CKD Flashcards
Define chronic kidney disease
Abnormalities of kidney structure of function, present for >3 months, with kidney damage (abnormalities or markers of damage including those in blood or urine tests or imaging) or GFR
What are the stages of CKD
1: normal, structural abnormality/persistent haematuria or proteinuria (GFR >90l/min per 1.73m^2)
2: mildly reduced function, asymptomatic (GFR 60-89ml/min per 1.73m^2)
3: Mod. reduced function, renal osteodystrophy (GFR <15ml/min per 30-59m^2)
4: Severe reduced function, metabolic derangement, anaemia (GFR 15-29ml/min per 1.73m^2)
5: End stage renal failure (GFR <15ml/min per 1.73m^2)
Note: Stage 5 renal failure is much less common in children than in adults
What are the causes of chronic kidney disease
Congenital/inherited: PKD, Alport’s syndrome, congenital hyperplasia
Renal dysplasia ± reflux
Obstruction: myeloma, HIV nephropathy, scleroderma, gout, renal tumour, inborn errors of metabolism
Glomerular: glomerulonephritis, DM, amyloid, SLE
Congenital nephrotic syndrome
Vascular: HTN, renal artery atheroma, vasculitis
Metabolic
Congenital and familial causes are more common in childhood- e.g. structural malformations and hereditary nephropathies
What are the symptoms of chronic kidney disease
Stage 4/5 CKD
Polydipsia and polyuria
Urine: cola-coloured, foamy urine
Faltering growth/ growth failure
Anorexia and lethargy
Nausea ± vomiting
Pruritus
Anaemia: Dyspnoea
Oedema e.g. ankle swelling, weight gain
Restless legs
Arthralgia
Acute-on-chronic renal failure (precipitated by infection or dehydration)
What investigations should be done for chronic kidney disease
Bedside:
- Urine dip: proteinuria
- Urinary albumin: mod. increase (used for albumin excretion rate (AER) or albumin: creatinine ratio)
Bloods
- FBC: normochromic, normocytic anaemia (anaemic of chronic disease)
- Renal screen: Raised urea and creatinine, eGFR <60ml/min/1.73m^2
- Calcium: hypocalcaemia (vit D)
- ALP: increased, phosphate and PTH also increased
- BNP: raised
- Blood film: echinocytes or Burr cells (“spiky membrane”)
Other:
- Renal US: small kidneys seen ± obstruction/hydronephrosis, kidney stones
- Renal biopsy
- CXR: ? fluid overload
What is the management for CKD
Dietary changes
Prevent renal osteodystrophy
Salt supplements and fluids
Bicarbonate supplements (prevent acidosis)
EPO supplementation (for anaemia due to reduced EPO)
Recombinant human GH (due to GH resistance → poor growth)
Dialysis and transplantation
What dietary changes should be recommended for CKD
Calorie supplements ± NG/gastrostomy feeding to optimise growth due to anorexia and vomiting in CKD
Ensure sufficient protein intake
How do you prevent osteodystrophy in someone with CKD
Reduce phosphate intake (reduce milk)
Phosphate binders e.g. calcium carbonate, sevelamer
Vit D supplements: alfacalcidol, calcitriol
Consider parathyroidectomy (due to secondary hyperPTH)
What are the considerations for kidney transplantation in children
A child must meet a minimum weight before transplant (avoid renal vein thrombosis)
Living related donors are more successful than deceased donor kidneys
Survival is high
Immunosuppression: tacrolimus, mycophenolate mofetil, prednisolone
What are the types of dialysis for CKD in children
Peritoneal: cycling overnight OR a continuous cycling machine OR manual exchange over 24h (continuous ambulatory)
Haemodialysis: 3-4x per week in hospital
What are the complications of CKD
Metabolic acidosis
Water retention: Pulmonary/peripheral oedema, ascites, raised JVP
Hyperkalaemia and check potassium levels every 4 hours
Hyponatraemia
Toxin accumulation e.g. urea
Blood pressure: normal in AKI, raised in CKD
EPO: normal in AKI, raised in CKD
Vitamin D: normal in AKI, reduced in CKD
