Give 3 common causes of CKD
- renovascular disease
- hypertension
- diabetes
- glomerular nephritis (nephrotic and nephritic syndromes)
- Hereditary diseases like APCKD
less common causes in autoimmune disease (SLE), myeloma etc
What are the 3 classic findings in nephrotic syndrome?
- high cholesterol
- gross protein urea (causes frothy urine)
- Low serum albumin
How does nephrotic syndrome usually present?
- pitting odema in legs
- odema in face worse in morning
- any age
- predisposing factor eg diabetes, fhx
- frothy urine
- incidental finding of gross protein urea
Give 3 secondary causes of nephrotic syndrome?
- diabetes
- lupus nephritis
- myeloma
- amyloid
- pre- eclampsia
give 3 primary causes of nephrotic syndrome
- FSGS
- minimal change
- membranous nephropathy
What are the classical findings of nephritic syndrome?
- blood and small amounts of protein in urine
- no swelling
- vague symptoms
How may CKD present?
- vague symptoms like fatigue, malaise, anorexia, weakness
- swelling of face and legs
- breathlessness due to pulmonary odema
- pruritis, lethargy, cramps and headaches due to raised urea
- insomnia
- polyurea
- sexual dysfunction
- predisposing factors often present
- usually picked up incidentally by urine dips
How is CKD investigated?
- urine dip
- 24 hr urine collection/ spot urine collection to look at ACR
- bloods: u&e, alk phos, parathyroid hormone, plasma glucose and HbA1c, serum ablumin, lipid screen (usually high), FBC (normocytic anaemia), anti nuclear antibodies, serum free light chains, c ANCA and p ANCA, anti GMB if no clear cause
- ECG and echo as heart failure is often a differential and LVH often occurs due to fluid overload
- Renal USS if suspect APCKD, obsutruction, haematuria, low GFR
- renal biopsy when indicated
When should a renal biopsy be done in someone with CKD
Progressive disease, nephrotic syndrome, systemic disease, AKI without recovery, unknown cause
When should the GP refer someone with CKD to a nephrologist?
- When reach stage 4
- ACR>70 mg/mmol unless due to DM
- ACR >30 with haematuria
- eGFR decrease by 15% in 12 months or >25% total
- high BP poorly controlled despite >4 antihypertensives at theraputic dose
- known or suspected rare or genetic cause of CKD
Describe stage 1-5 CKD
1= eGFR> 90 2= 60-89 3= 30-59 4= 15-29 5= <15
List 5 complications of CKD
- hypertension
- odema
- hyperkalaemia
- uremia
- coagulopathies
- acidosis
- anaemia of chronic disease
- hypocalcamia with hyperparathyroidism
- rugger jersey spine/mineral bone disease (related to above)
- CVD due to high BP, vascular stiffness, inflammation, oxidative stress, abnormal endothelial function
What treatment is given in CKD to slow disease progression
- ACEi or ARB (not both) and check K+ before and 2 weeks after starting treatment
- Good glyaemic control
- lifestyle advice
- Avoid NSAIDS, nephrotoxic drugs and K+ sparing diuretics (amiloride and spironolactone)
- Adjust doses of renal metabolised/ excreted drugs
What treatments are given for CKD complications?
- odema: furosemide/ bumetanide, restrict sodium and fluid intake
- Anaemia: ferrous sulphate or IV iron then EPO if not work
- Acidosis: sodium bicarb supplements
- high phosphate and K+: reduce in diet (refer to dietician), calcium acetate works as phosphate binder
- hyperparathyoidism/ hypocalcaemia: give adcal D3/ alphacalciferol
- CVD: anti platelets (aspirin) and statin
Describe the management of hyperkalaemia? inc doses
- Do ECG and VBG to confirm
- If K+> 6.5 or ECG changes, give IV calcium gluconate 10mg 10% over 10 mins and actrapid 10 units and 50mls 50% dextrose immediately
- Also give calcium resonium (15-45mg) to bind the Ca2+
- Give 5-10mg salbutamol neb if K+ not coming down
- sodium bicarb and call renal reg if still refractory
- Final option is dialysis
- If k+ 6-6.5 or no ECG changes, give calcium gluconate usually, stop K+ sparing diuretics, give fluids/ hydrate, think about loop diuretics if refractory
Give 2 pre renal, 2 renal and 2 post renal causes of AKI
Pre: hypovolaemia, sepsis, cardiac failure, renal artery occlusion, renal vein thrombosis
Renal: small vessel vasculitis, glomerular disease (anti GBM, lupus), ATN (ischaemia, nephrotoxins, rhabdomylosis) acute interstitial nephritis (drugs, infection)
Post: calculi, retroperitoneal fibrosis, bladder outlet obstuction (tumour)
What are the 3 criteria for AKI?
- Rise in serum creatinine of > 26 umol/L over 48hrs
- 50% or greater increase in creatinine within 7 days
- fall in urine output to less than 0.5 ml/kg/hr for more than 6 hrs
What investigations would you do for suspected AKI?
Urinalysis: dipstick for blood, nitrates, leukocytes, glucose, osmolality
Bloods: FBC, Blood film, U&Es, coag studies (DIC), CK, myoglobinurea (?rhabdomyalysis), autoantibody screen virology
USS when ?obstruction
CXR- pulmonary odema, AXR- renal calculi
Doppler USS to look for stenosis or renal arteries and veins
How is AKI managed?
- monitor fluid and electrolyte balance closely
- treat cause
- pre renal aki: fluid replacment
- withdraw nephrotoxic drugs
- identify and treat complications (hyperalaemia, acidosis, pulmonary odema, bleeding)
- restrict oral K+ and monitor carefully
When should renal replacement therapy be used in AKI? (6)
- Hyperkalaemia (>6.5) refractory to medical management
- pulmonary odema/ fluid overload refractory to medical management
- metabolic acidosis refractory to medical therapy
- uraemia complications (pericarditis or uraemic encephalopathy)
- CKD stage 4/5
- dialysable nephrotoxin
- intrinsic renal disease (vasculitis, GN, SLE) suspected
When does a pt with CKD need specialist renal care? (7)
- GFR < 30 with or without diabetes (stage 4)
- ACR 70 or more unless diabetes
- ACR 30 or less with haematuria
- sustained decrease in GFR or 25% or more
- Hypertension which remains poorly controlled despite 4 drugs at theraputic doses
- known or suspected rare or genetic causes of CKD
- Suspected renal artery stenosis
- outflow obstruction should go to urology
Describe how youd undertake a fluid assessment?
look at tongue, JVP, skin turgor, HR,RR BP, cap refill, pulmonary odema, peripheral odema
Give adv and dis avd of haemodialysis
Disadv: need to go in hospital 4x 3 hrs a week, need access with central line or fistula, diet restrictions
Adv: can sometimes be done at home, other hrs of week they can do as please, can remove fluid at same time,
What are the two types of peritoneal dialysis
APD: nightime bags
CAPD: continuous bags
The more concentrated the bags the more fluid is removed
