Ckd

Question 1

What is apckd

Answer 1

• Autosomal dominant (+ new mutations)
• ~ 1:1000 births
• Mutation in either:
• PKD 1 gene ( ~ 85%) mean age 53 (Causes earlier disease on average Established (end stage) renal disease)
• PKD 2 gene
• Cysts grow with age, generally presents in adulthood
• Diagnosed with ultrasound (can’t exclude if < 30 yrs old)
• Genetic testing (not widespread)
• Prognosis depends on rate of increase in kidney size and age

Question 2

Describe the appearance of apckd

Answer 2

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Question 3

Whar are the complications of apckd

Answer 3

• Cysts fluid filled and can cause secondary complications:
– Pain
– Bleeding into cyst
– Infection
– Renal stones (stasis)

• Hypertension very common (before renal function changes)
• Rate of decline in function variable even between families
• Increased incidence of intra-cranial aneurysms
• Increased incidence of heart valve abnormalities

Question 4

Descrbe teh management of apckd

Answer 4

• Treat hypertension block RAAS
• Diet
– Drink plenty of fluid
– Low salt
– Normal but not excessive protein
• Tolvaptan - Blocks ADH - use ift for patients with hyponatraemia. Also a relationship between how cyst grow
• Others (somatostatin analogues)

Question 5

Define ckd

Answer 5

The irreversible and sometimes progressive loss of renal function over a period of months to years
Renal injury causes renal tissue to be replaced by extracellular matrix in response to tissue damage

Question 6

Why is early management important

Answer 6

• In some patients CKD inexorably worsens with progressive loss of renal function
• Associated with substantial cardiovascular morbidity and mortality even with mild CKD

Question 7

Describe ckd stagng

Answer 7

Creatinine decline - go through stages
Most ppl in stage 3a - good prognosis
The ppl in g4+ will end up with esrd if they get that far
Relatively normal kidney unction but a lot of protein - risk of ckd??

Question 8

Describe teh epidemiology of ckd

Answer 8

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Question 9

Describ the life expectancy changes n ckd

Answer 9

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Question 10

Descirb teh appearance of ckd

Answer 10

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Question 11

Wha are the causes of ckd

Answer 11

• Diabetes 
• Hypertension 
• Immunologic  glomerulonephritis 
• Infection – pyelonephritis 
• Genetic – Adult Polycystic Kidney Disease, Alport’s 
• Obstruction and reflux nephropathy (OU) 
• ATN 
• Vascular 
• Systemic diseases
(– e.g. myeloma)
• Cause unknown

Question 12

Descrbe the investigations of ckd

Answer 12

Define degree of renal impairment
• Define cause of renal impairment
• Provide patient with diagnosis and prognosis
• Identify complications of CKD
• Plan long term treatment (delay progression and plan for dialysis
and transplantation)

Question 13

What needs to be measured in ckd

Answer 13

Blood pressure, creatinine, dipstick

Question 14

Describe egfr in ckd

Answer 14

Only accurate in adults
• Correction needed for black patients (not Asians)
• It defines CHRONIC kidney disease and is not useful in acute kidney injury (intercurrent illness or haemodynamic problems)

Question 15

What are the blood tests done in ckd (general

Answer 15

• Urea & Electrolytes • Bone biochemistry • Liver function tests (albumin) • Full blood count • CRP
• +/- iron levels (ferritin, iron, reticulocyte haemoglobin) • +/- PTH
Ferritin, transferrin, reticulocyte

Question 16

Descrbe blood tests to determine the cause of ckd

Answer 16

• If there is clinical suspicion of the following:
• Auto-antibody screen (auto-immune disease)
• Complement levels (auto-immune disease)
• Anti-neutrophil cytoplasmic antibody (vasculitis)
• Serum immunoglobulin screen (myeloma)
• Protein electrophoresis & serum free light chain measurement
(myeloma)

Question 17

What are the other investigations

Answer 17

• Ultrasound scan
– Kidney size
– Evidence of obstruction (hydronephrosis)
• Kidney biopsy
(check kidney size first)
– Cause unknown
– Haematuria
– Proteinuria
Other investigations if specific causes considered:
– CT scan (stones / mass) 
– MRI scan (mass)
– MR angiogram  (renal artery stenosis)

Question 18

Describe the prevention/ delay progression of ckd

Answer 18

• Modifiable risk factors for CKD
– Lifestyle
– Smoking
– Obesity
– Lack of exercise

• Uncontrolled diabetes
• hypertension
• Proteinuria Blockers (ACE-Inhibitors / Angiotensin Receptor) - Ace I can make Kai worse bc of haemodynamic effect of AE. But they reduce proteinuria and reduce risk - so want them to be on aces. But if they have acute chance - want to stop it for a bit, but start it again
• Lipids

Question 19

Describe regulation of water and salt in ckd in terms o treatment

Answer 19

• 80-85% CKD patients are hypertensive - 3 or 4 hypertensive agents, 1 not enough.
– Anti-hypertensives – Diuretics – Fluid restriction

Question 20

Desribe the effect of ckd on water/salt handling my kidney

Answer 20

Reduced GFR:
Lose ability to maximally dilute and concentrate urine (200 – 300 mOsmol/kg – vs – 50 – 1200 mOsmol/kg)

Small glomerular filtrate but same solute load causes osmotic diuresis (reduces maximum concentrating ability and response to ADH)…nocturia

Low volume of filtrate reduces maximum ability to excrete urine therefore maximum urine volume much smaller

Question 21

Describe hyperkalaemia in ckd

Answer 21

• Can occur once eGFR < 20 mls / min
• Less likely when good urine output maintained

May require:
• Stopping ACE-Inhibitor / Angiotensin receptor blocker
• Avoidance of other drugs that can increase K+ (amiloride, spironolactone, trimethoprim)
• Altering diet to avoid foods with high potassium

Question 22

Descrbe acidosis in ckd

Answer 22

May affect:
- muscle https://anidonat.com/2013/12/03/acidosis-and-alkalosis/
- bone - renal function progression
Treat with oral NaHCO 3 tablets

Question 23

Whar are causes of anaemia in ckd

Answer 23

Descreased epo production, absolute iron deficiency - dont clot as well, lose blood, short rbc life span, co -morbidities, Brown marrow suppression by uraemia, ck mineral and bone disorder, medications egi acei, b3 folate deficiency, high hepcidin level - inflammation infection- may contribute to functional iron deficiency nd impaired bm responsiveness to epo

Question 24

What is treating anaemia important

Answer 24

• Improves exercise capacity • Improves cognitive function • Helps regulate left ventricular hypertrophy • Helps slow progression of renal disease • Reduces mortality
• Makes patients feel better

Question 25

Describe the treatment of anaemia in ckd

Answer 25

• Always check iron stores first • If iron low, replace iron first (oral or intravenous) • When iron supplies ok, re-check haemoglobin • If haemoglobin still low, start erythropoietin stimulating agent (ESA / Epo) • Aiming for haemoglobin of 100 g/L – 120 g/L • Cost of Epo: minimum ~ £1000 / annum

Question 26

Describe mineral bone disease

Answer 26

1-a-calcidol have a role. Holding onto phosphate when gfr <60. Early stages of ckd. At iris, body Compensated. Klotho and fibroblast growth factor 23 help to expels phosphate. But klotho recedes in ckd. Path increased can expel phosphate but not good if this is high. Vit d deficient. Secondary hyerparathyroidism - more pth to get everythign pack.

Question 27

Describe the management of ckd-bmd

Answer 27

• Reduce phosphate intake (as much as is practical) • Phosphate binders – Many contain calcium – caution re: how much calcium patient given • 1-α-calcidol • (Vitamin D)

Question 28

Describe altered drug metabolism in ckd

Answer 28

• Lots of drugs require dose alteration in CKD / ESRD due to reduced metabolism & / or elimination • Drug sensitivity can be increased even if elimination unimpaired meaning side effects more likely e.g. statins Statins - give to most patient with kid to help with lipids, but they are more sensitive to side effects

Question 29

Desribe accusation o waste products in ckd

Answer 29

• Contribute to uraemic symptoms • Reduced appetite • Nausea and vomiting • Pruritus…

Question 30

Describe esrd and renal replacement therapy

Answer 30

Definition: Established (End-Stage) Renal Failure • When death is likely without renal replacement therapy • eGFR <15 mls/min Renal Replacement Therapy • required when native renal function declines to a level no longer adequate to support health • usually when eGFR 8-10 ml/min (normal ~ 100 ml/min)

Question 31

Descrbe the symptoms with esrd/dialysis

Answer 31

``` • Tiredness – Overwhelming fatigue – Physically and mentally incapacitated – Feelings of guilt & ineptitude at needing rest • Difficulty sleeping • Difficulty concentrating ``` * Symptoms and signs of volume overload (SoB, oedema) * Nausea & vomiting / reduced appetite * Restless legs / cramps * Pruritus * Sexual dysfunction / reduced fertility * Increased infections (reduced cellular & humeral immunity)

Question 32

What are the options when kidneys fail

Answer 32

* Haemodialysis * Peritoneal dialysis * Which would you choose? * Conservative care * Transplant - best solution for a hance a a more normal life

Question 33

Describe unit based harmodalysis

Answer 33

• 4 hours, 3 times per week • Night-time • Designated slot Advantages – Less responsibility – Days off ``` Disadvantages – Travel time / waiting – ‘tied’ to dialysis times – Big restriction on fluid/food intake ```

Question 34

What are the contraindications an complications of hd

Answer 34

HD contra-indications and complications • Contra-indications – Failed vascular access – Heart failure a relative contraindication – Coagulopathy a relative contraindication • Complications – Lines: infection, thrombosis, venous stenosis – AVF: thrombosis, bleeding, access failure, steal syndrome – CVS instability – Feel chronically unwell – Accumulate morbidity (CVS, Bone etc)

Question 35

Describe bone hd/ nocturnal had

Answer 35

• Allows more dialysis hours • Better large molecule clearance • Patients often feel better • Patients often need fewer medications (BP meds, phosphate binders etc) • Home HD requires someone at home with you

Question 36

Describe peritoneal dialysis

Answer 36

• 2 options • CAPD : 4-5 bags throughout day (30 min exchange) • APD: overnight dialysis • You are responsible for your care ``` • Advantages • Self-sufficient / independence • Generally less fluid/food restrictions • Fairly easy to travel with CAPD • Renal function may be better preserved initially ``` Disadvantages • Frequent daily exchanges or overnight • responsibility

Question 37

What are the contraindications and complications of copd

Answer 37

• Contra-indications – Failure of peritoneal membrane – Adhesions, previous abdo surgery, hernia, stoma – Patient (or carer) unable to connect / disconnect – Obese or large muscle mass (relative CI) ``` • Complications – Peritonitis, exit or tunnel site infections – Ultrafiltration failure – Leaks (scrotal, diaphragmatic) – Development of herniae ```

Question 38

Descrbe kidney transplant

Answer 38

* Reduced mortality and morbidity compared to dialysis * Better quality of life * Peri-operative risk (mortality risk greatest for first 3 months) * Malignancy risk * Infection risk * Risk of diabetes, hypertension from meds

Question 39

Describe transplant medication

Answer 39

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Question 40

What are renal replacement therapy options

Answer 40

• Patients with ESRD have – Reduced life expectancy – Reduced quality of life • Transplant is best for survival and QoL • Nocturnal HD / Extended hours Home HD comes close • Try understand what patients with long-term conditions have to put up with!