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REGUB Medicine: CKD/Nephritic/Nephrotic Syndrome (ii) (Urine crystals…
REGUB Medicine: CKD/Nephritic/Nephrotic Syndrome (ii)
Bone + mineral disorders in CKD
hyperphosphataemia (4/5)
insufficient phosphate filtration
hypocalcaemia
vit D deficiency (kidneys + skin convert vit D to its active form calcitriol via 1alpha hydroxylase) - active vit D needed to absorb Ca from gut
fibroblast GF 23 levels increase progressively from early CKD - physiological adaptation to lower serum phosphate - phosphaturia
however decreases production of calcitriol
secondary hyperparathyroidism
usually patient on dialysis @ this stage
due to hypocalcaemia
high PTH - activates osteoclasts - increased bone resorption - weak bones + fractures
Tx
vit D replacement (1 alfa calcicole 0.5ug)
phosphate control
diet - avoid processed foods
binders: can be Ca-containing (e.g. Ca acetate - risk of vasc calcification) or non Ca-containing (e.g. sevelamer)
adequate dialysis
calcimimetics (e.g. cincacalcet/mimpara) fools parathyroid Rs
Dialysis options
no dialysis (conservative management)
doesn't necessarily reduce survival compared to dialysis
good if patient has poor QOL already (elderly, co-morbidites)
peritoneal dialysis
day time exchanges
night time automated PD
more independent
not for those with abdo operations
should have space @ home to store PD fluid
better for those with HF or vasc access problem
more constant
better for travel + diabetics
risk of peritonitis
Haemodialysis
usually hosp based
home - good for younger
loses residual renal function v quick
only once every 24hrs - lots of fluid to remove in a 3/4 hr session, BP drops, not good for heart to take off this much fluid @ once
better for those who a elderly + not independent
generally gives better adequacy if sufficient dialysis time
patient preference NB
Renal transplant
tx of choice for most with CKD
improves QOL
living or deceased donor
risks vs benefits
age of recipient
effects of long-term immunosuppression
Urinalysis dipstick
cheap + easily preformed
can be used in many situations to aid dx + screening disease/comps
UTI
HTN
abnormal renal function
DKA
diabetic nephropathy
vasculitis
haematuria
renal calculi
infective endocarditis
preeclampsia
routine health check
colour changing pads, compared against a colour scale, 30-120s needed before comparison
parameters
leucocyte esterase
Pyuria (UTI or sterile - atypical infection, TB, STI, stones, tumour)
nitrites - UTI
protein (albumin)
sometimes UTI (transient)
CKD
nephrotic syndrome
won't detect microalbuminuria (special dipstick)
blood
contamination (menstruation/post-catheter)
UTI (transient)
nephritic syndrome
tumour
stones
urobilinogen
liver disease
haemolysis
pH
specific gravity (ability of urine to conc/dilute urine)
ketones (DKA, malnutrition, starvation)
bilirubin
bile duct obstruction
liver disease
glucose (DM)
Urine visual inspection
clear + light yellow = normal
turbid - possibly UTI
red/brown - haemauria, beetroot, rhubarb, drugs (rifampicin), rhabdomyolysis
dark yellow/brown - jaundice
Urine microscopy
RBCs
WBCs
Casts
formed in distal convoluted tubule/collecting duct
clumps of cells compressed into shape of tubule (cylindrical)
seen on urine sediment analysis
some are physiological: e.g. uromodulin (most abundant protein in urine)
increased by low urine flow rate, high salt conc, low pH
hyaline
granular
red cell
white cell (pyelonephritis)
Urine crystals
uric acid (stones)
Ca oxalate (stones, ethylene glycol intoxication)
Ca phosphate (stones)
Chol (marked proteinuria, nephrotic syndrome)
cysteine (stones)
can be due to drugs (e.g. acyclovir) - esp in overdose/dehydration
renal bx indications
unexplained significant proteinuria/nephrotic syndrome (>1g/L)
unexplained AKI/CKD
transplant dysfunction
microhaematuria
renal dysfunction in systemic disease
familial renal disease