Chronic Kidney Disease & Renal Failure

Question 1

What is CKD?

Answer 1

CKD is defined as abnormalities of kidney structure or function, present for >3 months.

Question 2

What GFR parameter defines CKD?

Answer 2

• GFR <60mL/minute/1.73m2

Question 3

What are the symptoms of CKD?

Answer 3

Albuminuria/proteinuria, haematuria, electrolyte abnormalities detected by imaging.

Question 4

What endocrine functions are performed by the kidneys?

Answer 4

Erythropoietin synthesis

1-alpha hydroxylase vitamin D

Question 5

What homeostatic are performed by the kidneys?

Answer 5

Electrolyte balance
Acid-base balance
Volume homeostasis

Question 6

What are the excretory functions of the kidneys?

Answer 6

Nitrogenous waste
Middle sized molecules
Hormones, peptides
Salt and Water

Question 7

What are the functions of the kidney regarding glucose metabolism?

Answer 7

Gluconeogenesis

Insulin clearance

Question 8

Disruptions to the homeostatic balance of the kidneys can manifest as what?

Answer 8

Hyperkalaemia
Reduced bicarbonate - decreases pH and manifests as metabolic acidosis
Increased phosphate
Salt want water imbalance

Question 9

What are the endocrine imbalances that occur in kidney dysfunction?

Answer 9

Increased PTH
Anaemia - reduced EPO production
Hypocalcaemia- reduced calcitriol synthesis

Question 10

Why is there parathyroid hyperplasia associated with kidney dysfunction?

Answer 10

There is a reduction of calcitriol synthesis, due to insufficient activity of renal 1-alpha hydroxylase, manifesting as chronic hypocalcaemia, this increases PTH secretion to potentiate bone resorption

Question 11

Why does anaemia occur in kidney dysfunction?

Answer 11

Reduced erythropoeitin production

Question 12

What are the symptoms associated with kidney failure and reduced secretion of sodium chloride?

Answer 12

Hypertension
Oedema
Pulmonary Oedema

Question 13

Why is salt and water loss evident in tubulointestinal disorders?

Answer 13

Damage int he concentrating mechanism of the juxtamedullary interstitial - water reabsorption decreased

Question 14

Why does metabolic acidosis occur in kidney failure?

Answer 14

Reduced excretion of hydrogen ions from the distal convoluted tubule into the filtrate, manifests as acid retention

Question 15

Why does hyperkalaemia occur in kidney failure?

Answer 15

Reduced potassium excretion

Question 16

What is used to treat hyperkalaemia in an acute setting?

Answer 16

Sodium bicarboante- neutralises the hydrogen ions, such that potassium can re-enter the cells

Question 17

What can acidosis cause?

Answer 17

Anorexia and muscle catabolism

Question 18

What are the symptoms of hyperkalaemia?

Answer 18

Cardiac arrhythmias
Neural muscular activity
Vomiting

Question 19

What features on an ECG suggest hyperkalaemia?

Answer 19

Peaked T waves
P-waves: Broadens, reduced amplitude
QRS widening
Heart block
Asystole
VT/VF

Question 20

What type of hyperparathyroidism is linked with chronic kidney failure?

Answer 20

Tertiary hyperparathyroidism

Question 21

Why is there an increased cardiovascular risk with chronic kidney disease?

Answer 21

There is an increased cardiovascular risk, since cardiac ventricular myocyte contraction is directly related to extracellular concentrations of calcium (arrythmias) + increased calcification risk.
• Predictor of end stage renal failure is CKD
• Outcome for a patient with CKD  Cardiovascular disease

Question 22

What are the standard cardiovascular risk?

Answer 22

Hypertension
Diabetes
Lipid abnormalities

Question 23

What is the immediate treatment in a patient with hypovolaemia?

Answer 23

Give fluids

Question 24

What is the immediate treatment for a patient with hypervolaemia?

Answer 24

Fluid restriction, consider diuretics/dialysis

Question 25

What is the treatment for hyperkalaemia?

Answer 25

Drive into cells – sodium bicarbonate Insulin dextrose (caution) – carries hypoglycaemic risk. Insulin is a potassium drive (short term solution) Drive out of the body – Diuretics/dialysis Gut absorption – Potassium chelating agents

Question 26

How does insulin dextrose treat hyperkalaemia?

Answer 26

Insulin induces a potassium drive (short-term solution).

Question 27

What is the long term management for CKD?

Answer 27

* Erythropoietin injections to correct anaemia * Diuretics to correct salt-water overload * Phosphate binders * 1-25 Vitamin D supplements

Question 28

What home therapy is available for CKD?

Answer 28

* Haemodialysis * Peritoneal dialysis/assisted programmes  The peritoneum behaves as a semipermeable membrane and a dialysate is delivered with specific concentrations (hyperosmolar to generate drive, fluid into the peritoneal cavity)

Question 29

What is a fistula in terms of CKD?

Answer 29

A fistula is created by connecting an artery directly to the vein – vein swells for ease of access.

Question 30

Where should taking blood be avoided in patients with renal failure?

Answer 30

avoid taking blood or inserting IV lines into the veins of the antecubital fossa or cephalic vein at wrist level

Question 31

Which veins should be used when taking blood or IV lines for patients with renal failure?

Answer 31

Dorsal venous structures

Question 32

Why should transfusions be avoided in patients with renal failure?

Answer 32

• Transfusions will sensitise anaemia (haemolytic anaemia, as foreign antigens are detected, and antibodies are formed)  Autoimmune mediated rejection of transplanted kidney).

Question 33

Why is urea a poor indicator of GFR?

Answer 33

Poor indicator | Confounded by diet, catabolic state, GI bleeding (bacterial breakdown of blood in gut), drugs, liver function

Question 34

What factors affect creatinine within patients with renal failure?

Answer 34

Affected by muscle mass ,age, race and sex

Question 35

What is the most appropriate radionucleotide studies in patients with renal failure?

Answer 35

EDTA

Question 36

What calculation is used, to estimate GFR in patients?

Answer 36

Modification of Diet in Renal Disease (MDRD) GFR (mL/min/1.73m2) = 175 x (SCr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if Afr American) or CKD Epidemiology Collaboration (CKD-EPI) GFR = 141 x min (SCr/K,1)-α x max (SCr/K,1)-1.209 x 0.993Age x 1.018 [if female] x 1.159 [if black]

Question 37

Which GFR-CKD classification is recommended by NICE and why?

Answer 37

NICE guidelines to use CKD-EPI (At high GFR, it is more accurate)