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chronic kidney disease Flashcards

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1
Q

Functions

What is the function of the kidneys

Homeostasis ones

A

Homeostasis ones
* Water/ fluid
* Electrolytes
* Acid-Base
* Blood pressure
* Elimination of waste
* Excretion of drugs & drug metabolites

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2
Q

Functions

What are the endocrine/metabolic functions of the kidneys

A

synthesis of hormones
* Vitamin D
* Erythropoietin
* Renin

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3
Q

Assessing kidney function in clinical practice

what is the gold standard of kidney functioning measurements

A

Exogenous filtration markers
* E.g. inulin, 51Cr-EDTA
* Require injection or infusion
* Require multiple sample collection, so it’s quite intrsuive

Endogenous Filtration Markers
* E.g. urinary clearance of creatinine
* Requires accurate timed urine collection
-matched serum sample
- need time and mutiple samples again

only use methods when there is uncertentity about kidney functions, not used in clincial practise as much

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4
Q

How do we measure kidney function in clinical practise

A
  • Serum creatinine
  • use it to estimate GFR
  • not a linear relationships
  • for example when kidney function is very good will lead to big chnages in egfr
  • when kidney function is low big changes in creatnine shows up as small changes in egfr

creatnine breakdown from mucsles

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5
Q

What factors can affect creatanine

the non renal ones

A

creatnine: breakdown of muscles, muscle mass effects it

Non-renal determinants of serum creatinine include
- Age
- Sex
- Ethnicity
- Body habitus
- Diet

ethnicty has been dropped from the equations

For example a 20 year old with 100 serum cretanien has the egfr of 80 compared to 80 year old female with the same creatanine has 40 eGFR

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6
Q

Proteinuria

What do injured, inflammed glomeurli/kidneys leak

A

Proteins

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7
Q

Proteinuria

How do we quantify proteinuria

A

measure total amount: proudce 24hr urine sample, (and you’ll see the amount of protein proudced over 24 hours)

Measure ratio to reference analtye
we use an albumin to creatinine ratio. to assess how much protein would be in someones urine if done over 24 hours

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8
Q

CKD

What is CKD

A

defined as abnormalties of kidney structure and function that has been there for over 3 months

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9
Q

CKD

What if someone has normal kidney function, can they still have CKD

A

Yes

if they have protein in urine, or blood, or if they have scarring (seen on ultrasound)

some of these can point to glomeruli

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10
Q

Stage 1

What happens in stage 1 of CKD

A

when someone’s eGFR is over 90 ml per minute (that means they have normal function)

*if they have proteinuria, or blood then they have CKD stage 1

normal is about 120 ml per minute

btw when eGFR increases your confiedence decreases

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11
Q

Stage 2

What is stage 2 classified as

A

eGFR is between 60-90 ml per minute

as we get older, eGFR reduces anyway

To call it CKD you need to have something

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12
Q

Stage 3

What is Stage 3 CKD

A

30-60ml per minute (eGFR)

at that point you have CKD with reduced kidney function (mild-moderate)

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13
Q

Stage 3

What is the difference between stage 3a and b

A

stage 3a: 45-59
stage 3b: 44-30 (see the complications of CKD)

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14
Q

stage 4

What is stage 4

A

Severe kidney impairement
eGFR less than 30

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15
Q

What happens in stage 5

A

eGFR is less than 15

atp you start dialysis, or do transplant

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16
Q

CKD

People can progress through the stages of CKD

what does this mean for the kidneys

A

it means there’s an irreverisble loss of nephrons
- so loss of renal filtration function

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17
Q

Stage 5

What are the types of renal replacment therapies

A

Haemodialysis
Peritoneal dialysis
Kidney transplantation

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18
Q

CKD

How else can we classify CKD

A

the amount of proteinuria present
A1 - normal (no proteinuria)
A2 -significant proteinuria
A3 - severe proteinuria (about half a gram of protein a day)

A3: either have signgficant CKD, or an inflamtorty disease of kidney

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19
Q

Proteinuria

Why is it important to know if someone has proteinuria

A
  • can help determine the cause
  • risk of death

can end up doing a biposy to determine cause

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20
Q

Renal disease

What are the imporant risk factors are there

population wise, medical disease, social factors, lifestyle

A
  • Age
  • Social deprivation
  • Black or South Asian ethnicity
  • Hypertension
  • Diabetes
  • Smoking
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21
Q

Causes of Chronic Kidney Disease

What are the common causes of CKD

A
  • Diabetes
  • Hypertension
  • Genetic
  • Glomerulonephritis
  • other reasons
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22
Q

Diabetic nephropathy

What is Diabetic nephropathy characterised by

like what will the person present with

A

proteinuria

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23
Q

What is the pathology of diabetic nephropathy

A

thickening of basement membrane
* mesangial expansion
* hyperglycaemia stimulates increased matrix production
by mesangial cells
* stimulation of TGF-b release (causes fibrosis)
* glomerulosclerosis
* due to intraglomerular hypertension or ischaemic damage
* essentially lose filtration power

hyperglycemria: increase filtration due to dilation of afferent ateriole, but you get increase glomerular pressure, causes damage with time

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24
Q

Diabetic Nephropathy

True or flase

there is a correlation between diabetic retinopathy and Diabetic
Nephropathy

A

True

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25
What is the natural history of diabetic nephropathy
cba check the lecture slides
26
# Diabetic nephropathy How do we treat diabetic nephropathy
Treat underlying disease * Good blood sugar control (diet & medications) Reduce proteinuria * use ACE inhibition & SGLT2 inhibitor Limit cardiovascular risk * Control blood pressure * Treat hyperlipidaemia *Stop smoking, etc.
27
# Hypertensive nephropathy What is hypertensive nephropathy
When yo get glomerular hypertension intermial thickiening of blood vessles * leads to narrowing of blood vessels * and glomerular ischaemia * end up with proegessive CKD and firbosis due to hypertension Glomerular hypertension causes injury and sclerosis over prolonged periods
28
Renal atery stenosis can cause CKD what is it?
find answer
29
# Glomerulonephritis What is glomerulonephritis
immune-mediated injury to glomeruli
30
# Glomerulonephritis What can cause glomerulonephritis
* IgA nephropathy (most common one) * maybe associated with infection (e.g streptococcus, HIV) * can be part of systemic disease process (e.g. systemic lupus erythematosus, vasculitis)
31
# Glomerulonephritis How do we diagnose glomerulonephritis
usually there may be blood and or protein in urine and they don't have oher reaosns to cause this
32
# Autosomal dominant polycystic kidneys What is polycystic kidneys
when cyst on the kidneys the cysts replace kidney tissue so reduces function can cause pain - if they repture (cause haemturia)
33
# Polystsic kidneys When can someone get autosmal domianat polycystic kidneys and when can someone get autosomal reccessive polycystic kidneys
Reccessive: manifest in childhood Dominant: adulthood
34
# Causes What else can cause CKD not mentioned
* Medications (NSAIDs, chemotherapy, others) * Recurrent urinary tract infection * Urinary outflow obstruction (bladder obstruction, cause of that bengin hyperplastic prostate) * Trauma * Interstitial nephritis * Recurrent/ persistent acute kidney injury
35
# Consequences of impaired kidney function What are the complications related to CKD
* increased mortality (3) * cardiovascular disease & hypertension (3) * Altered drug handling (3) * Anaemia(4) * Vitamin D, phosphate & parathyroid disturbance(4) * Acidosis(4) * Hyperkalaemia(4) * Fluid retention (5) * Uraemia (5) ## Footnote brackets allude to stages
36
# CVS risks in CKD What are the tradional risks factors of CVS in CKD
* Diabetes * Hypertension * Dyslipidaemia * Smoking ## Footnote Dyslipidaemia & Smoking share some risk factors
37
# Cardiovascular risk in CKD What are the non classical risks
* Endothelial dysfunction * Inflammation * Oxidative stress * Catabolic state ## Footnote how they think CKD affects CVS mortality
38
# Cardiovascular risk in CKD What are the CKD related risks
* Fluid retention * Anaemia * Hyperparathyroidism * Vascular calcification
39
Why is hypertension important when it comes to ckd
* can accelerates decrease of kidney function * Can contribute to cardiovascular risk - (stroke, myocardial infarct, heart failure)
40
# Hypertension What are the mechanims that hypertension can contribute to CKD | like who can HT cause CKD
* Sodium retention * Volume expansion * Renin-angiotensin-system activation * Sympathetic nervous system activation * Endothelial dysfunction
41
How do we manage hypertension
* Moderate salt intake * Renin-angiotensin system blockade * diuretics * Other anti-hypertensive medications
42
# PTH Parathyroid hormone mechanism | and how does this affect the kidney
1. Low calcium 2. stimulates parathyroid 3. stimulates PTH 4. PTH acts on kidney to stimulate kidney to activate vitamin D 5. VD acts on gut to increase calcium absoption 6. increases serum calcium 7. increased calcium serum which acts on parathyroid to stop PTH if blocked * there wil be cnstant sectreiton of PTH * bone resoption to increase calcium * can end up with 2nd or 3rd hyperparathyroodism
43
# Mineral bone disease How do we manage mineral bone disease?
* Correct Vitamin D deficiency if present (colecalciferol, ergocalciferol) * Supplement activated Vitamin D (alfacalcidol, calcitriol) * Control high phosphate levels (dietary restriction, phosphate binders) * Offer calcimimetics (use drugs to stop producing PTH) * Last resort: parathyroidectomy
44
# Anaemia How can anaemia impact people's lives
Impaired quality of life * reduced exercise capacity * impaired cognition * increased risk of Left Ventricular Hypertrophy * increased CV disease in patients with CKD and anaemia compared to those with CKD without anaemia
45
# Anaemia How do we treat CKD with anaemia
* Correct iron deficiency if present * Recombinant erythropoietin ## Footnote don't give blood tranfusion all the time because of iron overload, also don't want to sensitise patients if they are going to recieve transplant
46
# Bicarbonate -carbonic acid buffer What happens during with the bicarbonate - carbonic acid buffer system during CKD
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3 - There is adFailure to excrete acid (H) in CKD so increase ↑ H+ -→↑H+.HCO3 → ↑CO2 +↑H2O means increased co2 and water This is removed by lungs to maintain pH
47
# Metabolic Acidosis What is the impact of Metabolic Acidosis
Impact * Increased respiratory rate * Acute – life-threatening metabolic dysfunction * Chronic - loss of bone and muscle mass
48
How do we manage metabolic acidosis
Management * Sodium bicarbonate * Dialysis (or transplantation)
49
# Hyperkalaemia True or false the body has little reserve of pottassium
False it has a large functional reserve to excrete potassium ## Footnote with severe hyperkalaemia happens when GFR decrease 10ml/min
50
# Hyperkalaemia Why do people with hyperkalemia
Excessive load * Interferance with potassium excretion * acidosis with volume contraction * diabetic nephropathy
51
# Hyperkalaemia What can happen when pottassium goes outside normal range
life threatning you can get * Alterations in membrane excitability * cardiac arrythmias Can see ECG changes * Tall T waves * Long QRS interval * Long PR interval * Cardiac arrest
52
# hyperkalaemia How do we manage hyperkalaemia
* restricting dietry pottassium * Potassium binders (not used in CKD in clincial practise as much) * dialysis
53
# Sodium and fluid retention what happens when there is failure of fluid retention
* can't conc urine * inablity to excrete water load (so can have dilutional hyponatraemia, oedma, hypertension)
54
# Sodium & fluid retention What can high levels of sodium lead to
Confusion, fits and coma ## Footnote for normal neurological function, sodium needs to be in normal rnage
55
# Sodium & fluid retention What can the loss of nephrons reduce
ablity to excrete salt and water ## Footnote which can cause hypertension and fluid overload
56
# Fluid overload How do we manage fluid overload?
Intake (dietry) * Reducing/restric salt * Reducing/restrict Fluid Output * Diuretics * Dialysis or transplant
57
# Uraemai What is it
When urea is high aren't clearing toxins that well may mainain nitrogenous waste, and things like urate, phosphate TNF alpha ## Footnote can affect peoples brains
58
What are the consequences of uraemia | life threatning ones
Encephalopathy Pericarditis ## Footnote Pericarditis: inflammation of oericardium, can bleed into it, bled into tight space which can compress the heart, and you can get cardiac tampondae Encephalopathy: twiching because uranmic (indication to start dialysis)
59
# Drugs Drugs are metabolsied and excreted by the kidneys What is the consequnce of impaired renal clearance
Can get toxicity from high drug levels and prolonged action (since they aren't being cleared)
60
# Drugs What adverse effects can opiates accumliating cause
Reduced consciousness & respiratory arrest
61
# Drugs What adverse effects can antoboitics not being cleared cause
Encephalopathy | can affect brain function
62
# Drugs What adverse effects can lithium accumliating cause
Vomiting, tremors, confusion
63
# Drugs What adverse effects can digoxin accumliating cause
arrthymias
64

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