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Flashcards in Chronic Kidney Disease Deck (50):
1

What is the current definition of chronic renal failure?

•Chronic kidney disease (CKD) is defined by either the presence of kidney damage (abnormal blood, urine or x-ray findings) or GFR<60 ml/min/1.73m2 that is present for ≥3 months

2

What are the different classifications of chronic kidney disease?

3

When will creatinine be raised?

Only until about 60% of the total kidney function is lost 

4

Which demographic has a high serum creatinine?

African Americans - because they have a higher muscle mass

5

What factors are involved in estimating the GFR from serum creatinine?

Age

Weight

Female/male

Ethnicity

 

The vraiables used depend on which formulae you are using

 

6

What funtion of the kidney does eGFR measure?

Excretory function

7

What things cross the GBM?

Water

Urea

Electrolytes

Creatinine

8

What things cross the GBM but are reabsorbed in the proximal tubule?

Glucose

Low molecular weight proteins - a2, microglobulin

9

What things don't cross the GBM?

Cells (RBC, WBC)
High molecular weight proteins - albumins, globulins

10

How do we assess the filtration (keep in function) of the kidney - 

Check for the presence of blood or protein in the urine

11

How do we assess the anatomy of the kidney?

Histology

Radiography

12

What are the complications of CKD?

Acidosis

Anaemia

Bone Disease

CVS

Death

Dialysis

Electrolytes

Fluid Overload

Gout

Hypertension

Iatrogenic issues

 

More likely with worsening eGFR: Vit D deficiencym hyperphosphataemia, hypoalbuminaemia, hyperparathyroidism

13

What are the different aetiologies of CKD?

Diabetes

Glomerulonephritis (all causes)

Hypertension

Renovascular disease

Polycystic kidney disease

 

Myeloma

IgA nephropathy

Sarcoidosis

Chronic exposures to nephrotoxins (NSAIDs, lithium, lead, ceratin herbs)

Reflux nephropathy and scarring

Chronic obstructive nephropathy (prostatic disease, metastatic cancer, retroperitoneal fibrosis, PUJ obstruction

14

Give examples of renovascular disease

 

Renal artery stenosis from atherosclerosis of fibromusclular dysplasia

- Leads to ischaemic nephropathy

 

Persistently decreased renal perfusion - ongoing heart failure and cirrhosis

15

What are some symptoms and signs of CKD?

Anaemia - pallor and SOB

SOB also caused by fluid overload

Hypertension

Itch and Cramps

Cognitive changes

GI - anorexia, vomitting, taste disturbance

Haematuria

Proteinuria

Peripheral oedema - exacerbated by hypoalbuminaemia - reduced oncotic gradient

16

What are the important parts of the history to uncover for a patient with potential CKD?

 

Previous evidence of renal disease

History of systemic diseases

Drug exposure

Pre/post renal factors

Uraemic symptoms

Previous evidence of renal disease:

  • Raised urea/creatinine
  • Proteinuria/haematuria
  • Hypertension
  • LUTs
  • Family History

History of systemic diseases:

  • Diabetes mellitus
  • Collagen vascular disease (scleroderma, SLE, vasculitis)
  • Malignancy (myeloma, breast, lung, lymphoma)
  • Hypertension
  • Amyloidosis
  • Sickle cell disease

Drug exposure

  • NSAIDs
  • Penicillins/aminoglycosides
  • Chemotherapeutic drugs
  • Narcotic abuse
  • ACE i / ARBs

 

Pre/post renal factors

  • Congestive cardiac failure
  • Diuretic use
  • Nausea, vomiting, diarrhoea
  • Cirrhosis
  • LUTS / pelvic disease

Uraemic symptoms - THESE ARE IN LEARINNG OUTCOMES

  • Nausea, anorexia, vomiting
  • Pruritis
  • Weight loss
  • Weakness, fatigue, drowsiness

17

What are the examinations for CKD?

•Vital signs

–Fever, blood pressure

•Volume status

–Deplete:

–Orthostatic BP, skin turgor/temperature

–Overload:

–Raised JVP, crepitations, ascites, oedema

•Systemic illness

–Skin

–Rash – malar (lupus), purpuric (vasculitis), macular (AIN)

–Auscultation

–Cardiac murmurs (endocarditis)

–Abdomen

–Bruits, palpable organs

–Extremities

–Livedo reticularis (vasculitis, atheroembolism),

–splinter haemorrhages (endocarditis)

–Pulses

–Absent (vascular disease)

–Bones and joints

–Tender (malignancy)

–Inflammed (lupus)

–Gouty tophi

 

Obstruction

- Percussable bladder, enlarged prostate, flank masses

18

How do we detect the underlying pathology in CKD?

Blood tests

U and E's

FBC

 

 

Urine Tests

Urine dip

Urine PCR or ACR

 

Histology - renal biopsy

 

Radiology

19

What are the investigations to exclude active disease?

CK - rhabdomyolysis

Urine Protein : Creatinine ratio - intrinsic renal disease

Serum and Urine electrophoresis - myeloma

20

How do we quantify protein in the urine?

Protein : creatinine ration

Albumin : Creatinine ration

 

24 hour urine collection

 

Renal disease is often asymptomatic - only sign may be abnormal BP or urinalysis

21

What imaging techniques are used in detecting the aetiology of CKD?

•Ultrasound - no functional date, may provide information about chronicity of renal disease

•Plain radiology

•CT

•Nuclear medicine

•MRI

22

What does bilateral small kidneys with thinned cortices suggest?

Intrinsic disease (glomerulonephritis)

23

What does unilateral small kidney indicate?

Renal artery disease

24

What does clubbed calyces and cortical scars suggest?

Reflux with chronic infection or ischaemia

25

What do large cystic kidneys suggest?

Cystic kidney disease

26

How do we slow the rate of renal decline?

Blood pressure control (High Bp is associated with faster decline in GFR)

Control proteinuria (ACEi and ARBs)

Reverse other contributing factors - treat causes

•Others

–Allopurinol

–Dietary protein restriction

–Fish oils

–Lipid lowering

–Control acidosis

27

How do we assess the complications related to reduced GFR?

 

Acidosis

Anaemia

Bone disease

CV risk

Death & Dialysis

Electrolytes

Fluid overload

Gout

Hypertension

Iatrogenic issues

28

When is metabollic acidosis normally seen?

•Not usually seen until GFR<20mls/min

•Most marked in tubular-interstitial disease

29

What are the effects of acidosis on potassium and bone disease?

•Worsens hyperkalaemia

•Exacerbates renal bone disease

30

How is acidosis treated?

Treated with oral sodium bicarbonate

31

What causes anaemia in CKD? When does it occur

Caused by reduced erythropoietin production

Caused by reduced red cell survival 

Usually manifests when GFR is less than 20 mls / min

 

32

What is the treatment for anaemia that is secondary to chronic renal disease?

Iron replacement therapy

ESA therapy (erythropoeitin stimulating agent)

Oral vs Intravenous

33

What causes bone disease in chronic kidney disease?

The kidney's function to excrete phosphate is impaired (reduced serum calcium)

 

The combination of low calcium and high phosphate stimulates PTH - Bone resorption

 

The kidney has impaired ability to hydroxylate vitamin D (low levels of 1  a hydroxylase- leads the reduced absorption of calcium) - high phosphate results in reduced 1 a hydroxylase - therefore low vitamin D

Liver + cholecalciferol = 25 hydroxycholecalciferol

+kidney = 1,25 dihydroxycholecalciferol

 

(high phosphate is also associated with vascular and cardiac calcification)

34

What is the management of renal bone disease?

Control of phosphate:

- Diet - try to reduce phosphate

- Phosphate binders 

- Calcium carbonate, ca, Acetate, sevelamer, lanthanum)

 

Normalise calcium and PTH:

Active vitamin D anologues (calcitrol)

Tertiary disease (parathyroidectomy and celcimetics - cinacalcet)

35

What is tertiary parathyroidism?

When there is prolonged hypersecretion it can become uncontrolled

36

Name some cardiovascular risks

•Hypertension

•Hyperlipidemia

•Smoking

•Underlying disease (e.g. diabetes)

•Renal bone disease (perhaps because increased phosphate)

•Endothelial dysfunction

•Uraemic pericarditis

•Lifestyle factors

Improve above factors

37

Where is potassium normally exchanged with sodium?

Normally excreted by exchange with sodium in the distal tubule

38

How does the delivery of sodium change when GFR falls?

When GFR falls there is reduced delivery of sodium to the distal tubule 

39

How does an ACE i affect potassium levels?

ACE i causes the retention of potassium 

40

What foods are high in potassium?

Bananas

Avacado

Tomatos

Milk

Yoghurt

Chocolate

Seeds and nuts

41

What level of potassium can induce fatal cardiac arrhythmia?

When potassium is greater than 7mmol/l

42

What is the treatment for hyperkalaemia?

Acute

•Stabilise

–Calcium Gluconate

•Shift

–Salbutamol

–Insulin-Dextrose

•Remove

–Dialysis

–Calcium resonium

 

Chronic

•Diet

•Drug modifications

43

When us fluid overload a problem?

WHen GFR is less than 20 mls/min

The kidney is unable to excrete and excess sodium load

Leads to sodium and water retention

44

What are the complications of sodium and water retention?

Oedema and hypertension

45

What is the treatment for fluid / volume overload?

Sodium restriction

Fluid restriction

Loop diuretics

46

What is the blood pressure aim for CKD with proteinuria and withour proteinuria?

With - aim for less than 125/75

Without - aim for 130/80

47

Which drugs cause acute kidney injury on top of CKD?

Contrast agents

Antibiotics

48

What is the risk of the build of of urea?

Uraemic pericarditis

49

Haemodialysis vs Peritoneal

50