1
Q
What are the key indicators for the detection of CKD?
A
Decreased GFR and increased albuminuria or other markers of kidney damage
Both indicators are often silent and require laboratory tests for detection.
2
Q
What is the significance of biological and analytical variability in serum creatinine (SCr) and urine albumin/protein?
A
Necessitates verification of unexpected results before diagnosing CKD, especially in individuals without risk factors.
3
Q
What should be assessed in the evaluation of CKD?
A
- Past measurements/estimations of GFR
- Past measurements of albuminuria or proteinuria
- Urine microscopic examinations
- Imaging findings
- Kidney pathological findings
- Medical history
4
Q
What is the minimum duration required to prove chronicity in CKD?
A
Minimum 3 months.
5
Q
What are some functions of the kidneys?
A
- Metabolism
- Substance excretion
- Blood pressure regulation
- Erythropoietin production
- Electrolyte regulation
6
Q
What is the preferred method for initial testing of albuminuria?
A
Morning midstream sample.
7
Q
How often should albuminuria and GFR be assessed in people with CKD?
A
At least annually.
8
Q
What is the suggested monitoring frequency for CKD stages G1-G5?
A
- Annually for CKD G1-G2
- Every 6 months for CKD G3
- Every 3 months for CKD G4
- Every 6 weeks for CKD G5
9
Q
What does a doubling of the ACR on a subsequent test indicate?
A
Exceeds laboratory variability and warrants evaluation.
10
Q
What are some common manifestations of CKD?
A
- Increased BP
- Anemia
- Dyslipidemia
- CKD-mineral and bone disorder
- Potassium disorders
- Severe Acidosis
- Decreased fertility and pregnancy complications
11
Q
What is the recommended protein intake for adults with CKD G3-G5?
A
0.8 g/kg body weight/d.
12
Q
What sodium intake is suggested for people with CKD?
A
<2 g of sodium per day.
13
Q
What blood pressure target is suggested for adults with high BP and CKD?
A
SBP <120 mmHg when tolerated.
14
Q
What is the role of Renin-Angiotensin System inhibitors (RASi) in CKD management?
A
Should be administered at the highest approved dose that is tolerated.
15
Q
What are SGLT2 inhibitors recommended for?
A
Patients with type 2 diabetes (T2D), CKD, and an eGFR ≥20 ml/min per 1.73 m².
16
Q
What are the benefits of SGLT2 inhibitors?
A
- Substantially reduce the risk of kidney failure
- Reduce hospitalization for heart failure
- Moderate reduction in cardiovascular death and myocardial infarction
17
Q
What is the definition of hyperkalemia in CKD?
A
Serum potassium levels above 5.0 mmol/l.
18
Q
What is the prevalence of anemia in CKD stage G5?
A
60.7% in those with diabetes and 57.4% in those without diabetes.
19
Q
What is CKD-mineral bone disorder (CKD-MBD)?
A
Changes in bone mineral metabolism and disruptions in calcium and phosphate homeostasis occurring early in CKD.
20
Q
What is hyperuricemia and its relation to CKD?
A
Can result from increased urate production or decreased kidney excretion of uric acid; therapy is suggested for CKD stages G3-G5.
21
Q
What is the preferred treatment for symptomatic hyperuricemia in CKD?
A
Xanthine oxidase inhibitors.
22
Q
Fill in the blank: The suggested protein intake for older adults with stable or slowly progressing CKD is _______.
A
1.0–1.2 g/kg body weight/day.
23
Q
What is the preferred treatment for symptomatic hyperuricemia in people with CKD?
A
Xanthine oxidase inhibitors
Uricosuric agents are less preferred in these cases.
24
Q
What is recommended for acute gout treatment in CKD patients?
A
Low-dose colchicine or intra-articular/oral glucocorticoids
NSAIDs are less preferable.
25
What happens to the risk of atherosclerotic disease as eGFR decreases?
The risk of atherosclerotic disease rises
## Footnote
CVD mortality may exceed kidney failure progression risk in CKD patients.
26
What should be considered when interpreting troponin levels in CKD patients with eGFR <60 ml/min?
Use of more sensitive troponin assays and assay-specific optimal cutoff levels
## Footnote
Caution is advised in diagnosis of acute coronary syndrome.
27
What lipid management strategy is recommended for people with CKD?
Statin based regimens to maximize LDL cholesterol reduction
## Footnote
PCSK-9 inhibitors may also be prescribed for those with indications.
28
What is the recommended lifelong use for secondary prevention of ischemic CVD in patients with known CVD?
Low-dose aspirin (75–100 mg)
## Footnote
This is strongly recommended.
29
What should be monitored in CKD patients regarding medication safety?
eGFR, electrolytes, and therapeutic medication levels
## Footnote
Special attention should be given to narrow therapeutic range drugs.
30
What adjustments are needed for medications in pregnant CKD patients?
Some CKD-specific medications should be continued
## Footnote
Examples include hydroxychloroquine, tacrolimus, and colchicine.
31
What is the significance of the Cockroft-Gault equation?
It is used for dose adjustments in CKD patients
## Footnote
Also, CKD-EPI equations are more accurate in patients with solid tumors.
32
What should be done for children with a confirmed ACR of 30 mg/g?
Refer to specialist kidney care services
## Footnote
This is crucial for timely diagnosis and management.
33
What is the most prevalent symptom reported by CKD populations not on KRT?
Fatigue
## Footnote
Sexual dysfunction is reported as the most severe symptom.
34
What common symptoms should be managed in CKD?
CKD-associated pruritis, emotional distress, sexual dysfunction, sleep disturbances, pain, depression, and restless leg syndrome
## Footnote
Research is needed for some symptoms.
35
What is recommended for patients with CKD regarding malnutrition screening?
Screen twice annually using a validated assessment tool
## Footnote
Especially for those with CKD G4–G5, age >65, or symptoms of malnutrition.
36
What is the role of telehealth technologies in CKD care?
To deliver education and care effectively
## Footnote
Particularly useful during the COVID-19 pandemic.
37
What should be considered when initiating dialysis in adults?
Composite assessment of symptoms, signs, QoL, preferences, level of GFR, and laboratory abnormalities
## Footnote
Planning for preemptive kidney transplantation is also important.
38
What is the recommended first-line therapy for type 2 diabetes in CKD?
Sodium-glucose co-transporter-2 inhibitors (SGLT2i)
## Footnote
SGLT2i lowers blood glucose and enhances kidney outcomes.
39
What is the significance of the 2022 guideline for initiating SGLT2i?
Initiate for patients with T2D and CKD with eGFR >20 ml/min
## Footnote
This is a change from the previous threshold of >30 ml/min.
40
Which drug class is recommended as second-line therapy after lifestyle modifications for T2D and CKD?
GLP-1 receptor agonists
## Footnote
Effective for those not meeting goals with SGLT2 inhibitors and metformin.
41
What benefits does finerenone provide?
Reduces kidney failure, cardiovascular events, and mortality
## Footnote
Hyperkalemia is a common side effect but rarely leads to discontinuation.
42
What is the impact of combining steroidal and non-steroidal MRAs?
May increase adverse effects and is not recommended
## Footnote
Steroidal MRAs are primarily evaluated for heart failure.
43
What is chronic kidney disease (CKD)?
A spectrum of pathophysiologic processes associated with abnormal kidney function and a progressive decline in glomerular filtration rate.
44
What is end-stage renal disease?
A stage of CKD where the accumulation of toxins, fluid, and electrolytes normally excreted by the kidneys leads to death unless removed by renal replacement therapy.
45
What are the two broad sets of mechanisms of damage in CKD?
* Initiating mechanisms specific to the underlying etiology
* Hyperfiltration and hypertrophy of the remaining viable nephrons
46
List some risk factors for chronic kidney disease.
* Small for gestation birth weight
* Childhood obesity
* Hypertension
* Diabetes mellitus
* Autoimmune disease
* Advanced age
* African ancestry
* Family history of kidney disease
* Previous episode of acute kidney injury
* Presence of proteinuria
* Abnormal urinary sediment
* Structural abnormalities of the urinary tract
47
What is the normal glomerular filtration rate (GFR)?
Approximately 120 mL/min per 1.73 m².
48
What is albuminuria?
A marker for nephron injury in response to therapy and a screening marker for systemic micro-vascular disease and endothelial dysfunction.
49
What does the urinary albumin to creatinine ratio (UACR) indicate?
It is a measure pointing to glomerular injury and serves as a marker for detection of primary kidney disease and systemic micro-vascular disease.
50
What are common complications of CKD?
* Anemia
* Easy fatigability
* Decreased appetite with progressive malnutrition
* Abnormalities in mineral-regulating hormones
* Abnormalities in calcium, phosphorus, sodium, potassium, water, and acid-base homeostasis
51
What are the three spheres of dysfunction in uremic syndrome pathophysiology?
* Accumulation of toxins that normally undergo renal excretion
* Loss of other kidney functions
* Progressive systemic inflammation and its vascular and nutritional consequences
52
What are dietary recommendations for sodium and water homeostasis in CKD?
* Dietary salt restriction
* Loop diuretics
* Water restriction
53
What is the treatment for hyperkalemia in CKD?
* Dietary restriction of potassium
* Kaliuretic diuretics
* Avoidance of potassium supplements
* Dose reduction or avoidance of potassium-retaining medications
* Potassium-binding resins
* Dialysis
54
What causes secondary hyperparathyroidism in CKD?
Declining GFR leads to reduced excretion of phosphate, phosphate retention, and decreased levels of ionized calcium.
55
What is the classification of major disorders of bone disease in CKD?
* High bone turnover with increased PTH levels (osteitis fibrosa cystica)
* Low bone turnover with low or normal PTH levels (adynamic bone disease)
56
What are the clinical manifestations of hyperparathyroidism in CKD?
* Bone pain and fragility
* Brown tumors
* Compression syndromes
* Erythropoietin resistance
57
What is calciphylaxis?
A condition heralded by livedo reticularis and advancing to patches of ischemic necrosis, especially on the legs, thighs, abdomen, and breasts.
58
What is the goal of hypertension therapy in CKD?
To prevent the extrarenal complications of high blood pressure.
59
What is the most common hematologic abnormality in CKD?
Normocytic, normochromic anemia due to insufficient production of EPO by the diseased kidneys.
60
What are some treatments for anemia in CKD?
* Recombinant human ESA
* Iron supplementation
* IV iron infusion
* Vitamin B12 and folate
61
What are some neurologic complications of CKD?
* Central nervous system (CNS) abnormalities
* Peripheral neuropathy
* Autonomic neuropathy
* Abnormalities in muscle structure and function
62
What is bruising?
A discoloration of the skin caused by bleeding underneath.
63
What is menorrhagia?
Prolonged or heavy menstrual bleeding.
64
What is desmopressin (DDAVP) used for?
Treatment of bleeding disorders.
65
What is cryoprecipitate?
A blood product used in the treatment of bleeding.
66
What are blood transfusions used for?
To replace lost blood or components in patients.
67
What does ESA therapy refer to?
Erythropoiesis-stimulating agents used to treat anemia.
68
What is the role of optimal dialysis in hemostasis?
To correct prolonged bleeding time.
69
What are neuromuscular abnormalities?
Conditions affecting the muscles and nerves.
70
What is uremic neuromuscular disease?
A condition evident at stage 3 CKD involving muscle and nerve dysfunction.
71
What are early manifestations of neuromuscular abnormalities?
Mild disturbances in memory, concentration, and sleep.
72
What are late-stage manifestations of neuromuscular abnormalities?
Neuromuscular irritability, including hiccups, cramps, and twitching.
73
What are advanced symptoms of neuromuscular abnormalities?
Asterixis, myoclonus, seizures, and coma.
74
When does peripheral neuropathy become clinically evident?
After the patient reaches stage 4 CKD.
75
What is 'Restless Leg Syndrome'?
Ill-defined sensations of discomfort in the legs relieved by movement.
76
What is uremic fetor?
A urine-like odor on the breath due to urea breakdown.
77
What are gastrointestinal and nutritional abnormalities associated with?
Retention of uremic toxins leading to anorexia, nausea, and vomiting.
78
What can be a consequence of low protein and caloric intake in CKD?
Weight loss and protein-energy malnutrition.
79
What promotes protein catabolism in CKD?
Metabolic acidosis and activation of inflammatory cytokines.
80
What endocrine-metabolic disturbances occur in CKD?
Impaired glucose metabolism and elevated plasma insulin levels.
81
What happens to insulin therapy in CKD?
May require progressive reduction in dose due to diminished renal degradation.
82
What is indicated for women with CKD?
Low estrogen levels leading to menstrual abnormalities and infertility.
83
What are common dermatologic abnormalities in CKD?
Pruritus and increased pigmentation.
84
What is nephrogenic fibrosing dermopathy?
A skin condition associated with CKD, characterized by subcutaneous induration.
85
What is the initial approach in evaluating CKD?
History and physical examination, laboratory investigation, imaging studies, kidney biopsy.
86
What aspects of history are important for renal disease evaluation?
* History of hypertension
* History of diabetes
* Abnormal urinalysis
* Pregnancy complications
87
What does a renal ultrasound verify?
The presence of two kidneys and checks for symmetry, size, and obstruction.
88
What are contraindications to renal biopsy?
* Bilaterally small kidneys
* Uncontrolled hypertension
* Active urinary tract infection
89
What is the most important initial diagnostic step in CKD?
Distinguishing newly diagnosed CKD from acute or subacute renal failure.
90
What is the target blood pressure in proteinuric CKD patients?
130/80 mmHg.
91
What are second-line antihypertensive agents for CKD?
* Diltiazem
* Verapamil
92
What are clear indications for initiation of renal replacement therapy?
* Uremic pericarditis
* Encephalopathy
* Intractable muscle cramping
93
What is a 'healthy' start in renal replacement therapy?
Starting dialysis before severe uremic symptoms appear.
94
What is the recommendation for patient education regarding renal replacement therapy?
Begin educational programs no later than stage 4 CKD.
95
What is recommended for blood pressure management in CKD?
Treat with BP-lowering drugs to maintain target BP levels.
96
What dietary advice is given for individuals with CKD?
Receive expert dietary advice tailored to CKD severity.
97
What is recommended for glycemic control in CKD?
Target hemoglobin A1c of ~7.0%.
98
What should be avoided in medication management for CKD?
Nephrotoxic and renally excreted drugs in those with GFR <60.
99
What is the recommendation for sodium intake in CKD?
Lower salt intake to <90 mmol per day.
100
What is insufficient evidence regarding hyperuricemia in CKD?
Use of agents to lower serum uric acid concentrations.
101
What is recommended for treatment of acidosis in CKD?
Oral bicarbonate supplementation if serum bicarbonate concentration <22 mmol/L.
102
What should all people with CKD be considered at risk for?
Increased risk for cardiovascular disease.
103
What should be regularly examined in adults with CKD?
Signs of peripheral arterial disease.
104
What is the recommended management for patients with GFR < 60 undergoing elective investigations involving iodinated radiocontrast media?
Manage according to KDIGO Clinical Practice guideline for AKI, including:
* Avoidance of high osmolar agents
* Use of lowest possible radiocontrast dose
* Withdrawal of potentially nephrotoxic agents before and after the procedure
* Adequate hydration with saline before, during, and after the procedure
* Measurement of GFR 48-96 hrs after the procedure
## Footnote
KDIGO stands for Kidney Disease: Improving Global Outcomes
105
When should gadolinium-based contrast media not be used?
In people with GFR < 15 unless there is no alternative appropriate test
## Footnote
Gadolinium-based contrast agents are associated with nephrogenic systemic fibrosis in patients with severe renal impairment.
106
What type of bowel preparation is recommended against in people with GFR < 60?
Oral phosphate-containing bowel preparation
## Footnote
Phosphate nephropathy can occur in patients with pre-existing renal impairment.
107
What vaccination is recommended annually for all adults with CKD?
Influenza vaccine
## Footnote
Vaccination is crucial to prevent infections in high-risk populations.
108
Who should receive the polyvalent pneumococcal vaccine?
Adults with GFR < 30 and those at high risk of pneumococcal infection
## Footnote
Pneumococcal infections can lead to severe complications in immunocompromised patients.
109
What are the circumstances that warrant referral to specialist kidney care services in CKD patients?
Referral is recommended for:
* CKD and hypertension refractory to treatment with 4 or more antihypertensive agents
* Persistent abnormalities of serum potassium
* Recurrent or extensive nephrolithiasis
* Hereditary kidney disease
* AKI or abrupt sustained fall in GFR
* GFR < 30 ml/min/1.73
* Significant albuminuria > 300 mg/24 hrs
* Progression of CKD
* Urinary red cell casts
## Footnote
Early referral can improve management and outcomes.
110
When should timely referral for planning renal replacement therapy (RRT) be considered?
In people with progressive CKD with a 10-20% or higher risk of kidney failure within 1 year
## Footnote
Validated risk prediction tools should be used for assessment.
111
What conditions may indicate the initiation of dialysis?
Dialysis should be initiated when:
* Symptoms attributable to kidney failure
* Inability to control volume status or blood pressure
* Progressive deterioration in nutritional status refractory to dietary intervention
* Cognitive impairment
## Footnote
These conditions often occur when GFR is between 5 and 10 ml/min/1.73.
112
When should living donor preemptive renal transplantation be considered?
When GFR is < 20 ml/min/1.73 and there is evidence of progressive and irreversible CKD over the preceding 6-12 months
## Footnote
Preemptive transplantation can prevent complications associated with dialysis.
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