Chronic Kidney Disease Flashcards by Annie Caldwell

Functions of the kidney

Body fluid homeostasis
Electrolyte balance
Excretory function 
Regulation of vascular tone
Acid base homeostasis
Endocrine function

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Traditional definition of chronic renal failure

Irreversible and significant loss of renal function and thus problems with the functions of the kidneys

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Definition of chronic kidney disease

Either the presence of kidney damage (abnormal blood, urine or x ray findings) or GFR <60ml/min/1.7m^3 that is present for >3 months

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What are the stages of CKD?

1 - kidney damage / normal or high GFR - GFR > 90
2 - kidney damage / mild reduction in GFR - GFR = 60-89
3a/b - moderately impaired = 45-59, 30-44
4 - severely impaired = 15-29
5 - Advanced or on dialysis = < 15

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What does pressure difference in the glomeruli lead to?

Glomerular filtration

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What is GFR measured in?

ml/min

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What crosses the GBM?

Water
Electrolytes
Urea
Creatinine

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

Glucose

Low molecular weight proteins (a2 microglobulin)

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What does not cross the GBM?

Cells (RBCs, WBCs)

High molecular weight proteins (albumin, globulins)

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Should there be blood or protein measurable in urine if filtering properly?

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How is protein in the urine quantified?

Protein creatinine ratio (PCR)

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What stage of CKD is most prevalent?

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What is kidney failure replaced by?

Dialysis

Transplant

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Complications of CKD

Acidosis
Anaemia
Bone disease
CVD
Death and dialysis
Electrolytes
Fluid overload
Gout
HTN
Iatrogenic issues

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Complications of CKD are more likely with worsening what?

eGFR

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What does RRT stand for?

Renal replacement therapy

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What is RRT for?

End stage renal disease

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Causes of CKD

DM
GMN
HTN
Renovascular disease 
- renal artery stenosis from atherosclerosis or fibromuscular dysplasia 
- leads to ischaemic nephropathy 
Polycystic kidney disease
Myeloma
IgA nephropathy 
Nephrocalcinosis
Sarcoidosis
Chronic exposure to nephrotoxins (NSAIDs, lithium, lead, certain herbs)
Reflux nephropathy 
Chronic obstructive nephropathy 
- prostate disease
- metastatic cancer
- retroperitoneal fibrosis
- PUJ obstruction

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Presentation of CKD

Pallor secondary to anaemia of CKD
HTN
SOB
Cognitive changes
GI symptoms
- Anorexia
- vomiting
- taste disturbance 
- uraemic odour
Polyuria
Nocturia 
Frothy urine
Haematuria
Proteinuria
Peripheral oedema
Itch 
Cramps

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When are cramps mostly common in CKD?

At night

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Why do cramps occur in CKD?

Neuronal irritation caused by the biochemical abnormalities of CKD

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Investigations of CKD

USS
XRAY
CT
MRI 
Bloods + blood film 
Biochemistry 
Coagulation screen
Urine protein:creatinine ratio 
CK
Anti-GBM
ANCA or ELISA
C3, C4, auto antibody scren

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USS advantages

Non invasive
Non ionising radiation
May provide info about chronicity of renal disease
No functional data
Can be used to detect progressive obstruction

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What are key goals of treatment of CKD?

Slowing the rate of decline

Assessment of complications related to reduced GFR

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How is it possible to slow the rate of renal decline in CKD?

``` BP control Control proteinuria Treat causes Allopurinol Dietary protein restriction Fish oils Lipid lowering Control acidosis ```

What is high BP associated with in CKD?

Faster decline in GFR

Investigations of the complications of CKD

Bicarbonate, pH (acidosis) Blood count, film, haemantics (anaemia) Calcium phosphate albumin parathyroid hormone (bone disease) Electrolytes including K (electrolytes) Exam including BP, oedema, JVP, CXR (fluid overload) BP +/- 24 hour tape (HTN) Ask about medication (iatrogenic issues)

What GFR level would metabolic acidosis be seen in?

<20mls/min

What does metabolic acidosis worsen?

Hyperkalaemia | Renal bone disease

Treatment of metabolic acidosis

Oral Na Bicarbonate

What GFR does anaemia usually manifest at?

< 20mls/min

What type of anaemia is seen in renal disease?

Normochromic normocytic

What does reduced GFR have an effect on phosphate?

Hyperphosphatemia

Effect of CKD on vitamin D

``` Loss of renal tissue Lack of activated vit D Low 1a hydroxylation in CKD, so low activation of vit D Low Vit D levels lead to low calcium - reduced intestinal absorption - reduced tubular resorption ```

Management of 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 calcimetrics (cinacalet)

What is potassium normally excreted with in the distal tubule?

Na+

What happens to Na+ excretion as GFR falls?

Reduced delivery of Na+ to distal tubule as GFR falls

What level of K+ may induce fatal cardiac arrhythmia?

>7mmol/l

Treatment of hyperkalaemia

``` Acute - stabilise - calcium gluconate - shift = salbutamol + insulin dextrose - Remove dialysis and calcium resonium Chronic - diet - drug modifications ```

Examples of high potassium foods

``` Avocadoes Bananas Mangoes Kiwi Oranges Peas Pumpkins Sweet potatoes Tomatoes Ice cream Milk Dairy Chocolate Seeds and nuts ```

Examples of food that contain low potassium

``` Apples Berries Grapes Watermelon Carrots Lettuce Onion Unsalted popcorn ```

At what GFR is fluid/volume overload usually problematic?

GFR < 20mls/min

Why do people get volume overload?

Unable to excrete an excess Na+ load

What does volume overload lead to?

Oedema | Hypertension

Treatment of volume/fluid overload

Na+ restriction Fluid restriction Loop diuretics

What is HTN as a complication of CKD often assosiated with?

Volume overload

What BP is aimed for in CKD with and without proteinuria?

With - < 125/75 | Without - 130/80

What does a build up of urea toxin lead to?

Uraemic pericarditis

Management of acidosis due to reduced GFR

Bicarb

Management of anaemia due to reduced GFR

EPO | Iron

Management of CV risk due to reduced GFR

``` BP Drugs Aspirin Cholesterol Exercise Weight loss ```

Management of risk of dialysis and death due to reduced GFR

Counsel and prepare

Management of electrolyte imbalance due to reduced GFR

Diet | Consider drugs

Management of fluid overload

Salt and fluid restriction | Diuretics

Modalities of renal replacement therapy

Haemodialysis Peritoneal dialysis Transplant Conservative care

How many stages are there of CKD?

What are the stages of CKD according to their GFR levels?

``` Stage 1 - GFR > 90 Stage 2 - GFR 60 - 90 Stage 3a - GFR 45 - 60 Stage 3b - GFR - 30 - 45 Stage 4 - GFR - 15 - 30 Stage 5 - GFR - 0 - 15 ```

What level of GFR cannot be measured above?

> 60

What is erythropoietin released by and in response to what?

Kidney | In response to cellular hypoxia

What are the main uses of erythropoieitin as treatment?

Treat anaemia associated with CKD | Treat anaemia associated with cytotoxic therapy

S/Es of erythropoietin treatment

Accelerated HTN potentially leading to encephalopathy and seizures (BP increases in 25% of patients) Bone aches Flu like symptoms Skin rashes, urticaria Pure red cell aplasia (due to Abs against erythropoietin) Raised PCV increases the risk of thrombosis (e.g. fistula) Iron deficiency 2ndry to increased erythroporesis

What is the angion gap used for?

To classify metabolic acidosis into either - raised anion gap e.g. seen in DKA - normal anion gap e.g. seen in patients with diarrhoea due to GI bicarb loss

How to calculate the anion gap

(Na + K) - (Cl + HCO3)

Who is iron deficiency anaemia a worrying sign in?

Elderly

Are erythropoietin injections any use in patients who are iron deficient?

How can CKD result in osteomalacia?

Due to high phosphate levels - this 'drags' calcium from the bones

If prescribing fluids, what is someones glucose requirements per day? Is this calculated with their weight?

50 - 100g/day | Irrespective of their weight

Chronic Kidney Disease Flashcards

(67 cards)