CKD

Question 1

How long must symptoms be present to make a diagnosis of CKD?

Answer 1

CKD is defined as abnormality of kidney structure or function, present for >3 months, with implications for health

Question 2

What is AKI?

Answer 2

This is sudden deterioration of the kidney in the absense of a prior abnormality.

Question 3

What is acute-on-chronic renal failure?

Answer 3

This is the sudden deterioration on a background of CKD

Question 4

Name as many causes of CKD

Answer 4

Diabetic nephropathy
Glomerulonephritis
Hypertension
Systemic disease e.g. SLE, vasculitis, amyloid, myeloma
Renal Artery Stenosis
Hereditary e.g. polycystic kidney disease
Chronic pyelonephritis/vesicoureteric reflux
Urinary tract obstruction (e.g. prostatic disease)
Heart failure
Drugs e.g. NSAIDs
Unknown

Question 5

Which types of patients should receive continuous monitoring due to their risk of contracting CKD?

Answer 5

Nephrotoxic drugs (inc NSAIDs, lithium)
Diabetes
Hypertension
Cardiovascular disease (IHD, CCF, CVD, PVD)
Structural renal disease (prostatic hypertrophy, recurrent calculi)
Multisystem illness (e.g. SLE)
Family history ESRD
Opportunistic detection of haematuria
Following episode of acute kidney injury

Question 6

What are the eGFR values with each stage of CKD?

Answer 6

Stage 1 <90, Stage 2 60-90, Stage 3a 45-60, Stage 3b 30-45, Stage 4 15-30 Stage 5 <15

Question 7

When can you only make a diagnosis of stage 1 and 2?

Answer 7

In the presence of other evidence of CKD, ie not just on eGFR alone.

Question 8

How is proteinuria classically measured?

Answer 8

24 hour urine collection
In practice – quantified by spot urine sample (preferably morning) for protein/creatinine ratio (PCR) in urine, or albumin/creatinine ratio (ACR)

Question 9

Why are these ratios important?

Answer 9

PCR, ACR are ratios of concentrations of protein or specifically albumin, to creatinine – both measured in urine; this gives a quantitative measure of overall protein (or albumin) excretion which correlates with 24hr excretion

Question 10

What happens to serum urea in reduced kidney function and why?

Answer 10

Serum urea increased with reduced renal excretion
Breakdown of amino acids (protein catabolism)
Relatively high serum urea
Catabolic state, high protein intake, gastrointestinal bleed, glucocorticoids
Dehydration/cardiac failure
Relatively low urea
Low protein intake, liver failure

Question 11

What happens to serum creatinine in reduced kidney function?

Answer 11

Serum concentrations increased with reduced renal excretion

Question 12

What is the production of creatinine linked to?

Answer 12

Muscle mass, so young muscular male will have a higher serum creatinine than an old frail lady.

Question 13

How do you calculate eGFR?

Answer 13

Calculated from blood results and demographic data – e.g. age and gender (on lab reports)

Question 14

How do you manipulate the eGFR in a black afro-carribean?

Answer 14

x1.2

Question 15

How do you investigate for CKD?

Answer 15

Clinical history
Biochemistry / haematology
Urine – dipstick, microscopy (cells, casts)
Immunology screen (e.g. SLE, vasculitis, myeloma)
Renal Ultrasound – “normal”, obstruction, cystic disease, scarring, renovascular (e.g. renal asymmetry/Dopplers), small kidneys
+/- renal biopsy, angiography in some cases

Question 16

What are the specific complications of CKD?

Answer 16

Anaemia- due to reduced erythropoeitin production, bone-mineral disorder (low serum Ca and high phosohate, high parathyroid hormone), METABOLIC ACIDOSIS and hyperkalaemia.

Question 17

What are the clinical features of CKD?

Answer 17

Fluid retention, polyuria, nocturia ( due to loss of ability to concentrate the urine), HTN, odema, LVH dysfunction, vascular disease, dyslipidaemia (kidneys have a role in lipid metabolism), vascular calcificatio. Anorexia, nausea, vomiting, malnutrition, peptic ulceration

Neurological
Peripheral neuropathy, restless legs
Dermatological
Pigmentation, pruritus
Endocrine
Erectile dysfunction (vascular damage), oligoammenorrhea (hormone dysfunction), reduced fertility / ability to carry pregnancy
Musculoskeletal
Bone pain, fractures, arthropathy

Question 18

Management for CKD?

Answer 18

Treatment of underlying cause of CRF (if possible)
GFR may decline even if cause “inactive”
Lifestyle
Blood pressure control
CVS risk reduction
Diet
Anaemia – erythropoietin
Bone disease
Vitamin D analogues, phosphate control (diet, phosphate binders)
Bicarbonate supplements for acidosis

Question 19

What are the main risk factors for progression of CKD?

Answer 19

More advanced stage, lower eGFR, BP control, proteinuria or albuminuria.

Question 20

Other risk factors

Answer 20

Race, Gender
Smoking
Hyperglycaemia, hyperlipidaemia
Obesity
CVS disease
Ongoing nephrotoxic drugs

Question 21

What life style advice would you give a patient?

Answer 21

Stop smoking, exercise, maintain acceptable body weight, avoid NSAIDS, lithium, radiological contrast.

Warn pt of risk of acute deterioration with DEHYDRATION, avoid fasting in hospital etc.

Question 22

Diet advice for the patient….

Answer 22

Varies according to degree of impairment eGFR and individual patient results
Salt intake restriction
Calories (avoid/treat obesity and malnutrition)
Phosphate, potassium – restrict as needed
Avoid (or treat) malnutrition

Statins – primary/secondary prevention as in general population

Question 23

How should bp be maintained in patients with CKD?

Answer 23

140/90 or less,

IF CKD + Diabetes then 130/80 OR if CKD + ACR of 70mg/mol 130/80

Question 24

What are the first line drugs for HTN in CKD?

Answer 24

Ace inhibitors and ARBs EXCEPT in renal artery stenosis- if you gave a pt this then noticed a sudden drop in eGFR query renal artery stenosis.

Risk of hyperkalaemia however so monitior U&Es baseline and 1 week after.

Question 25

Be careful what drugs you prescribe in CKD

Answer 25

NO NSAIDS, digoxin, aminoglycosides, acyclovir

Question 26

Which drugs can increase the risk of hyperkalaemia?

Answer 26

ACEi, ARBs, amiloride, spironalactone, potassium supplements

Question 27

Which diuretic has reduced efficacy in CKD?

Answer 27

Thiazides

Question 28

What must you prepare the patient about in CKD?

Answer 28

CKD may progress to point where patient develops symptoms and eventually unable to sustain life – patient should be aware of risk Advanced education and counselling about options to facilitate decision-making when CKD more advanced Typically discuss ESRD options when eGFR <20 Dialysis not usually needed until eGFR <10

Question 29

What are the options for ESRD management?

Answer 29

Haemodialysis Peritoneal dialysis Kidney transplantation Conservative care

Question 30

Explanation to pt

Answer 30

Chronic kidney disease (CKD) is a long-term condition where the kidneys don't work as well as they should. It's a common condition often associated with getting older. Anyone can get it, although it's more common in black people and people of south Asian origin. CKD can get gradually worse over time and eventually the kidneys may stop working altogether, but this is uncommon. Many people with kidney disease are able to live long, largely normal lives. CKD can range from a mild condition with no or few symptoms, to a very serious condition where the kidneys stop working, sometimes called kidney failure. Most people with CKD will be able to control their condition with medication and regular check-ups. CKD only progresses to kidney failure in around 1 in 50 people with the condition. But if you have CKD, even if it's mild, you're at an increased risk of developing other serious problems, such as cardiovascular disease. This is a group of conditions affecting the heart and blood vessels, which includes heart attacks and strokes. Cardiovascular disease is one of the main causes of death in people with kidney disease, although healthy lifestyle changes and medication can help reduce your risk of developing it.

Question 31

What is the comment cause of glomerulonephritis world wide?

Answer 31

IgA nephropathy, aka verger's disease. (overlap with HSP)

Question 32

What conditions are associated with IgA nephropathy?

Answer 32

Coeliac disease/dermatitis herpetiformis | Henoch-Schonlein purpura

Question 33

What would you do if a pt with suspected lung ca needed a CT contrast but had a crap eGFR?

Answer 33

the evidence base currently supports the use of intravenous 0.9% sodium chloride at a rate of 1 mL/kg/hour for 12 hours pre- and post- procedure. There is also evidence to support the use of isotonic sodium bicarbonate

Question 34

Most common nephrotic syndrome?

Answer 34

Minimal change nephropathy

Question 35

What are the associations of minimal change disease?

Answer 35

MCD mostly affects children and is associated with facial/periorbital swelling and frothy urine. Also, Note: MCD also has an association with atopy and Hodgkins lymphoma.

Question 36

Some causes of nephrotic syndrome?? (other than idiopathic)

Answer 36

drugs: NSAIDs, rifampicin Hodgkin's lymphoma, thymoma infectious mononucleosis

Question 37

Why do people with nephrotic syndrome tend to develop dvts?

Answer 37

Loss of anti-thrombin 3 apparently.

Question 38

NB

Answer 38

Think compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis.

Question 39

Definition of acute kidney injury?

Answer 39

* Rise in serum creatinine greater than 26 µmol/L within 48 hours or * Rise in serum creatinine 1.5 × baseline value within 1 week or * urine output less than 0.5 ml/kg/hr for 6 consecutive hours (also called stage 1 AKI)

Question 40

Tx of AKI?

Answer 40

* ABCDE * Obtain intravenous access for bloods as described above * Treat underlying cause (e.g. intravenous fluids for hypovolaemia and antibiotics for sepsis) * Treat complications of AKI (e.g. hyperkalaemia, pulmonary oedaema, acidosis, pericarditis) * Review of the drug chart (dose adjustments and to avoid nephrotoxins) * Renal replacement therapy if indicated (e.g. intractable hyperkalaemia, pH < 7.15, intractable pulmonary oedema, uraemic pericarditis or encephalopathy) * Monitor (daily volume assessment, fluid balance, U&Es, bicarbonate)

Question 41

Stage 2 AKI?

Answer 41

Serum creatinine 2-2.9x baseline | Urine output of <0.5/ml/kg for 12 hours

Question 42

Stage 3 AKI?

Answer 42

Creatinine 3x baseline or >354 or UO of less than 0.3ml/kg/hour

Question 43

How might you treat hypokalaemia?

Answer 43

Transfer to high care area with cardiac monitoring, 3 x 1litre bags of 0.9% saline with 40mmol KCL per bag over 24 hours.

Question 44

What are the symptoms of hypokalaemia?

Answer 44

Weakness, leg cramps and palpitations

Question 45

Which score is used to assess someone with an upper GI bleed?

Answer 45

Use the Blatchford score at first assessment, and | the full Rockall score after endoscopy

Question 46

CKD on haemodialysis, what is the most common cause of death?

Answer 46

Ischaemic heart disease

Question 47

Who has an inappropriately low eGFR?

Answer 47

Body builders.

Question 48

Which virus is important to consider in renal transplant patients?

Answer 48

CMV