Chronic Kidney Disease Flashcards Preview

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Flashcards in Chronic Kidney Disease Deck (49):
1

What is the traditional definition of chronic renal failure?

Irreversible and significant loss of renal function

2

How do we assess for kidney disease?

Excretory function
-Glomerular Filtration Rate (eGFR from creatinine blood test)

Filtering function
-Check for presence of blood or protein in urine

Anatomy
-Histology, radiology

3

What is the problem with the relationship between serum creatinine and GFR (for measuring eGFR)?

Creatinine will not be raised above the normal range until 60% of total kidney function is lost

4

What effects serum creatinine levels?

Muscle mass:
-Age,
-Ethnicity (African Americans)
-Gender (Male)
-Weight

5

Give some formulae to estimate GFR from serum creatinine

Cockcroft Gault

MDRD 4 variable equations

CKD-EPI equation

6

What crosses the GBM?

Water
Electrolytes
Urea
Creatinine

7

What crosses the GBM but is reabsorbed in the proximal tubule?

Glucose

Low molecular weight proteins (a2-microglobulin)

8

What doesnt cross the GBM?

Cells (RBC, WBC)

High molecular weight proteins (albumin, globulins)

9

How much blood or protein should you be able to measure in a normal kidney?

Should be no blood or protein measurable in urine if filtering properly

10

How can you test for protein or blood in urine?

Urinalysis ("dipstick")
-Blood
-Protein

Protein quantification
-Protein creatinine ratio (PCR)

11

What is the current chronic kidney disease definition?

Chronic kidney disease is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR /= 3 months

12

What is the prevelence of CKD?

Increases with age

About 8-12% in UK

Mostly stage 3

13

Give some of the complications of chronic kidney disease

Acidosis
Anaemia
Bone disease
Cardiovascular
Death and dialysis
ELectrolytes
Fluid overload
Gout
Hypertension
Iatrogenic issues

14

How much does CKD cost?

About £35,000pa for 1 patient

Around £6,500 drug costs
£20,000 transplant

15

What is the aetiology of CKD?

Polycystic kidney disease

Diabetes

Glomerulonephritis
-And all the causes of that

Hypertension

Renovascular disease

etc

16

What is the clinical approach to CKD?

Detection of the underlying aetiology
-Treatment for specific disease

Slowing the rate of renal decline
-Genetic therapies

Assessment of complications related to reduced GFR
-Prevention and Treatment

Preparation for Renal replacement therapy

17

What are you looking for in terms of previous evidence of renal disease in a CKD history

Raised urea/ creatinine

Proteinuria/ haematuria

Hypertension

LUTS

18

What systemic diseases do you need to keep an eye out for in a CKD history?

Diabetes Mellitus

Collagen vascular diseases:
-SLE, Scleroderma, Vasculitis

Malignancy:
-Myeloma, Breast, lung, lymphoma

Hypertension

Sickle cell disease

Amyloidosis

19

What drugs are you keeping an eye out for in CKD history?

NSAIDs

Penicillins/ aminoglycosides

Chemotherapeutic drugs

Narcotic abuse

ACE inhibitor/ ARBs

20

What uraemic symptoms may you be looking for in a CKD history?

Nausea, anorexia, vomiting

Pruritus

Weight loss

Weakness, fatigue, drowsiness

21

What are some of the clinical signs of depleted volume status?

Orthostatic BP

Skin turgor/ temperature

22

What are some of the clinical signs of fluid overload?

Raised JVP

Crepitations

Ascites

Oedema

23

What chemistry investigations may you want to carry out to look for CKD aetiology?

U&E (Na, K, Cl)

Creatinine

Bicarbonate

Total protein, albumin

Calcium, phosphate

Liver function tests

Creatine Kinase

Immunoglobulins, serum protein electrophoresis

24

What haematology investigations may you want to carry out to look for CKD aetiology?

FBC
-Hb
-MCV
-MCH
-WBC
-Platelets
-% hypochromic RBCs

25

What will be included in a coagulation screen you may want to carry out?

PT

APPT

+/- Fibrinogen

26

What imaging may you want to carry out to find the aetiology of CKD?

Ultrasound
Plain radiology
CT Nuclear medicine
MRI

27

When can pathology be useful for finding the aetiology in CKD?

Unexplained renal failure and Normal sizes kidneys

28

How can you slow the rate of renal decline?

BP control

Control Proteinuria

Reverse other contributing factors - treat causes

Others:
-Allopurinol
-Dietary proetin restriction
-Fish oils
-Lipid lowering
-Control acidosis

29

What investigations can you carry out to assess complications related to reduced GFR?

Blood count and Film
- ?Anaemic

Calcium Phospate Albumin PTH
- ?Renal bone disease

Creatine Urea
- ?GFR

Bicarbonate
- ?Acidosis

Electrolytes
- ?Hyperkalaemia

Urine Protein excretion (Pr:Cr)
- ?Degree of proteinuria

30

When does anaemia usually manifest in CKD?

When GFR

31

Describe the anaemia resulting from CKD?

Normochronic Normocytic

Reduced erythropoietin production

Reduced red cell survival

Increased blood loss

32

How do you treat anaemia due to CKD?

Usually treat if

33

When is metabolic acidosis usually seen in CKD?

When is metabolic acidosis most marked?

Nor usually seen until GFR

34

What are the symptoms of metabolic acidosis due to CKD?

General symptoms

Worsens hyperkalaemia

Exacerbates renal bone disease

35

How do you treat metabolic acidosis in CKD?

Treat with oral Na Bicarbonate
-Care with volume overload

36

How does CKD result in bone disease?

Reduced GFR leads to hyperphosphataemia

Loss of renal tissue leads to lack of vitamin D
-(indirect reduction in Ca absorption)

Low Calcium and raised phosphate

Secondary hyperparathyroidism (elevtaed PTH)

May progress to tertiary hyperparathyroidism

37

How does CKD effect activation of vitamin D?

Vitamin D, derived from sunlight or diet, requires to be hydroxylated to be active - 1,25 (OH) 2 D

The 1a hydroxylation is catalysed by 1a hydroxylase in the kidney

CKD -> low 1a hydroxylase, so low activation of vitamin D

38

How does low vitamin D lead to low calcium?

Reduced intestinal absorption

Reduced tubular reabsorption

Resulting stimulation of PTH secretion (i.e. secondary hyperparathyroidism)

39

What does high phosphate levels cause?

Reduced 1a hydroxylase therefore low vitamin D

Stimulates PTH production

Associated with vascular and cardiac calcification

40

How do you manage renal bone disease?

Control phosphate
-Diet

-Phosphate binders
---CaCO3, Ca Acetate, Sevelamer, lanthanum


Normalise Calcium and PTH
-Active Vit D analogues (Calcitriol)

-Tertiary disease
---Parathyroidectomy and Calcimetics (Cinacalcet)

41

Why does CKD result in Hyperkalaemia?

Normally excreted by exchange with Na+ in distal tubule

Reduced delivary of Na+ to distal tubule as GFR falls

Other factors include underlying disease, drgs and diet

42

How do you treat acute hyperkalaemia?

Stabilise cardiac membrane
-Calcium Gluconate

Shift K+ into cells
-Salbutamol
-Insulin-Dextrose

Remove calcium from body:
-Dialysis
-Calcium resonium

43

How do you treat chronic hyperkalaemia?

Diet

Drug modifications

44

When does fluid/ volume overload become problomatic in CKD?

When GFR

45

How does CKD lead to fluid/ volume overload?

Unable to excrete an excess Na+ load

Na+ and water retention

Oedema and hypertension

46

How do you treat fluid overload in CKD?

Na+ restriction

Fluid restriction

Loop diuretics

47

How do you tackle hypertension in CKD?

Treatment as per slowing rate of progression

Most imporatnt in proteinuric renal disease

ACEI may offer additional advantage

Otherwise tailored therapy

Aim

48

What drugs should by be weary of in CKD?

The main effect of kidney disease is reduced excretion of drugs and their toxins
-Beware antibiotics, morphine, digoxin, metformin amongst others

In those with CKD certain drugs and agents can cause acute kidney injury on top of CKD:
-Contrast agents, antibiotics

49

What is associated with worse outcomes in CKD?

Worse kidney function (GFR)

More proteinuria