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Chronic Kidney Disease (Management (Anaemia: look for cause, correct Fe…
Chronic Kidney Disease
Causes/Risk factors
Diabetes (biggest risk factor)- hyperglycaemia --> formation of advanced glycosylated end products --> mesangial oxidative stress --> matrix expansion and increased vascular permeability --> attracts inflammatory mediators --> collagen production --> glomerular sclerosis
HTN- arterial damage causes ischaemia --> affects vasculature and tubulo-interstitial components of kidney --> loss of nephron mass, atrophy + fibrosis of tubules and interstitium; note: increase RAAS activation --> scarring
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Obesity- is a risk factor for DM, HTN and renal disease
Other
Structural- VUR, PCKD, obstructive causes
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Glomerulopathies- post-strep GN, toxins (e.g. NSAIDs), infection (e.g. HIV, Hep C)
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Other risk factors include: Black/Hispanic, family Hx, male, previous AKI
Definition
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Structural evidence of disease for > 3 months e.g. proteinuria, radiological abnormalities or pathological (i.e. on biopsy)
Investigations
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Assess Severity
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UECs: increased urea, creatinine & K+
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Stages
Stage 3a: GFR 45-60, Stage 3b: GFR 30-45
HTN, hyperlipidaemia, bone disease begins, poor nutrition, weightloss, increased risk of infection, changes in protein metabolism
Stage 4: GFR 15-30
Anaemia, electrolyte abnormalities (arrhythmias), worsening of LVF, bone problems, malabsorption/decreased appetite (Vit B12, folate)
Stage 2: GFR 60-90
Systemic fatigue, weakness, cramps, easy bruising
Stage 5: GFR < 15
N&V, lethargy, uraemia (encephalopathy)
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Management
- Anaemia: look for cause, correct Fe deficiency, EPO (nephrologist)
- Renal osteodystrophy: phosphate binders e.g. calcium carbonate (for high PO4). Vit D & calcium supplementation (if low Ca)
- Hyperkalaemia Mx: resonium
- Fluid overload: fluid restriction, salt restriction, frusemide
- Acidosis Mx: sodium bicarbonate
- Manage HTN: early on ACEi/ARB are renoprotective. When creatinine begins to rise it suggests the drug is nephrotoxic (by decreasing filtration pressure due to post-gromerular vasodilation) --> change to BB which has antirenin action OR CCB (dihydropyridine) OR methyldopa (decreases sympathetic response centrally by replacing NA)
- Encephalopathy: look for peripheral neuropathy
- Manage other complications: N/V, heart disease, pruritis (capsaicin cream), pain (paracetamol, fentanyl), etc.
- Avoid nephrotoxic agents: NSAIDs, ACEi/ARB, diuretics, lithium, contrast
- Manage other risk factors: smoking, DM, cholesterol
- Renal replacement therapy: dialysis (haemo vs peritoneal), transplant
Complications
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Renal osteodystrophy:PO4 excretion is decreased in CKD --> high PO4 increases PTH --> increased Ca (if kidney vit D mechanisms are working) OR decreased Ca (due to low vit D activation due to renal insufficiency and reduced intake)
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Protein malnutrition: malabsorption, decreased appetite, N&V all contribute
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