Chronic Kidney Disease

Question 1

What is chronic kidney disease?

Answer 1

Defined by the presence of kidney damage (abnormal blood, urine or imaging findings) or GFR <60ml/min/1.73cm2 that has been present for more than 3 months

Question 2

What can cause chronic kidney disease?

Answer 2

DM

Chronic glomerulonephritis

HTN

Age related decline

Polycystic kidney disease

Renovascular disease

Nephrotoxicity

Chronic pyelonephritis

Smoking

Question 3

How does chronic kidney disease present?

Answer 3

Normally asymptomatic and diagnosed on routine testing

Pruritis, incompletely understood

Oedema

N&V, incompletely understood

Cognitive changes, due to urea build up

Pallor due to anaemia

HTN

Muscle cramps, neuronal irritation

Peripheral neuropathy

Urine symptoms

• Polyuria
• Oliguria
• Nocturia
• Proteinuria
• Haematuria

Question 4

What investigations are used in chronic kidney disease diagnosis and monitoring?

Answer 4

U&E

• eGFR, two tests are required 3 months apart to confirm a diagnosis
• Hyperkalaemia
• Hypocalcaemia, due to lack of vitamin D

Urinalysis

• Haematuria, significant result is 1+ of blood
• Proteinuria, ≥ 3mg/mmol is significant

US

• Bilateral small kidneys

Renal biopsy

FBC

• Chronic normochromic anaemia

ABG

• Metabolic acidosis

LFTs

• Hypoalbuminemia detects those at risk of nephropathy earliest

Question 5

What biopsy signs are seen in chronic kidney disease?

Answer 5

Glomerulosclerosis

Kimmelstiel-Wilson lesions in diabetic neuropathy

Question 6

What US signs can be seen in chronic kidney disease?

Answer 6

Bilateral small kidneys with thinned cortices for intrinsic disease

Question 7

How is chronic kidney disease managed?

Answer 7

Treat underlying cause, such as pyelonephritis

Optimise risk factors

• DM control
• BP control, ACEI is first line
• Atorvastatin 20mg for primary prevention of cardiovascular disease

Lifestyle

• Stop smoking
• Increased exercise
• Dietary advice about phosphate, sodium, potassium and water intake

Complication management

• Oral sodium bicarbonate for metabolic acidosis
• Iron supplementation and erythropoietin/ESA for anaemia
• Vitamin D and bisphosphonates for renal bone disease
• Gout management

Renal replacement therapy for end stage renal disease

Question 8

When is specialist referral indicated for CKD?

Answer 8

eGFR < 30, or falls progressively by over 15 in a year

ACR ≥ 70 mg/mmol

Uncontrolled hypertension despite ≥ 4 antihypertensives

Question 9

Describe stage 1 chronic kidney disease based on GFR

Answer 9

Kidney damage

GFR>90 and supporting evidence

Question 10

Describe stage 2 chronic kidney disease based on GFR

Answer 10

Kidney damage

GFR 60-89 and supporting evidence

Question 11

Desribe stage 3a chronic kidney disease based on GFR

Answer 11

Moderately impaired

GFR 45-59

Question 12

Describe stage 3B chronic kidney disease based on GFR

Answer 12

Moderately impaired

GFR 30-44

Question 13

Describe stage 4 chronic kidney disease based on GFR

Answer 13

Severely impaired

GFR 15-29

Question 14

Describe stage 5 of chronic kidney disease

Answer 14

Advanced/dialysis

GFR<15

Question 15

Describe stage 1 of chronic kidney disease based on albuminuria

Answer 15

Normal to mildly increased

<30mg/g

Question 16

Describe stage 2 of chronic kidney disease based on albuminuria

Answer 16

Moderately increased

30-300mg/g

Question 17

Describe stage 3 of chronic kidney disease based on albuminuria

Answer 17

Severely increased

>300mg/g

Question 18

Give complications of chronic kidney disease

Answer 18

Mortality and complications worsen with decreased renal function

Gout

• Uric acid builds up in joints due to failure of excretion

Hyperkalaemia causing arrythmias

Anaemia

• Reduced erythropoietin production
• Predisposes to left ventricular hypertrophy

Renal bone disease

• Reduced vitamin D production causes hypocalcaemia which stimulates release of PTH to release calcium from bone

Peripheral neuropathy

Question 19

When is an ACEI started in CKD?

Answer 19

Raised albumin:creatine ratio, over 70mg/mmol

Question 20

When is atorvastatin used in CKD?

Answer 20

Reccomended for all CKD patients

Question 21

What is used as vitamin D supplementation in end stage renal disease and why?

Answer 21

Alfacalcidol

Does not require activation in kidneys

Question 22

Give side effects of erythropoietin

Answer 22

Accelerated HTN, leading to encephalopathy amd seizures

Bone pain

Flu symptoms

Skin rashes/urticaria

Thrombosis

Iron deficiency secondary to increased erythopoiesis

Question 23

What should be checked prior to starting EPO in patients with CKD and anaemia?

Answer 23

iron status

Question 24

How do you prevent contrast induced nephropathy?

Answer 24

IV 0.9% NaCl pre and post procedure