Chronic Kidney Disease

Chronic Kidney Disease Definition Abnormal kidney function/structure for more than 3 months Epidemiology Affects 9 to 13% of adults worldwide Risk Factors Aged more than 50 History of AKI Diabetes Childhood kidney disease Diabetes Cardiovascular disease Obesity with metabolic syndrome Gout Singl functioning kidney. Smoking Black or Hispanic ethnicity Male Causes Diabetes Vascular disease E.g. hypertension Glomerulonephritis Polycystic kidney disease Multiple system disease with renal involvement SLE Vasculitis Myeloma Hepatitis B and C HIV Nephrotoxic drugs Aminoglycosides Bisphosphates Calcineurin Lithium PPIs Mesalazine NSAIDs CKD Classification Classified based on eGFR and proteinuria Stages 3 to 5 can be diagnosed on the basis of GFR alone Stages 1 and 3 need additional evidence as: Proteinuria Urine sediment abnormalities Electrolyte abnormalities Histological abnormalities History of kidney transplant Accelerated progression of CKD: Persistent decrease in eGFR of 25% of more and a change of CKD category within 12 months or persistent decrease in eGFR of 15 mL/min/1.73 m^2 within 12 months Clinical features Usually asymptomatic until stages 4 and 5 Usually detected though presence of: Hypertension Haematuria and proteinuria on urine analysis Decreased GFR with increased Cr History Physical Exam General symptoms Uraemic fetor Fatigue Ammonia like smell of breath Nausea Anaemia -> pallor Vomit. Cachexia Cramps Cognitive impairment Insomnia Fluid overload and anaemia ->Tachypnoea Restless legs Hypertension Taste disturbance Volume disturbances Urine output Peripheral oedema Polyurea Pulmonary oedema Oliguria Pleural effusions Nocturia Ascites Fluid overload Volume deletion Dyspnoea and orthopnoea Fundoscopy Sexual dysfunction For patients with diabetes or hypertension Severe uraemia Specific findings based on cases: Hiccups E.g. palpable bilateral of the flanks -> adult PKD Pericarditis May be accompanied by hepatomegaly due to liver cysts Coma Bladder palpation Seizures Obstructive uropathy often accompanied by prostatic enlargement in men Investigations Bedside BP Urinalysis Plasma glucose ECG Lab investigations FBC U&E: elevated Cr, decreased Cr and eGFR and electrolyte abnormalities -> elevated K+ and low bicarbonate Serum albumin: low Serum calcium: low, normal or high Serum phosphate: elevated Serum PTH: rises as GFR falls Serum alkaline phosphate: raised in presence of hyperparathyroidism Hyperlipidaemia is common Autoantibody serology e.g. ANCA, ANA ad complement proteins Biopsy Imaging Plain abdominal radiograph Radio-opaque stones or nephrocalcinosis Renal ultrasound Structural abnormalities such as polycystic kidney disease, hydronephrosis, infiltrative diseases, loss of cortex CT or MRI Define renal masses and cysts Management Lifestyle Exercise Healthy weight loss Smoking cessation Good glycaemic control BP control Immunisations: influenza and pneumococcus Diet: adequate protein intake, restricted Na+ and phosphate intake Assess for cardiovascular disk ACEi or ARBs First line in patients with diabetic renal disease or significant proteinuria Use with caution in renovascular patients, risk of volume depletion or impaired renal perfusion Discontinue nephrotoxic drugs 1 alpha hydroxycholecalciferol If there is secondary hyperparathyroidism Monitoring Low to moderate risk: monitor annually High risk: monitor every 6 months Very high risk: monitor every 3 to 4 months Monitoring requirements: FBC Iron studies -> anaemia Serum calcium Phosphate PTH Management of complications Hyperkalaemia -> insulin, SABA (Albuterol), bicarbonate, diuretics (loop and thiazide), cation exchanger (sodium polystyrene sulfonate) Hyperphosphatemia -> dietary restriction or phosphate binder (e.g. sevelamer hydrochloride) Hypocalcaemia -> calcium and vitamin D Secondary hyperparathyroidism -> cinacalcet (decreases PTH production) If medications fail -> parathyroidectomy Anaemia -> synthetic EPO Secondary HTN -> ACEi, ARBs or potassium sparing diuretics Managing water fluid balance -> diuretics and sodium intake restriction Acidosis -> sodium bicarbonate Albuminuria -> ACEi or ARBs -> unknown mechanism in proteinuria Dyslipidaemia -> statin Platelet dysfunction -> DDAVP=desmopressin -> increases platelet activity Renal replacement therapy Haemodialysis Peritoneal dialysis Types Continuous Automated Transplantation Complications Hypertension Most common Heart disease and stroke Fluid retention Anaemia Reduction in bone mineral density Hyperkalaemia Metabolic acidosis Gout Admission criteria Electrolyte disturbances Severe metabolic acidosis Severe uraemic syndromes Pericarditis, pleuritis, severe encephalopathy (confusion and seizures), persistent GI symptoms Severe hypertension AKI on CKD Severe anaemia Dialysis related emergencies