CKD - amboss

Question 1

define CKD

Answer 1

abnormality of kidney structure of function that persists > 3 months
common causes include diabetes, hypertension, and glomerulonephritis

Question 2

pathos of diabetic nephropathy

Answer 2

hyperglycaemia causes varying degrees of damage to all types of kidney cells

Question 3

pathos of hypertensive nephropathy

Answer 3

caused by protective autoregulatory vasoconstriction of preglomerular vessels
benign nephrosclerosis (sclerosis of afferent arterioles and small arteries
decreased perfusion
ischaaemic damage

Question 4

pathos of glomerulonephritis

Answer 4

noninflammatory GN eg. membranous nephropathy, focal segmantal glomerulosclerosis
inflammatory GN eg. lupus nephritis, post streptococcal GN, rapid progressive GN, haemolutic uraemic syndrome

Question 5

pathophys of CKD

Answer 5

reduced GFR causes decreased production of urine which leads to increase in extracellular fluid volume and total body volume overload
decrease in excretion of waste products eg. urea, drugs
decrease in excretion of phosphate causes hyperphosphataemia
decreased maintenance of acid base balance leads to metabolic acidosis
decrease in maintenance of electrolyte concentration causes electrolyte imabalances eg. Na retention

Question 6

reduced endocrine activity in CKD

Answer 6

decrease in hydroxylation of calcifediol causes decreased production of calcitriol - decreased serum Ca
decreased in erythropoetin excretion causes decreased stimulation of erythropoiesis
reduced gluconeogenesis causes increased risk of hypoglycaemia

Question 7

clinical features of CKD

Answer 7

patients are often asymptomatic until later stages due to the exceptional compensatory mechanisms of the kidneys
hypertension, heart failure, pulmonary oedema and peripheral oedema due to Na and H2O retention

Question 8

define uraemia

Answer 8

accumulation of toxic substances due to decreased renal excretion. These toxic substances are mostly metabolites of proteins such as urea, creatinine, β2 microglobulin, and parathyroid hormone.

Question 9

uremia symtpoms

Answer 9

constitutional: fatigue, weakness, headaches
GI symptoms: nausea and vomiting, loss of appetite, ammonia breath
derm: pruritis, skin colour changes, uremic frost
serositis: uremic pericarditis, pluritis
neuro: asterixis, uremic encephalopathy, peripheral neuropathy
haematologic: anaemia, leukocyte dysfunction, increased bleeding tendancy

Question 10

uremic fetor

Answer 10

characteristic ammonia or urine like breath odour

Question 11

uremic frost

Answer 11

uraemia leads to high levels of urea excreted in the sweat, the evaporation of which results in yellow white urea deposits on the skin

Question 12

serositis

Answer 12

An inflammation of any serous surface such as the pericardium, pleura, or peritoneum. Usually associated with autoimmune diseases, such as systemic lupus erythematosus and rheumatoid arthritis.

Question 13

uraemic pericarditis

Answer 13

complicaation of chronic kidney disease that causes fibrinous pericarditis
clinical features include chest pain worsened by inhalation
physical examination findings include friction rub on auscultation, ECG changes that would normlly be seen in non uremic pericarditis are not usually seen

Question 14

signs of uraemic encephalopathy

Answer 14

seizures
somnolence
coma

Question 15

criteria for chronic kidney disease

Answer 15

GFR < 60 for 3 months

Question 16

define end stage renal disease

Answer 16

irreversible kidney dysfunction with GFR < 15 mL
manifesttions of uraemia requiring chronic renal transplant therapy with either dialysis or renal transplantation
likely death by cardiovascular disease

Question 17

how do people with end stage renal disease usually die

Answer 17

Most likely due to associated complications (e.g., anemia of chronic kidney disease) and increased cardiovascular risk factors (e.g., hypertension)

Question 18

CGA classification of chronic kidney disease

Answer 18

classified according to GFR and albuminuria
higher stages correlate with poorer prognosis

Question 19

determining albuminuria category

Answer 19

Spot UACR: The ratio of urine albumin concentration to urine creatinine concentration. An ACR < 30 mg/g is considered normal to mildly increased; an ACR 30-300 mg/g for more than 3 months indicates likely chronic kidney disease. An ACR > 300 mg/g is severely increased.

Question 20

other urine studies for CKD

Answer 20

Spot UPCR: The ratio of total protein to total creatinine in the urine. The UPCR obtained from a single urinary sample (i.e., spot urine) can be used to estimate 24-hour protein excretion (assuming creatinine is excreted at a constant rate). A spot UPCR value typically approximates the number of grams of protein excreted in the urine in a 24-hour period (e.g., a spot UPCR of 3.0 can be used to estimate proteinuria of ~ 3.5 g/day).
urine dipstick: may show hematuria or proteinuria
urine microscopy: may show abnormal urine sediment

Question 21

US of kidneys and urinary tract

Answer 21

first line imaging technique for the assessment of kidney structure
conider obtaining for all patients to further support the diagnosis and help determine the etiology

Question 22

findings on US suggesting chronic kidney disease

Answer 22

decrease in kidney length <10cm
decrease in parenchymal and/or cortical thickness
increase in cortical echogenicity
cysts
califications

Question 23

findings on US that suggests specific aetiologies

Answer 23

ureteral or renal pelvic dilation suggests obstructive nephropathy
bilaterally enlarged kidneys with multiple cysts suggest polycystic kidney disease

Question 24

CRAB criteria

Answer 24

The CRAB criteria indicate organ damage related to multiple myeloma: Calcium increased > 11 mg/dL, Renal insufficiency (creatinine clearance < 40 mL/min or serum creatinine > 2 mg/dL), Anemia (Hb < 10 g/dL), and Bone lesions.

Question 25

suggestive features of renal artery stenosis

Answer 25

Treatment-resistant hypertension Abdominal bruit heard over the flank or epigastrium Evidence of other atherosclerotic diseases (e.g., CAD, PAD)

Question 26

suggestive features of amyloidosis

Answer 26

History of a chronic inflammatory condition (e.g., IBD, RA) or chronic infectious disease (e.g., tuberculosis, osteomyelitis) History of plasma cell dyscrasia Evidence of other organ involvement (e.g., macroglossia, restrictive cardiomyopathy, hepatosplenomegaly, malabsorption)

Question 27

nutritional management

Answer 27

fluid intake - avoid dehydration protein restriction in patients with high CKD category sodium restriction pottisum intake adjustment phosphorous intake adjustment

Question 28

medication management

Answer 28

for renally cleared drugs - adjust dosing based on patients GFR avoid nephrotoxics contrast is highest risk in pateints with GFR < 30

Question 29

renal replacement therapy

Answer 29

non operative: haemodialysis or peritoneal dialysis operative: kidney transplatation

Question 30

dialysis indications

Answer 30

hemodynamic or metabolic complications that are refrectory to medical therapy eg volume overload or hypertension metabolic acidosis hyperkalaemia serositis other symptoms of uremia refrectory deterioration in nutritional status

Question 31

ASCVD risk assessment

Answer 31

atherosclerotic cardiovascular disease screening for all patients with CKD diabetes mellitus screening screening for hypertension screening for lipid disorders cardiovascular risk

Question 32

blood pressure control

Answer 32

aim for systolic < 120 first line: RAAS inhibitors ie. ACE and ARBs consider combination therapy with calcium channel blocker or thiazide diuretic good blood pressure control is crucial to prevent ASCVD complications, reduce mortality and help delay disease progression in patients with CKD

Question 33

lipid management

Answer 33

fasting lipid panel may show dyslipidaemia (high triglycerides are common) statin therapy for patients >50 or with comorbidities, or for treatment of ASCVD

Question 34

antiplatelet therapy

Answer 34

usualy indicated for management of ASCVD may be considered for primary prevention of ASCVD in high risk individuals

Question 35

screening for CKD complications

Answer 35

FBC for normochromic, normocytic anaemia potassium for hyperkalaemia usually seen in advanced CKD PTH for secondary hyperparathyroidism hyperphosphataemia and hypocalcaemia typically seen with GFR < 30 Vit D monitoring shows decreased calcidiol and calcitriol coagulation screen blood gasses for metabolic acidosis

Question 36

calcidiol

Answer 36

total body vit D stores

Question 37

monitoring blood gasses

Answer 37

The kidneys are often no longer able to maintain acid-base balance when the GFR drops below 30 mL/min/1.73 m2. An accumulation of hydrogen ions leads to acidosis.

Question 38

coagulation screening

Answer 38

normal PT, PTT and platelet count increased bleeding time due to uraemic platelet dysfunction

Question 39

common acute complications of CKD

Answer 39

pulmonary oedema hyperkalaemia infection drug toxicity

Question 40

pulmonary oedema

Answer 40

Due to an inability in patients with very low GFR to clear excess fluids

Question 41

hyperkalaemia

Answer 41

May be triggered by excessive dietary potassium, nonadherence to diuretic therapy, or a new medication or medication interaction (e.g., ACE inhibitors, potassium-sparing diuretics)

Question 42

infection as a complication

Answer 42

bacteraemia secondary to UTI or pneumonia IV catheter-related infection haemodialysis catheter related infection peritoneal dialysis-associated peritonitis

Question 43

calciphylaxis

Answer 43

a rare but potentially life-threatening condition characterized by dermal and subcutaneous arteriolar calcifications that cause painful skin necrosis

Question 44

riisk factors for calciphylaxis

Answer 44

Most commonly seen in patients with ESRD who are receiving dialysis Comorbidities: diabetes mellitus, obesity, CKD-mineral and bone disorder, warfarin therapy

Question 45

clinical features of calciphylaxis

Answer 45

Intensely painful skin lesions, e.g.: livedo reticularis, purpura, plaques, nodules Necrotic skin ulcerations typically covered with black eschar Areas of firm, painful, subcutaneous tissue Secondary bacteremia and sepsis

Question 46

diagnosis of calciphylaxis

Answer 46

A skin biopsy is required for definitive diagnosis but may provoke new lesions. Clinical diagnosis may be made in patients with ESRD with a typical presentation.

Question 47

pathophys of anaemia of chronic kidney disease

Answer 47

decrease in synthesis of erythropoeitn decrease stimulation of RBC production normocytic, normochronic anaemia

Question 48

management of anaemia in CKD

Answer 48

diagnostic studies forr iron deficiency B12 and folate deficiency erythropoeitn stimulating agenst avoid blood transfusions

Question 49

CKD mineral and bone disorders

Answer 49

abnormalities in mineral and/or bone metabolism in CKD renal osteodystrophy refers specifically to issues with bone metabolism due to CKD

Question 50

pathophysiology of CKD mineral and bone disorder

Answer 50

CKD causes hypocalcaemia via two mechanisms 1. decrease in renal excretion of phosphate, hyperphosphataemia, calcium phosphate precipitation 2. decrease in renal hydroxylation of vitamin D, decrease in calcitriol, decrease in intenstinaal Ca bsorption chronically decrease calcium level can caause secondary hyperparathyroidism, which can progress to tertiary hyperparaathyroidism

Question 51

clinical features of CKD bone and mineral diseaase

Answer 51

fractures bone or periarticular pain muscular weakness and pain focal vascular calcification (atherosclerotic plaques) diffuse vascular calcification

Question 52

treatment of CKD bone and mineral disease

Answer 52

normlise phosphate, calcium and PTH levels dietary phosphate restriction phosphate binders treatment of hyperparathyroidism: supplimentation for vit D, calcimimetics, parathyroidectomy (last line)

Question 53

secondary hyperprathyroidism

Answer 53

Excessive excretion of parathyroid hormone and hyperplasia of the parathyroid glands in response to low serum calcium levels. Causes include hypovitaminosis D and chronic kidney disease.