Podcast
Questions and Answers
A patient presents with an estimated glomerular filtration rate (eGFR) that has been declining over the past year, accompanied by urinary albumin excretion of 350 mg/g creatinine. According to the KDIGO CKD classification, which stage of chronic kidney disease (CKD) does this presentation align with?
A patient presents with an estimated glomerular filtration rate (eGFR) that has been declining over the past year, accompanied by urinary albumin excretion of 350 mg/g creatinine. According to the KDIGO CKD classification, which stage of chronic kidney disease (CKD) does this presentation align with?
- G1A1
- G2A2
- G3aA2 (correct)
- G3bA3
In a patient with known chronic kidney disease (CKD) secondary to diabetes, which of the following mechanisms primarily contributes to the progression of glomerular damage?
In a patient with known chronic kidney disease (CKD) secondary to diabetes, which of the following mechanisms primarily contributes to the progression of glomerular damage?
- Decreased mesangial cell proliferation leading to reduced glomerular filtration surface area.
- Reduced efferent arteriolar tone causing decreased intraglomerular pressure and hyperfiltration.
- Non-enzymatic glycosylation of glomerular proteins resulting in basement membrane thickening. (correct)
- Increased synthesis of collagen type IV in the glomerular basement membrane.
A patient with stage 3b chronic kidney disease (CKD) and hypertension is prescribed an ACE inhibitor. Which of the following physiological responses is the primary mechanism by which ACE inhibitors slow the progression of CKD in this patient?
A patient with stage 3b chronic kidney disease (CKD) and hypertension is prescribed an ACE inhibitor. Which of the following physiological responses is the primary mechanism by which ACE inhibitors slow the progression of CKD in this patient?
- Increasing efferent arteriolar resistance in the glomerulus to enhance filtration.
- Reducing systemic blood pressure and decreasing intraglomerular pressure. (correct)
- Enhancing the breakdown of bradykinin to reduce vasodilation.
- Stimulating aldosterone release to promote sodium and water retention.
A patient with chronic kidney disease (CKD) is found to have Kimmelstiel-Wilson nodules on renal biopsy. Which of the following pathological processes is most directly associated with the formation of these nodules?
A patient with chronic kidney disease (CKD) is found to have Kimmelstiel-Wilson nodules on renal biopsy. Which of the following pathological processes is most directly associated with the formation of these nodules?
Which of the following is the most accurate statement regarding the role of the Renin-Angiotensin-Aldosterone System (RAAS) in the pathophysiology of chronic kidney disease (CKD)?
Which of the following is the most accurate statement regarding the role of the Renin-Angiotensin-Aldosterone System (RAAS) in the pathophysiology of chronic kidney disease (CKD)?
In the context of diabetes-induced chronic kidney disease (CKD), what is the primary mechanism by which SGLT2 inhibitors reduce hyperfiltration?
In the context of diabetes-induced chronic kidney disease (CKD), what is the primary mechanism by which SGLT2 inhibitors reduce hyperfiltration?
A patient with known autosomal dominant polycystic kidney disease (ADPKD) presents with a progressive decline in renal function. Which of the following pathophysiological mechanisms is MOST directly responsible for the progression of CKD in this condition?
A patient with known autosomal dominant polycystic kidney disease (ADPKD) presents with a progressive decline in renal function. Which of the following pathophysiological mechanisms is MOST directly responsible for the progression of CKD in this condition?
A 60-year-old male with a long-standing history of hypertension is diagnosed with chronic kidney disease (CKD). Histological analysis reveals glomerulosclerosis. Which of the following mechanisms most directly contributes to the development of this condition?
A 60-year-old male with a long-standing history of hypertension is diagnosed with chronic kidney disease (CKD). Histological analysis reveals glomerulosclerosis. Which of the following mechanisms most directly contributes to the development of this condition?
A patient presents with chronic kidney disease (CKD) and exhibits signs of volume overload. Which of the following findings would be most indicative of volume overload specifically related to CKD rather than other causes of edema?
A patient presents with chronic kidney disease (CKD) and exhibits signs of volume overload. Which of the following findings would be most indicative of volume overload specifically related to CKD rather than other causes of edema?
A patient with long-standing chronic kidney disease (CKD) presents with confusion and altered mental status. Which of the following differential diagnoses should be prioritized in this patient?
A patient with long-standing chronic kidney disease (CKD) presents with confusion and altered mental status. Which of the following differential diagnoses should be prioritized in this patient?
A patient with known CKD and a history of diabetes presents with acute-onset dyspnea and orthopnea. Which of the following findings would MOST strongly suggest that volume overload secondary to CKD is the primary cause of these symptoms rather than a primary cardiac pathology?
A patient with known CKD and a history of diabetes presents with acute-onset dyspnea and orthopnea. Which of the following findings would MOST strongly suggest that volume overload secondary to CKD is the primary cause of these symptoms rather than a primary cardiac pathology?
In evaluating a patient with suspected uremic encephalopathy due to chronic kidney disease (CKD), which of the following diagnostic findings would be MOST indicative of this condition as opposed to other causes of altered mental status?
In evaluating a patient with suspected uremic encephalopathy due to chronic kidney disease (CKD), which of the following diagnostic findings would be MOST indicative of this condition as opposed to other causes of altered mental status?
A patient with a history of diabetes and hypertension is diagnosed with CKD. Initial investigations reveal proteinuria and an eGFR of 40 mL/min/1.73 m². Which of the following would be the MOST appropriate initial diagnostic test to evaluate the cause of their CKD?
A patient with a history of diabetes and hypertension is diagnosed with CKD. Initial investigations reveal proteinuria and an eGFR of 40 mL/min/1.73 m². Which of the following would be the MOST appropriate initial diagnostic test to evaluate the cause of their CKD?
A patient with chronic kidney disease (CKD) has worsening eGFR, hyperkalemia, and metabolic acidosis. Which set of blood tests would be most important to monitor for complications of CKD?
A patient with chronic kidney disease (CKD) has worsening eGFR, hyperkalemia, and metabolic acidosis. Which set of blood tests would be most important to monitor for complications of CKD?
A patient with CKD presents with hyperkalemia (K+ > 6.0 mmol/L). After initial stabilization, which dietary modification should be recommended to manage hyperkalemia?
A patient with CKD presents with hyperkalemia (K+ > 6.0 mmol/L). After initial stabilization, which dietary modification should be recommended to manage hyperkalemia?
After optimizing a patient’s hypertension and glycemic control, what other aggressive management is most indicated?
After optimizing a patient’s hypertension and glycemic control, what other aggressive management is most indicated?
After conservative management is not enough for CKD patients, they may need renal replacement. Which can be remembered by AEIOU?
After conservative management is not enough for CKD patients, they may need renal replacement. Which can be remembered by AEIOU?
Which renal replacement therapy (RRT) option best fits the characteristics of at home either overnight or 4x 20min sessions during the day, and its access is Tenckhoff catheter?
Which renal replacement therapy (RRT) option best fits the characteristics of at home either overnight or 4x 20min sessions during the day, and its access is Tenckhoff catheter?
In managing anaemia associated with CKD, what considerations are most important when deciding if recombinant human erythropoietin (EPO) is indicated?
In managing anaemia associated with CKD, what considerations are most important when deciding if recombinant human erythropoietin (EPO) is indicated?
When assessing a patient with CKD it shows yellow discoloration of the skin, pruritis, asterixis, confusion and pericardial rub, what is the most correct diagnosis?
When assessing a patient with CKD it shows yellow discoloration of the skin, pruritis, asterixis, confusion and pericardial rub, what is the most correct diagnosis?
Which of the following is NOT a symptom of chronic kidney disease (CKD)?
Which of the following is NOT a symptom of chronic kidney disease (CKD)?
Which of the following is NOT a cause of CKD?
Which of the following is NOT a cause of CKD?
Which of the following is the best overall measure of kidney function?
Which of the following is the best overall measure of kidney function?
Which of the following kidney damage are the one or more markers?
Which of the following kidney damage are the one or more markers?
Patients who have CKD may be prescribed ACEi / ARBs. Why is that?
Patients who have CKD may be prescribed ACEi / ARBs. Why is that?
A patient with end-stage renal disease (ESRD) undergoing hemodialysis develops severe, persistent itching (pruritus) that is unresponsive to standard treatments. Which of the following interventions is MOST likely to provide significant relief from the pruritus?
A patient with end-stage renal disease (ESRD) undergoing hemodialysis develops severe, persistent itching (pruritus) that is unresponsive to standard treatments. Which of the following interventions is MOST likely to provide significant relief from the pruritus?
A 45-year-old patient with a history of autosomal dominant polycystic kidney disease (ADPKD) presents with flank pain, hematuria, and fever. Imaging reveals a complex cyst with internal debris. Which of the following is the MOST appropriate next step in management?
A 45-year-old patient with a history of autosomal dominant polycystic kidney disease (ADPKD) presents with flank pain, hematuria, and fever. Imaging reveals a complex cyst with internal debris. Which of the following is the MOST appropriate next step in management?
A 70-year-old patient with a history of hypertension and type 2 diabetes mellitus is diagnosed with stage 3b chronic kidney disease (CKD). What is the MOST appropriate blood pressure target for this patient to slow the progression of CKD?
A 70-year-old patient with a history of hypertension and type 2 diabetes mellitus is diagnosed with stage 3b chronic kidney disease (CKD). What is the MOST appropriate blood pressure target for this patient to slow the progression of CKD?
A patient with chronic kidney disease (CKD) experiences a sudden decline in eGFR after starting a nonsteroidal anti-inflammatory drug (NSAID) for osteoarthritis. What is the primary mechanism by which NSAIDs can cause acute kidney injury in patients with CKD?
A patient with chronic kidney disease (CKD) experiences a sudden decline in eGFR after starting a nonsteroidal anti-inflammatory drug (NSAID) for osteoarthritis. What is the primary mechanism by which NSAIDs can cause acute kidney injury in patients with CKD?
Which ECG findings should be considered for patients with hyperkalaemia change?
Which ECG findings should be considered for patients with hyperkalaemia change?
Which ECG characteristics has small or indiscernible P waves?
Which ECG characteristics has small or indiscernible P waves?
A patient scheduled for a kidney transplant asks about the possible implications of immunosuppressants. What is the doctor's most accurate response? Immunosuppressants:
A patient scheduled for a kidney transplant asks about the possible implications of immunosuppressants. What is the doctor's most accurate response? Immunosuppressants:
A nephrologist is counseling a patient with stage 4 CKD about dietary changes to prevent further kidney damage. Which one of the following suggestions is especially important?
A nephrologist is counseling a patient with stage 4 CKD about dietary changes to prevent further kidney damage. Which one of the following suggestions is especially important?
A patient in the intensive care unit develops acute kidney injury (AKI) with signs of severe volume overload and hyperkalemia. Which one of the following interventions is most appropriate?
A patient in the intensive care unit develops acute kidney injury (AKI) with signs of severe volume overload and hyperkalemia. Which one of the following interventions is most appropriate?
What are the general inspection signs for hands arms?
What are the general inspection signs for hands arms?
A patient with stage 5 chronic kidney disease (CKD) who is initiating hemodialysis is found to have an occult gastrointestinal bleed, resulting in iron deficiency anemia. Despite adequate erythropoietin-stimulating agent (ESA) administration, the patient's hemoglobin remains below target. What is the MOST appropriate next step in managing this patient's anemia?
A patient with stage 5 chronic kidney disease (CKD) who is initiating hemodialysis is found to have an occult gastrointestinal bleed, resulting in iron deficiency anemia. Despite adequate erythropoietin-stimulating agent (ESA) administration, the patient's hemoglobin remains below target. What is the MOST appropriate next step in managing this patient's anemia?
Which one of the following factors should be evaluated when assessing a patient with chronic kidney disease at a primary clinic appointment?
Which one of the following factors should be evaluated when assessing a patient with chronic kidney disease at a primary clinic appointment?
A patient with known chronic kidney disease (CKD) presents with the insidious onset of fatigue, pruritus, and metallic taste in their mouth. Their labs show a significantly elevated BUN and creatinine. Which of the following pathophysiological mechanisms is MOST directly responsible for these symptoms in CKD?
A patient with known chronic kidney disease (CKD) presents with the insidious onset of fatigue, pruritus, and metallic taste in their mouth. Their labs show a significantly elevated BUN and creatinine. Which of the following pathophysiological mechanisms is MOST directly responsible for these symptoms in CKD?
A 55-year-old patient with longstanding poorly controlled hypertension is diagnosed with CKD. Renal biopsy reveals nephrosclerosis. Which of the following cellular processes MOST directly contributes to the development of glomerular damage in hypertensive nephrosclerosis?
A 55-year-old patient with longstanding poorly controlled hypertension is diagnosed with CKD. Renal biopsy reveals nephrosclerosis. Which of the following cellular processes MOST directly contributes to the development of glomerular damage in hypertensive nephrosclerosis?
A patient with chronic kidney disease (CKD) is being evaluated for renal replacement therapy. Which of the following clinical findings would MOST strongly suggest the need for initiating renal replacement therapy, based on the AEIOU mnemonic?
A patient with chronic kidney disease (CKD) is being evaluated for renal replacement therapy. Which of the following clinical findings would MOST strongly suggest the need for initiating renal replacement therapy, based on the AEIOU mnemonic?
A patient with stage 3b CKD and diabetes is started on an ACE inhibitor to manage hypertension and slow CKD progression. After one week, their serum creatinine has increased by 25% from baseline. Which of the following is the MOST appropriate next step in managing this patient?
A patient with stage 3b CKD and diabetes is started on an ACE inhibitor to manage hypertension and slow CKD progression. After one week, their serum creatinine has increased by 25% from baseline. Which of the following is the MOST appropriate next step in managing this patient?
Which patient with CKD is most likely to benefit in terms of slowing disease progression?
Which patient with CKD is most likely to benefit in terms of slowing disease progression?
According to the KDIGO 2023 guidelines, what is the minimum duration for abnormalities of kidney structure or function to be classified as chronic kidney disease (CKD)?
According to the KDIGO 2023 guidelines, what is the minimum duration for abnormalities of kidney structure or function to be classified as chronic kidney disease (CKD)?
Which of the following findings, if present for more than 3 months, would NOT be sufficient to diagnose chronic kidney disease (CKD) according to current guidelines?
Which of the following findings, if present for more than 3 months, would NOT be sufficient to diagnose chronic kidney disease (CKD) according to current guidelines?
A patient's lab results show a urinary albumin-to-creatinine ratio (ACR) of 5 mg/g. According to the KDIGO CKD classification, which albuminuria category does this patient fall into?
A patient's lab results show a urinary albumin-to-creatinine ratio (ACR) of 5 mg/g. According to the KDIGO CKD classification, which albuminuria category does this patient fall into?
According to the KDIGO CKD classification, a patient with a GFR of 50 mL/min/1.73 m² would be classified as which stage of CKD?
According to the KDIGO CKD classification, a patient with a GFR of 50 mL/min/1.73 m² would be classified as which stage of CKD?
A patient has a GFR of 20 mL/min/1.73 m². According to the KDIGO CKD classification, what action regarding nephrology referral is MOST appropriate?
A patient has a GFR of 20 mL/min/1.73 m². According to the KDIGO CKD classification, what action regarding nephrology referral is MOST appropriate?
Which of the following pathophysiological mechanisms is LEAST likely to directly cause glomerular damage leading to CKD?
Which of the following pathophysiological mechanisms is LEAST likely to directly cause glomerular damage leading to CKD?
A patient with diabetes develops persistent glycosuria. Which of the following downstream effects is MOST directly related to the development of diabetic kidney disease?
A patient with diabetes develops persistent glycosuria. Which of the following downstream effects is MOST directly related to the development of diabetic kidney disease?
In the context of hypertension-induced CKD, what is the primary mechanism by which hypertension leads to glomerulosclerosis?
In the context of hypertension-induced CKD, what is the primary mechanism by which hypertension leads to glomerulosclerosis?
What is the underlying mechanism by which Alport's syndrome leads to chronic kidney disease (CKD)?
What is the underlying mechanism by which Alport's syndrome leads to chronic kidney disease (CKD)?
A patient with long-standing uncontrolled hypertension develops CKD. Which of the following mechanisms is MOST directly responsible for the salt and water retention that contributes to volume overload in this patient?
A patient with long-standing uncontrolled hypertension develops CKD. Which of the following mechanisms is MOST directly responsible for the salt and water retention that contributes to volume overload in this patient?
How does persistent activation of the Renin-Angiotensin-Aldosterone System (RAAS) contribute to the progression of CKD?
How does persistent activation of the Renin-Angiotensin-Aldosterone System (RAAS) contribute to the progression of CKD?
What is the MOST direct consequence of the mesangial cells attempting to regenerate in response to hyperglycemia in diabetic kidney disease?
What is the MOST direct consequence of the mesangial cells attempting to regenerate in response to hyperglycemia in diabetic kidney disease?
Why do patients with CKD often experience volume overload?
Why do patients with CKD often experience volume overload?
A patient with CKD reports feeling cold frequently, even in warm environments. Which underlying complication of CKD could explain this symptom?
A patient with CKD reports feeling cold frequently, even in warm environments. Which underlying complication of CKD could explain this symptom?
A patient with CKD reports itchy skin. What is the underlying cause of this symptom?
A patient with CKD reports itchy skin. What is the underlying cause of this symptom?
A patient with CKD develops orthopnea (shortness of breath while lying flat). What is the MOST likely underlying cause of this symptom?
A patient with CKD develops orthopnea (shortness of breath while lying flat). What is the MOST likely underlying cause of this symptom?
What finding upon general inspection would most strongly suggest volume overload secondary to CKD?
What finding upon general inspection would most strongly suggest volume overload secondary to CKD?
In a patient with CKD, what skin finding is MOST suggestive of uremia?
In a patient with CKD, what skin finding is MOST suggestive of uremia?
Which sign on physical examination would MOST strongly suggest a patient with CKD is undergoing hemodialysis?
Which sign on physical examination would MOST strongly suggest a patient with CKD is undergoing hemodialysis?
What is a common finding on abdominal examination that may suggest ADPKD?
What is a common finding on abdominal examination that may suggest ADPKD?
A patient post-kidney transplant is examined. Scars from removal are noted. What associated elevated risk are they at?
A patient post-kidney transplant is examined. Scars from removal are noted. What associated elevated risk are they at?
Which electrolyte imbalance in CKD can cause palpitations?
Which electrolyte imbalance in CKD can cause palpitations?
A patient with known CKD presents with tachypnea and bibasilar crackles on lung auscultation. Which is the MOST likely underlying cause?
A patient with known CKD presents with tachypnea and bibasilar crackles on lung auscultation. Which is the MOST likely underlying cause?
A patient with altered mental status is suspected of having either uremic encephalopathy or hepatic encephalopathy. Which of the following historical factors would MOST favor a diagnosis of uremic encephalopathy?
A patient with altered mental status is suspected of having either uremic encephalopathy or hepatic encephalopathy. Which of the following historical factors would MOST favor a diagnosis of uremic encephalopathy?
Which of the following would be LEAST helpful in differentiating volume overload due to CKD from volume overload due to heart failure?
Which of the following would be LEAST helpful in differentiating volume overload due to CKD from volume overload due to heart failure?
What is the MOST important initial investigation to diagnose CKD?
What is the MOST important initial investigation to diagnose CKD?
What urine dipstick result would be the STRONGEST indication of glomerulonephritis as a cause of CKD?
What urine dipstick result would be the STRONGEST indication of glomerulonephritis as a cause of CKD?
A patient with newly diagnosed CKD has no proteinuria on initial urinalysis. Which of the following tests would be MOST sensitive for detecting early kidney damage?
A patient with newly diagnosed CKD has no proteinuria on initial urinalysis. Which of the following tests would be MOST sensitive for detecting early kidney damage?
What finding is MOST helpful in differentiating between metabolic acidosis caused by CKD and respiratory acidosis?
What finding is MOST helpful in differentiating between metabolic acidosis caused by CKD and respiratory acidosis?
What is the effect of hyperkalemia on an ECG
What is the effect of hyperkalemia on an ECG
A patient with CKD has progressively worsening eGFR and is now at risk of requiring renal replacement therapy. What management is MOST important?
A patient with CKD has progressively worsening eGFR and is now at risk of requiring renal replacement therapy. What management is MOST important?
A patient with diabetic kidney disease and macroalbuminuria has a blood pressure of 145/95 mmHg. What is the MOST appropriate blood pressure target?
A patient with diabetic kidney disease and macroalbuminuria has a blood pressure of 145/95 mmHg. What is the MOST appropriate blood pressure target?
After implementing lifestyle modifications, a patient with CKD still has elevated blood pressure. What is the MOST appropriate next step in management?
After implementing lifestyle modifications, a patient with CKD still has elevated blood pressure. What is the MOST appropriate next step in management?
What is a KEY consideration regarding ACE inhibitors and ARBs in the setting of CKD?
What is a KEY consideration regarding ACE inhibitors and ARBs in the setting of CKD?
When should ACEi/ARB treatment for CKD be reviewed due to serum potassium levels?
When should ACEi/ARB treatment for CKD be reviewed due to serum potassium levels?
A patient with CKD and hyperkalemia is being treated with ACEi/ARB therapy. What is an appropriate strategy to allow continuation of ACEi/ARB?
A patient with CKD and hyperkalemia is being treated with ACEi/ARB therapy. What is an appropriate strategy to allow continuation of ACEi/ARB?
Which of the following is NOT a component of conservative management of CKD?
Which of the following is NOT a component of conservative management of CKD?
A patient with CKD presents with severe acidosis, pulmonary edema unresponsive to diuretics, and hyperkalemia refractory to medical management. According to the AEIOU mnemonic, which indication for renal replacement therapy (RRT) does this patient exhibit?
A patient with CKD presents with severe acidosis, pulmonary edema unresponsive to diuretics, and hyperkalemia refractory to medical management. According to the AEIOU mnemonic, which indication for renal replacement therapy (RRT) does this patient exhibit?
Which criteria would be MOST indicative of the need for renal replacement therapy (RRT) in a patient with CKD?
Which criteria would be MOST indicative of the need for renal replacement therapy (RRT) in a patient with CKD?
What is the MOST likely cause of death in patients with CKD?
What is the MOST likely cause of death in patients with CKD?
What treatment is unlikely to be used to manage Hyperkalaemia?
What treatment is unlikely to be used to manage Hyperkalaemia?
Which of the following is MOST specific feature of Hemodialysis?
Which of the following is MOST specific feature of Hemodialysis?
A patient receiving haemodialysis has high levels of anaemia, and require recombinant human EPO. Which treatment is not required?
A patient receiving haemodialysis has high levels of anaemia, and require recombinant human EPO. Which treatment is not required?
A patient with a history of diabetes and hypertension presents with an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73 m² and an albuminuria of 35 mg/g creatinine. According to the KDIGO CKD classification, what is the correct classification for this patient?
A patient with a history of diabetes and hypertension presents with an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73 m² and an albuminuria of 35 mg/g creatinine. According to the KDIGO CKD classification, what is the correct classification for this patient?
A patient with diabetes is found to have persistent glycosuria. Which of the following mechanisms is MOST directly related to the development of diabetic kidney disease?
A patient with diabetes is found to have persistent glycosuria. Which of the following mechanisms is MOST directly related to the development of diabetic kidney disease?
A patient with long-standing hypertension develops CKD. Which of the following mechanisms is MOST directly responsible for the hypertension leading to glomerulosclerosis?
A patient with long-standing hypertension develops CKD. Which of the following mechanisms is MOST directly responsible for the hypertension leading to glomerulosclerosis?
A patient with CKD reports bone pain and is found to have mineral bone disease secondary to hyperparathyroidism. Which of the following best describes the underlying pathophysiology?
A patient with CKD reports bone pain and is found to have mineral bone disease secondary to hyperparathyroidism. Which of the following best describes the underlying pathophysiology?
A patient with CKD presents with severe pulmonary edema and is oliguric despite diuretic administration. According to the AEIOU mnemonic, which indication for renal replacement therapy (RRT) does this patient exhibit?
A patient with CKD presents with severe pulmonary edema and is oliguric despite diuretic administration. According to the AEIOU mnemonic, which indication for renal replacement therapy (RRT) does this patient exhibit?
Flashcards
Chronic Kidney Disease (CKD)
Chronic Kidney Disease (CKD)
Abnormalities of kidney structure or function present for >3 months impacting health.
Markers of kidney damage in CKD
Markers of kidney damage in CKD
Markers include albuminuria, urinary sediment abnormalities, pathological/imaging abnormalities, or kidney transplant.
Decreased kidney function (GFR)
Decreased kidney function (GFR)
Measures kidney function decline and a hallmark of progressive kidney disease.
Causes of CKD
Causes of CKD
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Glomerular Damage in CKD
Glomerular Damage in CKD
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RAAS Activation in CKD
RAAS Activation in CKD
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Diabetes causes kidney damage via
Diabetes causes kidney damage via
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ADPKD in CKD
ADPKD in CKD
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Alport's Syndrome in CKD
Alport's Syndrome in CKD
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Chronic Pyelonephritis and CKD
Chronic Pyelonephritis and CKD
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Obstructive Uropathy in CKD
Obstructive Uropathy in CKD
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Symptoms of CKD
Symptoms of CKD
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Signs of CKD
Signs of CKD
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Differentials for Oedema and encephalopathy
Differentials for Oedema and encephalopathy
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Common causes for Volume Overload Include
Common causes for Volume Overload Include
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Why investigate for CKD
Why investigate for CKD
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Investigations to diagnose CKD include
Investigations to diagnose CKD include
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Investigations for the cause of CKD Include
Investigations for the cause of CKD Include
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Investigations for complications of CKD include:
Investigations for complications of CKD include:
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Aim to slow decline in eGFR with:
Aim to slow decline in eGFR with:
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Renal Replacement Therapy Includes
Renal Replacement Therapy Includes
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Mnemonic AEIOU highlights main indications for?
Mnemonic AEIOU highlights main indications for?
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KDIGO CKD Classification
KDIGO CKD Classification
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RAAS activation
RAAS activation
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Glycosuria in diabetes
Glycosuria in diabetes
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Glucose effect on glomerular membrane
Glucose effect on glomerular membrane
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Hyaline arteriolosclerosis
Hyaline arteriolosclerosis
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Kimmelstiel-Wilson nodules
Kimmelstiel-Wilson nodules
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Tubuloglomerular feedback in diabetes
Tubuloglomerular feedback in diabetes
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CKD caused by hypertension
CKD caused by hypertension
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Clinical Signs of CKD
Clinical Signs of CKD
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Common Symptoms Grouped by Cause of CKD
Common Symptoms Grouped by Cause of CKD
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Urine analysis in CKD
Urine analysis in CKD
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Urine results
Urine results
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Complications monitoring
Complications monitoring
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Strategies to allow ACEi/ARB use:
Strategies to allow ACEi/ARB use:
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Kidney/Renal Replacement Therapy
Kidney/Renal Replacement Therapy
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A - E - I - O - U
A - E - I - O - U
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Management of CKD
Management of CKD
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Study Notes
- Chronic Kidney Disease (CKD) is covered in this lecture by Dr. Carol Traynor, Consultant Nephrologist and Renal Transplant Physician.
- RCSI develops healthcare leaders who make a difference worldwide.
Definition of Chronic Kidney Disease (CKD)
- CKD is defined as abnormalities of kidney structure or function present for >3 months, with implications for health, according to the KIDIGO Guideline 2023 update.
- Markers of Kidney damage include one or more of the following: Albuminuria (ACR > 3.4mg/mmol), Urinary sediment abnormalities, Pathological (biopsy) or Imaging abnormalities, and Kidney Transplant.
- Decreased kidney function as measured by Glomerular Filtration Rate (GFR) is also indicative of CKD.
- Declining GFR is the hallmark of progressive kidney disease.
KDIGO CKD Classification
- Persistent albuminuria categories (A1, A2, A3) are used to classify CKD along with GFR categories (G1-G5).
- Referral decisions depend on GFR and albuminuria levels, with local nephrology guidelines also influencing decisions.
Causes of CKD
- Diabetes
- Hypertension
- Glomerulonephritis
- Autosomal dominant polycystic kidney disease (ADPKD)
- Alport's syndrome
- Chronic pyelonephritis
- Obstructive uropathy
How Causes Lead to CKD
- All causes result in glomerular damage, reducing glomerular filtration rate and causing eventual scarring, which can lead to glomerulosclerosis and tubular necrosis.
RAAS Activation
- The renin, angiotensin, and aldosterone system responds to reduced glomerular perfusion, which may stem from reduced circulating blood volume or thickened, scarred glomeruli.
- Renal arterioles constrict, worsening renal ischaemia.
- Salt and water retention result, leading to volume overload.
- Sustained activation worsens renal damage.
- Awareness of how ACE inhibitors/ARBs and SGLT2 inhibitors are used in CKD management is important.
Diabetes
- Excess glucose in the blood from type 1 or type 2 diabetes results in glycosuria.
- Glucose interacts with proteins in the glomerular basement membrane, causing it to thicken.
- Hyaline arteriolosclerosis results and causes an increase in glomerular pressure.
- The glomerulus expands and becomes more permeable.
- Mesangial cells try to regenerate, developing Kimmelstiel-Wilson nodules.
- Damaged, diffusely scarred glomeruli result, and the GFR declines.
Hypertension
- Hypertension leads to hypertensive nephropathy and chronic kidney disease (CKD).
Other CKD Causes
- ADPKD involves progressive replacement of the renal parenchyma with cysts.
- Alport's syndrome involves a genetic mutation in collagen type IV, resulting in a thin, poorly functioning glomerular basement membrane, and gradual scarring results in CKD.
- Chronic pyelonephritis causes scarring of the glomeruli due to chronic infection.
- Obstructive uropathy causes chronic backpressure, leading to progressive scarring of the glomeruli.
Common Signs and Symptoms
- Patients may be asymptomatic for a long time or have non-specific symptoms.
- Symptoms include:
- Frothy urine (proteinuria), decreased urine output which indicates kidney damage
- Lower limb swelling due to decreased oncotic pressure from albuminuria
- Orthopnoea/paroxysmal nocturnal dyspnea (PND) caused by volume overload and pulmonary edema.
- Bone pain (+/- fractures) caused by mineral bone disease (secondary to hyperparathyroidism).
- Symptoms of underlying causes such as diabetes, hypertension, ADPKD
- Encephalopathy
- Nausea and Vomiting, Anorexia/ Uremia
- Malaise, Lethargy, Fatigue
- Palpitations caused by Hyperkalaemia
- Pruritus caused by Uraemia
- Disordered Sleep, confusion
- Anaemia
- Signs include:
- Tachypnoea / accessory muscle use (Pulmonary oedema)
- Yellow skin discoloration (Uraemia)
- Cushingoid appearance (Chronic steroid use)
- Capillary glucose testing marks (Diabetes)
- Palmar crease pallor (Anaemia)
- Thin skin from chronic steroid use
- Asterixis (Uraemia)
- AV fistula (Haemodialysis)
- Hypertension (RF and consequence of CKD)
- BCC/SCC scars from removal due to risk of skin cancer on immunosuppressants following transplant
- Conjunctival pallor (Anaemia)
- Neck scars (Previous central lines for haemodialysis)
- Permcath (Tunnelled line for haemodialysis)
- Ascites (Volume overload, peritoneal dialysis)
- Tenckhoff catheter (Peritoneal dialysis)
- Ballotable kidneys (ADPKD)
- Hepatomegaly (Cystic liver in ADPKD)
- Renal angle scars (Nephrectomy)
- Kidney transplant
- Mass in the RIF, LIF
- Hockey stick/Rutherford-Morison scar
- Peripheral oedema (Volume overload or nephrotic syndrome)
- Bibasal crepitations (Volume overload)
- Pericardial rub (Uraemia)
- Rash (Vasculitis)
Summary of Signs Grouped by Cause
- Uraemia may present with yellow discoloration of the skin, pruritis, asterixis, confusion, pericardial rub.
- Anaemia may present with conjunctival pallor, palmar crease pallor.
- Volume overload may present with tachypnoea, bibasal crepitations, peripheral oedema.
- Renal replacement therapy may require neck scars, perm-cath, AV fistula, peritoneal dialysis catheter, and renal transplant.
- Complications of immunosuppression may cause BCC/SCC or scars from removal, Cushingoid appearance.
- Cause of CKD may be indicated by hypertension, glucose testing marks, ballotable kidneys.
Differential Diagnosis
- Volume Overload differentials include congestive cardiac failure, liver disease, pleural effusion, exacerbation of pre-existing chronic lung disease, protein-losing enteropathy, and lymphedema.
- Uraemic Encephalopathy differentials include acute liver failure, hepatic encephalopathy, sepsis (lactic acidosis), hypertensive encephalopathy, metabolic encephalopathy (diabetic ketoacidosis/hyperosmolar coma), hypoglycaemia, fluid and electrolyte disturbances, drug toxicity, and Wernicke-Korsakoff encephalopathy.
Investigations for CKD
- Diagnose CKD through:
- Blood tests for urea & electrolytes and estimated GFR (eGFR).
- Urine dipstick tests for blood, protein, nitrites, and ketones.
- Urine microscopy to check for red blood cells (RBCs), white blood cells (WBCs), casts, and crystals.
- Albumin/creatinine ratio to detect microalbuminuria.
- Renal ultrasound and CT-KUB (imaging), useful if the diagnosis is unclear
- Renal biopsy
- Determine cause of CKD with:
- Fasting glucose and HbA1c (diabetes).
- Urine dipstick for blood/protein (glomerulonephritis), protein (nephrotic syndrome), nitrites/leukocyte esterase (infection), and ketones (diabetes).
- 24-hour ambulatory BP monitor (HTN Dx).
- Investigate complications of CKD via:
- Blood tests for U&E (worsening eGFR, uraemia, hyperkalaemia), bone profile (calcium abnormalities, raised phosphate, low albumin), parathyroid hormone (PTH — raised in response to low Ca2+), full blood count (FBC – anaemia due to reduced EPO production), and arterial blood gas (ABG – metabolic acidosis).
- ECG (hyperkalaemia changes, tall tented T-waves).
- Imaging (CXR for pulmonary oedema).
Management of CKD
- Aim to slow the decline in eGFR through aggressive risk factor management
- Good diabetes control is important.
- Blood pressure should be maintained at <140/90mmHg, or <130/80mmHg if there is proteinuria/diabetes, and ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB) may be needed.
- Smoking cessation and avoiding nephrotoxins are important.
- Annual influenza and pneumococcal vaccines are recommended.
- Manage complications like anaemia (recombinant human EPO, iron transfusion, B12/folate replacement), mineral bone disease, and fluid balance; reduce CVD risk by prescribing aspirin or statins.
- RRT (Renal Replacement Therapy) is split into three categories:
- Kidney Transplant: The best option if possible; involves lifelong triple therapy immunosuppression.
- Hemodialysis: Typically done at home or in-unit, usually 3 days a week, with vascular access via AV fistula or central venous access.
- Peritoneal Dialysis: Generally, this is done at home either overnight or via 4 x 20-minute sessions during the day, using a Tenckhoff catheter for access.
- Indications for RRT:
- Acidosis (pH <7.0 mmol/L)
- Electrolyte imbalance (K+ >7.0 mmol/L or refractory hyperkalaemia with ECG changes)
- Intoxication (poisons like ethylene glycol and lithium)
- Overload (severe pulmonary oedema with oliguria or diuretic resistance)
- Uraemia (encephalopathy or pericarditis)
- Further indications include CKD with eGFR < 10, acute renal failure, and symptomatic uraemia.
Key Points
- CKD involves kidney structure or function abnormalities for >3 months, impacting health (KIDIGO 2023 guidelines).
- CKD is defined as GFR <60 ml/min/1.73m2.
- Diabetes and HTN are the most common causes.
- Symptoms/signs are numerous, group by cause as investigation.
- Investigation includes bloods, urine dipstick/microscopy, and imaging.
- Management includes RF modification and preparing for RRT.
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