Chronic kidney disease

Question 1

What is the definition of chronic kidney disease

Answer 1

Reduction in kidney function or structural damage or both, present for more than 3 months with associated health implications

Question 2

What are some causes of CKD?

Answer 2

Diabetes
Hypertension
PKD
Glomerular disease
AKI
Nephrotoxic drugs
Obstructive uropathy
Multisystem disease
Hereditary kidney disease
CVD
Obesity with metabolic syndrome

Question 3

What are some examples of potentially nephrotoxic drugs?

Answer 3

Aminoglycosides
ACEi and ARBs
Bisphosphonates
Calcineurin inhibitors
Diuretics
Lithium
Mesalazine
NSAIDs

Question 4

What are some causes of obstructive neuropathy that can cause CKD?

Answer 4

Calculi
Prostate (BPH, malignancy, etc)
Bladder (Malignancy, chronic cystitis)
Malignancy
Strictures/stenosis
Extrinsic compression

Question 5

What are the markers of kidney damage - “THE ASS-H”

Answer 5

T - Transplant - Previous transplant Hx
H - Histological abnormality on biopsy
E - Electrolyte abnormalities
A - ACR > 3mg/mmol
S - Sediment absnrmalities in urine (Blood, casts)
S - Structural abnormalities on imaging
H - Hereditary condition on genetic testing

Also an eGFR <60 ml/min/1.73m^2

Question 6

How many stages of CKD are there?

Answer 6

5 (6 including 3a and 3b)

Question 7

G1 CKD GFR

Answer 7

eGFR > 90

Question 8

G2 CKD GFR

Answer 8

eGFR 60-89

Question 9

G3a CKD GFR

Answer 9

eGFR 45-59

Question 10

C3b CKD GFR

Answer 10

eGFR 30-44

Question 11

G4 CKD GFR

Answer 11

eGFR 15-29

Question 12

G5 CKD GFR

Answer 12

eGFR < 15

Question 13

How many ACR classifications of CKD are there?

Answer 13

3

Question 14

A1 CKD ACR

Answer 14

ACR < 3

Question 15

A2 CKD ACR

Answer 15

ACR 3-30

Question 16

A3 CKD ACR

Answer 16

ACR > 30

Question 17

CKD 5D

Answer 17

eGFR < 15 and commenced on dialysis

Question 18

ERF

Answer 18

Established renal failure (eGFR < 15)

Question 19

KRT/RRT

Answer 19

Kidney/Renal replacement therapy

Question 20

ESKD

Answer 20

End-stage kidney disease - eGFR < 15 and on/approaching RRT or conservative management

Question 21

What is meant by accelerated progression of CKD?

Answer 21

• a persistent decrease in eGFR by 25% or more AND a change in CKD category within 12 months
• OR can also be defined as a persistent decrease in eGFR of 15 mL/min/1.73 m2 within 12 months

Question 22

How does CKD usually present?

Answer 22

Usually asymptomatic

Question 23

What are some possible symptoms of CKD?

Answer 23

Pruritus
Loss of appetite
Nausea
Oedema
Muscle cramps
Hypertension

Question 24

What are some investigations required in CKD?

Answer 24

U+Es
eGFR
Urinalysis (Proteinuria, haematuria)

Question 25

When may renal USS be used in CKD?

Answer 25

Accelerated CKD Haematuria Family history of PKD Evidence of obstruction

Question 26

How is CKD managed?

Answer 26

Manage the underlying condition - Diabetes - HbA1c to target - Hypertension - ACEi/ARB - Autoimmune - Immunosuppression - Obstruction - Relieve obstruction - Nephrotoxins - Stop drugs

Question 27

What is the BP target in CKD?

Answer 27

140/90

Question 28

What is the BP target in CKD + Diabetes or ACR>70mg/mol

Answer 28

130/80

Question 29

What is the link between CKD and CVD

Answer 29

≥ G3 CKD increases CVD risk by 40% compared to G1 or 2 25mg/mmol increase in urinary ACR leads to 10% increase in stroke risk

Question 30

What are some CVD risk modification strategies in CKD?

Answer 30

Smoking cessation Weight loss Aerobic exercise Limited salt intake Lipid-lowering therapy Aspirin (Possibly)

Question 31

Describe the link between AKI and CKD

Answer 31

AKI may initiate or accelerate CKD progression

Question 32

Describe the link between dyslipidaemia and CKD

Answer 32

Secondary causes of dyslipidaemia may include renal causes such as nephrotic syndrome

Question 33

Describe the use of lipid lowering therapy in CKD

Answer 33

- Offer atorvastatin for the primary or secondary prevention of CDK to people with CKD - Increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73 m2 or more

Question 34

What Hb level is classified as renal anaemia?

Answer 34

Hb < 110g/L

Question 35

How will renal anaemia present?

Answer 35

Tiredness Shortness of breath Lethargy Palpitations

Question 36

What is the cause of renal anaemia?

Answer 36

Thought to be caused by reduce EPO production by the kidneys, reduced RBC survival and iron deficiency

Question 37

What is the target Hb in renal anaemia treatment?

Answer 37

100-120g/L

Question 38

Which CKD stages are more prone to renal anaemia

Answer 38

> G3

Question 39

What investigations are required in renal anaemia?

Answer 39

Blood tests to rule out B12, folate and other causes of anaemia Check ferritin stores

Question 40

Renal anaemia management

Answer 40

Iron therapy: 1st line - Oral iron 2nd line - IV iron (Ferinject, vendor) If this doesn't work: - ESA (Athlete doping drug)

Question 41

What is renal mineral and bone disorder (MBD)

Answer 41

A complication of CKD in which there is an abnormality in bone turnover and mineralisation

Question 42

How does CKD MBD present?

Answer 42

Bone pain Increased bone fragility Extra-skeletal calcification of skin or blood vessels

Question 43

What causes CKD MBD?

Answer 43

Impaired regulation of intestinal absorption, renal tubular excretion and vitamin D activation in the kidneys This disturbs vitamin D, calcium, PTH and phosphate metabolism This causes abnormalities in bone turnover and mineralisation with vitamin D deficiency, raised serum phosphate, low serum calcium and 2º or 3º hyperparathyroidism

Question 44

What endocrine conditions can arise from CKD MBD?

Answer 44

2º or 3º hyperparathyroidism Vitamin D deficiency

Question 45

What are some dietary changes required in CKD MBD?

Answer 45

Phosphate restriction Consider salt, potassium and fluid restriction

Question 46

What are some drugs required in CKD MBD?

Answer 46

Oral sodium bicarbonate - Manage metabolic acidosis Alfacalcidol (Active vit D) Phosphate binders (Lanthanum/sevelamer)

Question 47

What are some other complications of CKD?

Answer 47

Peripheral neuropathy and myopathy Malnutrition Malignancy End-stage renal disease All cause mortality