CKD

Question 1

Definition of CKD

Answer 1

Either of the following for a minimum of 3m:
- GFR less than 60 on at least two occasions separated by a period of at least 3 months

• Markers of kidney damage (ASHUTE card)

Question 2

Can CKD cause dyslipidaemia

Answer 2

yes

Question 3

Can CKD cause neuropathy

Answer 3

Yes

Question 4

What incidental things should trigger you to do a work up for CKD

Answer 4

Raised creat +/- eGFR less than 60

Persistent Haematuria (>1+ on 2 out of 3 dips)

Protein on urine dip

A:Cr >3

Urine sediment abnormalities e.g. RBCs (may indicate glomerular disease); WBCs (may indicate pyelonephritis or interstitial nephritis); or granular casts and renal tubular epithelial cells.

Question 5

What is Oliguria

Answer 5

urine output less than 0.5 ml/kg/hour

Question 6

What Ix should you do if CKD is suspected and what to do with results

Answer 6

BLOODS:
U&E - if eGFR less than 60 –> rpt in 2 weeks to make sure no AKI. If stable in 2 weeks repeat again in 3m.
CVS screen - hba1c, lipids,

EARLY MORNING URINE
Send for A:Cr
A:Cr Between 3 and 70 — repeat within 3m to confirm

A:Cr 70 or more — a repeat test is not needed.
If the ACR is 70 mg/mmol or more, protein:creatinine ratio (PCR) can be used as an alternative to ACR.

Also dip for haematuria

OTHER:
BMI, bp

Question 7

CKD diagnostic criteria

Answer 7

Make a diagnosis of CKD after initial investigations if either of the following are present for a minimum of 3 months:

1) Markers of kidney damage:
(trouble with A SHUTE)

ACR ≥ 3

S - Structural abnormalities on imaging or histology issues
H - Haematuria (persistent)
U - Urine sediment abnormalities
T - Transplant (hx of renal transplant)
E - Electrolyte and other abnormalities due to tubular disorders.

2) eGFR is less than 60 mL/min/1.73 m2.

Question 8

eGFR CKD classification

Answer 8

1) ≥ 90
2) 60-89
3a) 45-59
3b) 30-44
4) 15-29
5) less than 15

Question 9

If theres a creatinine increase of more than 20% with a normal GFR would this worry you

Answer 9

Yes - could indicate significant renal impairment.

Question 10

A:CR Classification

Answer 10

Low risk - less than 3
Moderate risk - 3-30
High risk >30

Question 11

What is accelerated progression of CKD

Answer 11

To assess the rate of progression, repeat the serum eGFR three times over a minimum of 3 months.

sustained drop in eGFR of 25% or more and a change in CKD category within 12 months;

or

A sustained decrease in eGFR of 15 mL/min/1.73 m2 within 12 months.

Question 12

How frequently would you monitor a patient with CKD 5

Answer 12

A:CR and bloods at least 4x a year

Question 13

In whom should you do an FBC in the context of CKD and what do you do with it

Answer 13

Anyone with CKD stages 3-5.
If anaemic do a work up.
If you think this is renal anaemia then refer to renal.

Question 14

In whom would you check calcium, phosphate, parathyroid hormone and vitamin D in contact of CKD

Answer 14

Anyone with CKD 4 or 5

Question 15

When would you suspect renal artery stenosis

Answer 15

If there’s a 30% reduction in eGFR after starting or increasing dose of RAAS antagonist

Question 16

When to refer to renal

Answer 16

To use 5G you have to pay CAASH

5 Year risk >5% using equation
Genetic cause suspected e.g.PKD

Complications (MEAAN) - see bottom

Accelerated CKD

A:Cr >30 with haematuria or >70 without e.g. diabetes as an explanation

Stenosis of renal artery suspected

HTN - persistent despite 4 drugs

Complications: MEAAN
Mineral and bone disorder suspected
ESRD
Anaemia (renal)
Acidosis - persistent metabolic acidosis.
Nutritional probs/ hyperkalaemia

Question 17

What is the drug of choice for hypertension in a patient with CKD

Answer 17

Depends on A:Cr
If 30 or less go for whatever you’d give if they didnt have CKD

If over 30 then ACEi or ARB first line and titrate to the highest dose they can tolerate

Question 18

What would you do with a patient who has persistent proteinuria but not diabetes

Answer 18

If 30-70 monitor and consider renal advice

If over 70 refer renal and start an ACEi/ARB

Question 19

What would you do with a patient with proteinuria and diabetes

Answer 19

if 3 or more start ACEi or ARB

Question 20

Should patients with CKD be on a statin?

Answer 20

YES - dose depends on if you’re using for primary or secondary prevention and lipid targets are the same.
Can uptitrtte if eGFR>30 but if less than this would want renal advice

Question 21

Should patients with CKD be on an anti platelet?

Answer 21

Yes for secondary prevention.

Question 22

When would you offer dapagliflozin in CKD

Answer 22

Dapagliflozin if:
- Already on ACEi/ ARB and increased to max tolerated dose even if bp in target range (or C/I)
- eGFR between 25-75 at start of tx AND:
T2DM OR A:CR of 22.6 or more

Question 23

When would you offer empagliflozin in CKD

Answer 23

Another add on to optimised standard care so Already on ACEi/ ARB (or C/I)
Can give if:
eGFR 20 to < 45
Or
eGFR 45 or more and either T2DM or A:CR of 22.6 or more.

Question 24

When might finerenone be initiated

Answer 24

Secondary care if a patient with T2DM is already on ACEi/ARB and SGLT2

Question 25

When would you start ACEi or ARB in CKD

Answer 25

If the patient has HTN and an A:Cr of more than 30 If diabetic and A:Cr >3

Question 26

Bp targets for a patient with CKD?

Answer 26

If A:Cr ≥70: target less than 130/80 If A:Cr less than 70 then target is less than 140/90

Question 27

What on a U&E would make you not start an ACEi or ARB

Answer 27

K+>5

Question 28

What might be recommended for persistent hyperkalaemia?

Answer 28

sodium zirconium cyclosilicate (Lokelma) Patiromer

Question 29

When would you stop an ACEi vs recheck bloods

Answer 29

If eGFR drops by 25% or creat drops by 30% look for other causes and if none obvious stop the drug or drop it back to a lower tolerated dose. If it doesnt meet these thresholds then repeat in 1-2 weeks

Question 30

Below what eGFR value might anaemia be related to CKD

Answer 30

60. If eGFR is between 30 and 60 － investigate other causes of anaemia, but － use clinical judgement to decide how extensive this investigation should be, because the anaemia may be caused by CKD. If eGFR is below 30, think about other causes of anaemia but note that anaemia is often caused by CKD.

Question 31

What iron level is too high for anyone with CKD

Answer 31

Over 800.

Question 32

Names of some drugs used for anaemia and in what context

Answer 32

Roxadustat - symptomatic anaemia in adults with stage 3 to 5 CKD and no iron deficiency who are not on dialysis. Vadadustat - if on dialysis

Question 33

What is used to treat secondary hyperparathyroidism in pts on dialysis

Answer 33

Cinacalcet

Question 34

Target hb for pts with CKD on tx for anaemia

Answer 34

100-120

Question 35

What does anaemia in CKD do to the heart

Answer 35

Predisposes to the development of left ventricular hypertrophy which increases mortality

Question 36

What is recommended for hyperphosphataemai and when

Answer 36

Calcium acetate/ sevelamer

Question 37

Indications for bicarb supplement

Answer 37

eGFR less than 30 and serum bicarbonate concentration of less than 20

Question 38

What oedema can be cause by acei and what do you do

Answer 38

Bradykinin mediated angioedema. Steroids and antihistamines wont work icatibant (a bradykinin B2-receptor antagonist) or C1-inhibitor concentrate is the treatment in secondary care. Other causes of bradykinin mediated angioedema: - Hereditary angioedema (C1-inhibitor deficiency or dysfunction). - Acquired C1-inhibitor deficiency (rare; associated with lymphoproliferative or autoimmune disease).