Ckd Rrt Pckd Notes

Chronic Kidney Disease

Stage GFR ml/min

1 >90 Normal GFR + evidence of renal damage

2 60-89 Slight decrease in GFR + evidence of renal damage

3 30-59 Mod decrease in GFR + evidence of renal damage

4 15-29 Severe decrease in GFR + ii

5 <15 Established renal failure

Symptoms usually don’t occur until stage 4 is reached

ESRF occurs when dialysis or transplant is require to prolong life

Causes

• Diabetes

• Chronic glomerulonephritis

• Hypertension (renovascular damage + glomerular loss)

• Polycystic kidney disease

• Pyelonephritis

Clinical features

(Think of kidney functions and then symptoms of its dysfunction)

• Fatigue

• N+V

• Anorexia

• Pruritis

• Weight loss

• Restless legs

• Bone pain

• Dyspnoea

• Ankle swelling

• Altered urine output

Investigations

• Bloods

  • Normocytic, normochromic anaemia, ESR, U+E (raised urea and creatinine) glucose, raised alk phos, phosphate, low calcium, raised PTH

• Urine

  • MC+S, dipstick, 24hr urinary protein

• Imaging

  • USS – exclude obstruction, size of kidneys

  • CXR – cardiomegaly, pleural effusion, pulmonary oedema.

• Biopsy – if normal size kidneys + ? diagnosis

Management

• Early referral to nephrologist

• Treat reversible causes (e.g obstruction, stop nephrotoxins)

• Treat calcium levels asap (CVS risk)

• Hypertension – ACEi + ARB

• EPO for anaemia

• Hyperlipidaemia – statin

• Oedema – loop diuretics + fluid restriction

• Sodium restricted diet (helps control BP and oedema)

• Moderate protein intake (avoid malnutrition)

• Restless legs (gabapentin)

• Prepare for dialysis/transplant. Counselling and consent

Complications

• Increased cardiovascular risk (14/15 patients die of CVS events before ESRF)

• Anaemia

  • Usually occurs in CKD stage 4

  • Due to decreased EPO production and EPO resistance due to uraemia

  • Treat with EPO injections

• Renal Bone Disease (osteodystrophy)

GFR phosphate calcium PTH release

Inactive vit D Osteoporosis + hyperparathyroidism

Osteomalacia

• Need phosphate binders e.g calcichew (restrict dietary phosphate – milk, cheese, eggs)

• Need vit D analogues e.g alfacalcidol

• Need calcium supplements to decrease bone disease + HPT

NB in CKD prostaglandins maintain blood flow to kidneys – therefore NSAIDS (inhibitors of prostaglandins) can decrease renal function

Polycystic Kidney Disease

Autosomal dominant condition characterize by development of multiple fluid filled renal cysts

PKD1 –chromosome 16

PKD2 – chromosome 14

Clinical features

• Progressive renal impairment

  • Punctuated by episodes of acute loin pain + haematuria

• Commonly associated with a rise in BP

• Cyst infection

• Renal calculi

• PKD1 progresses more quickly than PKD2

• Males with PCKD reach ESRF 5-6 years earlier than females

Extra-renal

• Hepatic cysts

• Berry aneurysm – subarachnoid haemorrhage

• Mitral valve prolapse (pansystolic murmur)

• Diverticular disease

• Pancreatic cysts

Investigations

• Examination

  • Large and irregular kidneys

  • Murmur

  • Hepatomegaly

• USS

  • Definitive diagnosis

Management

• Monitor U+E

• Treat hypertension (decrease CVS risk)

• Treat infections

• Dialysis/transplant for ESRF

• Decrease pain by laparoscoptic nephrectomy

• Consider genetic counseling

Don’t need EPO as usually polycythemic due to increased mass of kidneys

Screening

• Screen for subarachnoid haemorrhage in 1^st degree relatives with MRI angiography offered to children and siblings of patients with established PCKD

Renovascular Disease

Renal artery stenosis

Caused by atherosclerosis in 80%

Clinical features

• Raised BP resistant to treatment

• Worsening renal function after ACEi/ARB

• “Flash”...

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