemia > HTN
The high pressures through the glomerulus cause mesangial expansion - there is fibrosis and collagen deposition
GBM becomes thickened as mesangium pushes on it
There is a reduction in glomerular SA to filter the urine through
There is effacement of the podocytes and the gaps between the podocytes become larger to allow larger molecules through them
Nephron ischaemia as they lead from afferent arteriole
How can diabetic nephropathy be staged/classed?
Stage 1 - Increased GFR due to HTN
Stage 2 - Preoteinuria
Stage 3 - Microhaematuria due to nephron death
Stage 4 - Oligouria
Class 1 = GBM thickening
Class 2 = mesangial expansion
Class 3 = nodular sclerosis
Class 4 = diabetic glomerulosclerosis
What can you pick up on a MSU?
Proteinuria Haematuria Brown muddy casts = tubular necrosis/renal ischaemia WBC casts = infection RBC casts = urothelial injury Glycosuria
What causes proteinuria?
Can be normal after a period of standing Can also be present: -After exercise -During infection -In pregnancy -HTN -Fever -Nephrotic/nephritic syndrome
When proteinuria has been found, can do ACR to quantify as it is more sensitive
>150mg is abnormal
Then, can use PCR, or 24 hour urinary collection to monitor the levels of protein in the urine
How can GFR help in CKD diagnosis?
Used in part of the definition of CKD as a measure of kidney function
Should consider those with different ethnicities and builds - will have varying amounts of creatinine naturally
Can use to monitor the kidney function rather than relying on a set value
Multiply creatinine x1.2 for those from Afro-Carribean origin due to increased muscle mass
How can USS help in CKD diagnosis?
Can visualise any obstruction e.g. ureteric stones
Can also see PKD - well differentiated round cysts
Indicated in: Persistent haematuria FHx PKD and aged 20+ GFR<30 Need to have a biopsy
How can biopsy help in CKD diagnosis?
To confirm a suspected diagnosis of glomerulonephritis
Can see glomerular sclerosis in DM
Interstitial nephritis
What are the stages of CKD?
Stage 1 GFR >90 - but with signs of kidney injury Stage 2 GFR 60-89 Stage 3a GFR 45 -59 Stage 3b GFR 30-44 Stage 4 GFR 15-29 Stage 5 GFR <15
Can treat 1 and 2 in primary care
4 and 5 need referral
3 needs referral if rapid decline in GFR, anaemia etc.
How can you stage CKD with ACR?
Using the GFR stage 1-5 ACR 1 = <30mg ACR 2 = 30-300mg ACR 3 = >300mg Can then have a combined G and A staging
Who do you screen for CKD?
Anyone who is likely to be vulnerable:
FHx
Older
Low kidney mass
Anyone with direct kidney damage: HTN DM Autoimmune Sepsis Obstruction Long courses of nephrotoxic drugs
How do you initially treat CKD?
Treat the underlying cause e.g. HTN/Diabetes
Ensure good nutrition and hydration
Treat complications
How can you treat hypertension in CKD?
ACE-i/ARB can still be used, but are only first line in diabetic nephropathy, high proteinuria or proteinuria and HTN
AIm for 140/90mmHg or 130/80mmHg in DM
Which diuretics can be used in CKD?
Loop diuretics e.g. furosemide
Osmotic diuretics e.g. mannitol
Thiazide-like diuretics e.g. bendroflumethiazide
Potassium sparing diuretics:
Aldosterone antagonists e.g. spironalactone
Amiloride
Carbonic anhydrase inhibitors
How do you alter CV risk in CKD?
Lifetsyle and dietary factors
Consider statins, aspirin etc. depending on QRISK
Biggest cause of mortality in CKD patients - due to HTN caused by CKD
Pros and cons of haemodialysis
Can be done in a clinic or at home
Need fistula inserting 3 months before - should prepare for this
3x a week for 4 hours at a time
Pros
In a clinic you will get to know other CKD pts
Delivered by trained professionals
Can be done at home at your own convenience
Can have more control over your care
Fewer ups and downs between treatment if at home
Cons
Ups and downs between treatments
Not flexible to yourmschedule if in a clinic
Having family treating you can be stressful
Less flexibility to travel
Strict diet
Pros and cons of peritoneal dialysis
Catheter needs to be inserted into eh abdomen prior to starting the treatment
Can be CAPD, or APD
CAPD - bag exchanges 4x a day
APD - overnight the machine cycles through about 3-5
Pros More control over your treatment Easier to travel Can be done anywhere May not need to exchange during the day with APD
Cons Risk of peritonitis Continuous treatment - needed 7 days a week Disruption of daily routine Restricted movement at night
Pros and cons of renal transplant
Pros Better quality of life, with easy travel More time, less spent on dialysis No special diet High graft survival Cheaper to the NHS
Cons Anti-rejection meds and immunosuppressants means very vulnerable to infection Extensive testing Can have a kidney rejected Wait for an average of 3 years Last for an average of 15y
What are some of the common immunosuppression drugs for CKD?
Tacrolimus Prednisolone Azothioprine Cyclosporin Sirolimus
