CKD FOR CKD FOR FINALSFINALS

Dr H. Elcome, FY1Dr H. Elcome, FY1Dr K. Thompson, FY1Dr K. Thompson, FY1

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Long term disease of the kidneys, causing either albuminuria or reduced function (eGFR)

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Case AetiologyHistory and ExaminationInvestigationsManagement

ConservativeMedicalSurgical

Complications

Plan

• Recognising stigmata of CKD• Investigations for CKD• Management plan in CKD• Pros/cons of RRT

Learning objectives

Case

A 58 yr old man presents to his GP with a history of feeling generally unwell and lethargic for six months but has not sought medical attention until now.

He has reduced exercise tolerance and feels nauseous.

What other questions would you like to ask?

Case

On further questioning you find he complains of:

Puritus resistant to PiritonGeneralised aching in his joints and backIncreased thirstA yellowing of the skin

Case

On Examination:

BP 160/95Jaundice with excoriated skinCV/Resp NAD

What tests would you like to order?

Case

Bloods:

Na: 143 (135-145)K: 5.8 (3.5-5.2)Ur: 55 (6-20)Cr: 398 (60-110)

Case

Case

What would your management plan be?

Aetiology• PRE-RENAL

– Atherosclerosis– Heart Failure– HTN

• RENAL– Congenital

• PCKD– Glomerular/Tubular

• SLE/Vasculitides• Amyloidosis• Drug overdoses• Diabetes

• POST-RENAL– Outflow tract obstruction

• BPH

StagingStage eGFR

1 > 90

2 60-89

3a3b

45-5930-44

4 15-29

5 < 15 or on Renal Replacement Therapy

PCKD

• COMMON FPE CASE!•Usually Autosomal, Dominant •(rarer recessive Childhood PCKD)

•Other organs:•Liver•Pancreas•Heart valves•Mitral Regurge.

•Aneurysms (CoW)•SA haemorrhage

History and Examination

• What are the main functions of the kidney?

1. ExcretionFiltration

2. EliminationVia the urine

3. RegulationBP Regulation RAASElectrolyte balanceVitamin D

Calcidiol->CalcitriolErythropoietin

AnaemiaPallor, SOBOE, Malaise and lethargy

HypertensionSigns of fluid overloading

ExcretionPruritus, jaundice

Electrolyte imbalancePotassiumSodium

Headaches, nausea

# due to osteomalacia

Urinary symptoms

Ask about immunosuppressants

History and Examination

Don’t forget...

• In the OSCE, do not forget to look and feel for

1. A/V Fistulae

2. Renal Transplant scar/organ

Investigations

• Bedside– ECG (CV disease)– Urine dip

• Bloods– U&E’s and eGFR– FBC– ESR (Long term inflammation)– Calcium (down)– Phosphate (up)– Urate (up)

• Imaging– USS– CT KUB– X-ray (Chest, abdo)

• Biopsy

Investigations- eGFR

• 1. Age• 2. Sex• 3. Race• 4. Serum Creatinine

Management...Conservative

Reduce dietary sodiumReduce dietary potassium

Management...MedicalEPOAntihypertensives (ACEI, diuretic, CCB)Calcium supplements (PO4 binders)Vitamin D

RRT-Haemodialysis-Peritoneal dialysis-Haemofiltration-Transplantation

Dialysis

HaemodialysisSemi-permeable membraneTime consumingTravel to hospitalRequires AV fistulae

Peritoneal DialysisPermanent catheter3L of fluid; uncomfortableHigher infection risk (SBP)

Transplant

Complications

• Anaemia • Renal osteodystrophy• Myopathy• Neuropathy• CVD• Infection (immunocompromise)

Questions?