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CKD Flashcards

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1
Q

What is the definition of CKD?

A

Chronic Kidney Disease - abnormal kidney structure or function, present for more than 3 months with implications for health - can also include those with just a reduced GFR of less than 60.
Irreversible.

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2
Q

Which things do we use to categorise CKD?

A

GFR
Albuminuria
Pathological cause

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3
Q

Describe the classification using GFR

A 
G1 = above 90
G2 = 60-89
G3a = 45-59 (mild)
G3b = 30-44 (moderate)
G4 = 15-29 (severe)
G5 = lower than 15 (failure)
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4
Q

Describe the classification of CKD with albuminuria

A

This is based on the ACR, and sometimes just use the Cr
A1 = 0-30
A2 = 30-300
A3 = above 300

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5
Q

What are the different types of renal pathology that can cause a CKD?

A 
Glomerular 
Tubulointerstitial
Vascular
Cystic/congenital
Transplant
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6
Q

What is the prognosis like for CKD?

A

This varies depending on the GFR and albuminuria.
If low GFR or high albuminuria, this is associated with a higher risk of:
mortality
CVD
ESRD
AKI

A1, G1/2 = low risk
A1, G3a = moderate risk
A1 G3b = high risk
A1 G4 = v high risk

A2 G1/2 = moderate risk
A2 G3a = high risk
A2 G3b = v high risk

A3 G1/2 = high risk
A3 G3-5 = v high risk

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7
Q

What are the most common causes of CKD in the UK?

A

Diabetes
Glomerulonephritis
Renovascular disease

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8
Q

What do you ask about in PMH to try to determine the cause of CKD?

A 
Previous UTI
Previous transplant
LRT symptoms
HTN
DM
IHD
Renal colic

DRUGS WHAT HAS BEEN RECENTLY STARTED

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9
Q

What do you ask about in the family to see what the risk of CKD is?

A

Renal disease

SAH

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10
Q

What sort of things cause vascular kidney disease?

A

Renal vasculitis
HF
TTP

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11
Q

What sorts of things cause glomerular CKD?

A

Membranous change

DM
Amyloidosis

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12
Q

What can cause tubulointerstitial CKD?

A

UTI
Pyelonephritis
Stones

Drugs
Toxins
Sarcoidosis

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13
Q

What can cause cystic/congenital CKD?

A

Renal dysplasia

Alport syndrome
Fabry disease

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14
Q

What can cause transplant CKD?

A

Recurrence of renal disease
Rejection
Calcineurin toxicity

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15
Q

What do we ask in a systems review for CKD?

A

Eyes, skin, join problems?

Malignancy signs

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16
Q

What are the symptoms of CKD?

A 
Fluid overload (SOB, PO, HTN)
Fatigue
Anorexia
Nausea/Vomiting
Pruritis

Bone pain
Arthralgia
Foamy or cola urine
Retinopathy

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17
Q

What are the risk factors of CKD?

A

Over 50
PMH of KD
DM
HTN

Male
Black/hispanic
FH
Smoking
Obesity
Long term analgesic/NSAIDs
AI
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18
Q

What peripheral signs indicate CKD?

A 
Vascular disease signs
Joint disease
Gouty tophi
Fistula
Bruising (steroids)
Encephalopic flap (high urea)

Anaemia
Xanthelasma
Uraemia (yellow tinge)
Jaundice (hepatorenal)
Gum hypertrophy (ciclosporin)
Cushingoid (steroids)
Periorbital oedema (nephrotic syndrome)
Taut skin (scleroderma)
Facial lipodystrophy (glomerulonephritis)

JVP (overload)
Parathyroidectomy scar
Lymphadenopathy

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19
Q

What signs from a CV exam can suggest potential kidney problems?

A

High BP
Sternotomy (recent mitral valve)
Cardiomegaly
Peripheral oedema

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20
Q

What signs from a resp exam indicate potential kidney problems?

A

Pulmonary oedema
Peripheral oedema
Pulmonary effusion

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21
Q

What signs from an abdo exam suggest potential kidney problems?

A

Ballotable kidneys
Palpable liver
Transplant scars
Catheter

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22
Q

What investigations do we do for CKD?

A 
FBC - ACD
Glc - DM
Serum Cr - raised
MSU - protein/blood/albumin/Bence Jones - Multiple myeloma/uPCR/uACR 
MCS
GFR

ANA, ANCA - AI
Low calcium - kidneys aren’t converting vit D so no Ca absorption
High phosphate - kidneys aren’t excreting
High PTH - stimulated by low Ca - renal osteodystrophy

Renal USS - usually small unless infiltrative disease (amyloid, myeloma), APKD and DM. Asymmetry in congenital and vascular diseases

Consider renal biopsy

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23
Q

What are ANA and ANCA?

A

Antinuclear antibodies
Anti-Neutrophilic Cytoplasmic Autoantibodies

Present in autoimmune disease

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24
Q

How often do we monitor those with CKD?

A

GFR and albuminuria:
Annually if low risk
6 monthly if moderate
3 monthly if high

Worry if eDFR drop >25%

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25
What makes CKD worse?
``` HTN DM Metabolic syndrome Dehydration Infection NSAIDs Smoking ```
26
Differentials of CKD?
Diabetic nephropathy HTN nephrosclerosis Ischaemic nephropathy Glomerulonephritis
27
What is urea?
This is a waste product of protein which is filtered by the kidney
28
What is creatinine?
This is a waste of muscle breakdown which is filtered by the kidneys
29
Which is better? Urea or creatinine?
Creatinine because it is affected less by diet.
30
What is uACR?
Urine albumin creatinine ratio. This is urine albumin/urine creatinine from a random urine and shows us albumin excretion in mg/day. This is classed as albuminuria if more than 30mg per day. Used because shows amount of albumin over a longer period of time.
31
What is uPCR?
Urine protein creatinine ratio. This is the protein/creatinine in a random urine. Gives us estimated protein excretion in mg/day. We worry if this is above 150mg
32
What do PD and HD stand for?
Peritoneal dialysis and haemodialysis
33
How long does CKD last for?
Lifelong
34
Why is MSU, MS? and when is best to get it?
It is midstream because this reduces the chance of cross contamination from the bacteria around the urethral opening. It is best to collect it in the morning because this is when the samples are most concentrated and abnormalities can be picked up more reliably.
35
What can cause proteinuria?
``` UTI CKD Fever HTN Nephrotic syndrome Pregnancy Recent exercise ```
36
Which cause of CKD does proteinuria indicate?
Glomerular | Tubulointerstitial
37
What does pyuria or WCC indicate?
Interstitial nephritis or UTI
38
Which urinary white cells strongly indicate nephritis?
Eosinophils
39
What reduces the risk of CVD the most?
Having a good BP
40
Why is there normally protein in the urine?
Tamm-Horsfall protein, also known as uromodulin, is secreted by renal tubules.
41
Which blood pressure tablet would you use for someone with DM, renal problems and HTN?
ACE-i/ARB | These are considered renoproductive and have been shown to slow the damage to the kidney and reduce albuminuria.
42
What is GFR?
THIS IS JUST AN ESTIMATED VALUE. Based on creatinine, age, sex and race. It is prone to error so don't take it as gospel.
43
How do ACEis and ARBs reduce proteinuria/albuminuria?
The efferent tubule is more vasodilated due to lack of RAS. This reduces the hydrostatic pressure in Bowman's space, reducing protein/albuminuria
44
What are the side effects of ACEis?
``` Dry cough, common Hypotension - dizziness, headache Angioedema Hyperkalaemia AKI ```
45
What is an acceptable rise of Creatinine after starting ACEi/ARBs?
25-30%
46
What would a significant rise of creatinine indicate?
Renovascular disease | Renal artery
47
What are the contraondications on ACEis and ARBs?
Pregnancy | AKI
48
When should you refer to renal?
If G5 refer immediately If G4 refer urgently If G3 refer routinely if other clinical signs such as anaemia, proteinuria, haematuria, abnormal salts or if recent fall in GFR ``` Refer in any: AKI Haematuria Proteinuria Hyperkalaemia Malignant HTN Nephrotic syndrome Systemic illness Outflow obstruction ```
49
What are the complications of CKD?
``` Renal Anaemia (low EPO) Oedema/hypervolaemia CVD CKDMBD (mineral bone disorder) low CA, HPT^ Metabolic acidosis (low HCO3) Restless leg syndrome (uraemia) Hyperkalaemia Hyponatraemia ```
50
What is a metabolic screen?
Blood tests that screen for metabolic complications, involving: Glucose (HbA1c) Calcium Proteins: albumin and total protein UEs: NA, K, Urea, Cr, Cl, CO2 LFTs: ALT, AST, ALP, Bilirubin
51
How do we treat renal secondary hyperparathyroidism?
Calcitriol/alphacalcidol
52
How do we treat renal anaemia?
EPO and IV iron Target ferratin at above 200 in CKD
53
How do we treat hyperkalaemia with CKD?
Dietary restriction and then ACEi if that doesn't work.
54
How do we treat the metabolic acidosis?
Oral alkali such as sodium bicarbonate
55
How do we reduce the progression of CKD?
Treat HTN Reduce cholesterol Prevent/treat UTI Treat the underlying cause e.g. diabetes
56
What would you see in a urine dipstick in CKD?
Proteinuria Haematuria Glucosuria
57
What is ESRD?
The point at which a person cannot live on their renal function and renal replacement therapy must occur - dialysis or transplant
58
How big are the normal and abnormalities of a kidney?
Normal - 11cm Atrophy - 7.5cm Hypertrophic - 13.5cm Polycystic - 18.4cm
59
What does acute on chronic renal failure mean?
That an AKI has occured in someone who has CKD
60
What is azotaemia?
Elevation of nitrogenous metabolic waste (urea) in the blood due to failure of clearance by the kidneys. Urea in the blood
61
What does uraemia mean?
This is a clinical syndrome, not just the presence of urea in the blood. A result of azotaemia which is failure of the kidneys and progressive azotaemia.
62
How can we assess kidney function?
``` Renal blood flow GFR Reabsorption: Glu, aa, phosphates, Na, HCO3 Urine concentration Excretion: K, H, Cr Renin EPO Activation of Vit D (colecalciferol to vit D) ```
63
What is the normal range for GFR?
100-130ml/min/1.73m2
64
Urine is what percent of the total volume filtered by the blood?
1% :o
65
How much filtrate gets absorbed in different parts of the tubules?
Proximal tubule - 80% reabsorbed LoH - 6% H2O and salt conservation to regulate fluid status Distal tubule - 9% reabsorbed and active secretion Collecting tubule - 4% filtrate reabsorbed
66
What are the different ways in which we can measure GFR?
Isotope GFR which is measured via radioactive Cr eGFR
67
Is a serum creatinine normal level the same for everyone?
Fuck no. eGFR is a good way of taking creatinine and telling us if that is okay or not. E.g. 110umol/L may be good for a young, strong man and very bad for a weaker old lady
68
Which diseases can cause direct kidney damage to put someone at risk of CKD?
``` Diabetes HTN AI Systemic sepsis UTI U stone U obstruction Drug toxicity ```
69
Which groups of people are at higher risk of CKD?
``` Older age FH Smaller kidneys Low birth weights Ethnic minorities Low income ```
70
What is nephrotic syndrome?
Triad of peripheral oedema, heavy proteinuria (more than 3.5g/day) and hypoalbuminaemia
71
What are some causes of nephrotic syndrome?
Diabetes Focal glomerulonephritis Membranous nephropathy Pre-eclampsia in late pregnancy
72
What sort of nutritional management do we use in CKD?
``` Adequate calorie and protein intake. Salt restriction Fluid management Supplement Lipid control Weight management ```
73
What do we aim for BP to be in those with CKD?
Threshold 140/90 Target 130/80 Target 125/75 if proteinuric states uPCR more than 100
74
With patients in CKD, we use ACEi and ARB and diuretics. When might we stop diuretics?
If eGFR lower than 30ml
75
When would we start preparing for renal replacements?
Stage 4 CKD
76
What immunisations do we give before renal replacements?
Pneumococcal Influenza Hep B
77
What are the symptoms of uraemia?
N/V Itching Pruritis Weakness
78
What are the options of treatment for renal replacement?
Peritoneal dialysis (CAPD, APD) Haemodialysis (at home too) Transplant Conservative management (palliative)
79
You stop diuretics at 30mL/min/1.73m2, what else do you stop?
Metformin and all diabetic drugs.
80
What does CAPD stand for?
Continuous ambulatory peritoneal dialysis.
81
What does CAPD involve?
A peritoneal tube inserted through the tummy, about the width of a pencil and 40cm long, 15cm of which remains outside. This is then connected to peritoneal dialysis bags 4 times a day in what is a called a PD cycle. The tube is changed every 6 months.
82
What is a peritoneal dialysis cycle?
``` This is PD done at home with CAPD and involves connecting a new and a drain bag. Draining the old fluid. Filling the new fluid in. Disconnecting the new bag. Uses osmosis. ```
83
What lifestyle changes do you advise in CKD?
Stop smoking Exercise Cholesterol
84
How do we treat HTN with CKD?
Stage 1&2 CKD - ACEI/ARB | Stage 3 - add a diuretic
85
How do we treat CVD risk with CKD?
Aspirin when Stage 3 & 4
86
Which statin should be used to lower lipids in CKD?
Atorvastatin Most clinical and cost effective
87
Can you take amplodipine and simvastatin at the same time?
Yes, but if taking more than 20mg amlodipine then higher risk of myopathy and rhabdomyolysis
88
Which consequences of CKD can cause breathlessness?
Anaemia Fluid overload/PO Metabolic acidosis HF
89
What are the indications to start dialysis?
Fluid overload Refractory hyperkalaemia Uraemic symptoms - N/V, w/l, neurological symptoms, uraemic pericarditis
90
If a patient chooses PD, what then needs to be inserted?
Tenckhoff catheter | catheter to peritoneum
91
If a patient chooses HD, what needs to be inserted?
AV fistula
92
When do those with advanced renal disease start dialysis
``` When they are symptomatic: fatigue nausea SOB decreased appetite ```
93
How long does it take to make dialysis happen?
3-6 months
94
What kind of donations can you have?
Deceased donor | Living donor
95
What is HD?
When the blood is passed through an outside kidney called a dialyser. This is done for 4 hours, three times a week and can be done from an AV fistula (takes about 3 months for a fistula to be ready)
96
What is dialysate?
The solution used in PD
97
What does APD stand for?
Automated peritoneal dialysis
98
What is APD?
This is peritoneal dialysis overnight (7-10 hours) so does it as you sleep
99
What can make home dialysis hard?
Addiction Mental Impairments Abdominal surgeries Too scared
100
What are the different challenges of home dialysis can we help to overcome?
Limited vision/hearing Learning problems Physical limitation We can have extra support or train family members and even start a mentorship scheme so you're not alone
101
If you can do what, you can do dialysis?
Manage an ATM and Button a shirt
102
What restrictions are there on HD that there aren't on PD?
Fluid restriction | Specific diet
103
Why might some people pick home dialysis?
``` Autonomy Live away from hospital Scared of needles Caring for others Travelling a lot ```
104
Where and when does HD happen and what do I need to do?
``` In a hospital, can be at home 4 hours 3x per week Make dietary changes Fluid restriction ```
105
Where and when does PD happen and what do I need to do?
``` CAPD - 30 minutes 4x day APD - 7-10 hours per night Portable Plan Don’t need to fluid restrict Helps preserve residual urine output Can have nurses sent out to help you set things up and run them until you are comfortable ```
106
What are contraindications for HD?
``` Absolute: no IV access Relative: Severe dementia Severe HF Severe psychotic disorder Bleeding disorder LBP ```
107
What are the absolute contraindications for PD?
``` IBD (active) Ischaemic bowel Diverticulitis Abdo abscess Pregnant in 3rd trimester ```
108
What are the relative contraindications for PD?
``` Abdo hernia Stoma Multiple abdo ops Blind Bad dexterity Obesity Poor hygiene Severe dementia Severe nephrotic proteinuria Severe obstructive resp Severe psychotic disorder ```
109
What are the absolute indications for transplant?
Active malignancy | Concurrent/recurrent infection
110
Which blood tests do you do for ESRD?
FBC - anaemia for EPO, ACD, Fe low UEs - hypercalcaemia, low bicarb Ca, Pi, PTH -
111
Why do you get iron deficient in ESRD?
Hepcitin helps absorb iron and allows it to store. It is secreted by the kidneys so if no kidneys, no hepcitin.
112
Which types of anaemia can you get in ESRD?
EPO Low Fe due to hepcitin ACD
113
What is PTHs main task?
Keep calcium in range 2.2-2.6
114
What are the disadvantages of PD?
Increased risk of peritonitis
115
How long do you continue on peritoneal dialysis?
About 5 or 6 years Peritoneal membrane can be damaged form the glucose in the dialysate which can cause sclerosing peritonitis. Risk after about 10 years
116
What are the benefits of HD?
4 days a week without anything Someone else does it for you. Trained to do it at home Treatment can be given during dialysis
117
What are the negatives of HD?
``` Fistulas are surgeries of the highest failure rate Harder to travel Fluid restriction Catheter ass infections Predominantly hospital based Makes you tired Rapid fluid shifts can cause symptoms Small bleeding risk ass with anticoagulants given to prevent clots in the dialysis process ```
118
What are the advantages of PD?
``` Less fluid restriction Home based No needles No blood More portable Can start quicker than HD ```
119
What are the disadvantages of PD?
``` Impact on daily routine Risk of peritonitis Peritoneal sclerosis risk Regular laxatives needed Home considerations Fails after 6 years ```
120
Transplant advantage
``` Independence Survival advantage No restrictions dietary Fewer symptoms Less IDA, MBD ```
121
Disadvantages of transplant?
Immunosuppressive side effects - malignancy, diabetes, weight gain, diarrhoea Infections Malignancy

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