Chronic Kidney DiseaseBy Nicholas Ashley

Key Aims

• Causes of CKD• What to ask in a history to get the diagnosis• How to treat CKD and its complications

Definition• Defined by the presence of kidney damage or decreased

kidney function for three or more months, irrespective of the cause

Causes of CKD• HYPERTENSION• DIABETES• PCKD

Staging

•Stage 1•Stage 2•Stage 3•Stage 4•Stage 5

Kidney Damage with normal/increase eGFR>90

Kidney Damage with mildly reduced eGFR60-89

Moderately reduced eGFR30-59

Severely reduced eGFR15-29

Kidney Failure<15

KIDNEY DAMAGE Persistent Proteinuria/MicroalbuminuriaPersistent HaematuriaChanges on Renal Imaging (Structural Abnormalities)

Detecting early CKD• Spot Urine Albumin Creatinine Ratio >30mg/g

Presentation of CKD

• Urea: Anorexia, Fatigue, Gout, Pruritis, Confusion, N/V,

Restless leg, Chest pain (pericarditis)

• Fluid: Oedema, Weight gain

• Acid: SOB

• Potassium: Palpitations, Syncope

• Vitamin D: Bony pains, Fractures

• EPO: Fatigue, SOB, Pallor

• B2 microglob: Peripheral neuropathy

AnorexiaFatiguePruritisOedemaPainsNumb feetN/V

Investigations

Bloods: FBC U+E eGFR Bone Urate PTH

Urine: DipstickMC+SACRUrinalysis

Imaging: USS

X-ray KUB

2nd Line Investigations

CT Abdomen

Angiography

Renal Biopsy

Management• CONSERVATIVE

Education (leaftlet and BKPA)Renal diet - Low fluid, sodium, potassium and phosphateAvoid renotoxic drugs (but keep ACEi)Cardiovascular Risk Factor addressing

• MEDICALSee Next Slide

• ESRFHaemodialysisContinuous Ambulatory Peritoneal DialysisTransplant

Remember to include any treatment for the underlying cause if there is one

EPO

Low CaHigh PO4

Bone Health

Vit D Urea/Pruritis

Fluid

DON’T FORGET CARDIOVASCULAR RISK FACTORS

Specific Treatments to Rote Learn

• CARDIOVASCULAR RISK +++ Statins, ACEi, Advice• ANAEMIA EPO• BP CONTROL ACEi (not in RAS)• OSTEOPOROSIS Bisphosphonates• VITAMIN D alfacalcidol/Calcitriol• HYPOCA++ Ca++ Supplements• HYPERPO4- Calcium Carbonate• OEDEMA Diuretics, Fluid/Na restrict• PRURITIS Cholestyramine• RESTLESS LEG Clonazepam

Note these factors together lead to the parathyroid response responsible for renal bone disease

Renal Replacement TherapyCAPD“Peritoneum is used as a semi-permeable membrane”

Instill 3L isotonic fluid 4x/day and allow 30mins for exchange

NB: Infrequently add glucose to dialysate to remove water

Haemodialysis

NB: Uses serial weights to measure water removal

PRO’s COMPLICATIONSCheaper SBPMore Convenient Psychosocial issuesEasy to teach Hernia

Infection

PRO’s COMPLICATIONSLess frequent A-V fistula neededNot DIY Transport to hospitalMeet other CKD - support

Dysequilibrium Syndrome

Learn about complications (biopsychosocial) of renal transplant and immunosuppression

Implications for Junior Doctors:

Not Many! (It is largely dealt with on an O/P basis as it is CHRONIC)

BUT Keep in mind CRF when considering Contrast imagingUsing renotoxic drugsPrescribing medicine dosesNever go near an AV fistula (BP, cannula)

Summary• Lots of complicated information• Learn the small print at home• For this session learn the key points

Causes of CKDWhat to ask in a history to get the diagnosis (7 key Sx)How to treat CKD and its complications

Quick Recap Quiz• 3 causes of CKD• The three markers of KIDNEY DAMAGE in staging disease• 7 key symptoms in history• 2 conservative and 3 medical treatments• The 3 renal replacement therapies

Any Questions?

Case Scenario• 58 year old man presents to his GP after his wife made him attend. He has been feeling generally

unwell and lethargic for 6 months but has not sought medical attention until now. On further questioning he also reports that he has reduced exercise tolerance and feels nauseous. He also complains of itching which is resistant to piriton. He also complains of some generalised pains in his joints and back which is worse at night. He has also been more thirsty than normal. He has no significant medical history and is on no medication and has no known allergies. No remarkable family history is noted. On examination his blood pressure is 160/95. His skin is slightly yellow and his has excoriations from scratching. His Cardiovascular, respiratory and abdominal examinations are unremarkable. The GP orders some blood tests and then later that day refers him to the medical registrar on call when he finds that the patients renal function is deranged with Na 143, K 5.8, Urea 55 and creatinine 398.

• What are your main differential diagnoses for this man? i.e CKD and causes (make sure these include all important differentials that must be ruled out)

• How would you investigate him?• What would your management plan be for him?• What are the various stages of CKD?• What are the complications of CKD?• What types of renal replacement therapy are available?