Chronic Kidney Disease

Front 1

What is CKD? CRD?

Back 1

Chronic Kidney Disease

Chronic Renal Disease

the same meaning

Front 2

What are the risk factors of CKD?

Back 2

- Women > men

- Age>65

- ethnicity (Afro-Caribbean, South Asian)

- High blood pressure

- High salt intake

- Diabetes

- Heart disease (heart failure or heart attack)

- Obesity (BMI>30) with lack of exercise

- Smoking

- High alcohol intake

- High cholesterol/fat

Front 3

what are the typical symptoms of CKD?

Back 3

 development of a high blood pressure

 changes in urinary frequency e.g. at night

 changes in the appearance of urine e.g. appearance of protein/blood

 development of leg/ankle oedema (possible pulmonary oedema)

 tiredness/lack of energy/loss of appetite/difficulty in sleeping

 weight loss; pale appearance due to anaemia

 muscle cramps

 headaches/lack of concentration

 shortness of breath/anaemia (Hb<10.5 g/dL) persistent itching

 nausea and vomiting/bad breath and a metallic taste in the mouth

Front 4

what are the stages of CKD?

Back 4

1: kidney damage with normal or raised eGFR

2: Kidney damage with mild decreased eGFR

3A: Moderate decreased eGFR

3B: Moderate decreased eGFR

4: Severe decreased eGFR

5: Kidney failure

Front 5

what is the GFR level with each stage?

unit ml/min/1.73m2

Back 5

1: more of equal to 90

2: 60-89

3A: 45-59

3B: 30-44

4: 15-29

5: less than 15 or dialysis

Front 6

Explain the early stage of CKD

Back 6

Amount of kidney damage is small

stage 1 or 2

slightly diminished function but no obvious symptoms; blood/urine tests can benormal.

changes in blood flow to parts of the kidney caused by local damage or blockages(kidney stones) could affect renal function.

Front 7

Explain the middle stage of CKD

Back 7

usually discovered following blood/urine test, kidney function tests that indicate abnormal levels of waste products in the blood.

Stage 3

feeling generally unwell and increase in urine frequency.

blood pressure can rise, which further increases the risk of kidney damage as well asheart disease, heart attack and stroke.

anaemia may develop as the erythropoetic function of the kidney decreases, causingweakness, fatigue and a shortness of breath.

Front 8

Explain the later stage of CKD

Back 8

Stage 4

high blood pressure is characteristic.

increased frequency of urination.

increased tiredness/reduced appetite.

Front 9

Explain the end stage of CKD

ESKD= End stage kidney disease

Back 9

Stage 5

 At this late stage, the function of the kidneys is reduced to ~10-15% of capacity, thusthey are unable to adequately filter waste products from the plasma, remove excesswater from the body and maintain the correct chemical balance of the blood.

 It is at this point that commencing dialysis or having a kidney transplant isconsidered

Front 10

What is AKI? what is the difference with CKD?

Back 10

AKI = acute kidney injury

AKI develops rapidly over a few hours or days and it is most common in critically ill people (or elderly)

Although the symptoms of AKI appears to be similar to CKD, CKD has the reduction in kidney function that must be present over 3 months

AKI can be reversible with the intensive treatment but CKD especially later stages are irreversible

Front 11

what are the less common causes of CKD?

Back 11

 Chronic glomerulonephritis (kidney inflammation)

 Pyelonephritis (kidney infection)

 Polycystic kidney disease

 Failure of normal kidney development

 Renal artery stenosis

 Systemic lupus erythematosus (autoimmune attack of the kidney)

 Long-term drug use (NSAIDs, aspirin, ibuprofen)

 Kidney stones

 Acute kidney injury (AKI)

 Prostate disease, bladder tumours (obstruction of urine flow)

Front 12

what is creatinine?

Back 12

creatinine is a normal waste molecule generated from metabolism.

Creatinine is transported through the bloodstream to the kidneys, where most of it is filtered out and disposed of it in the urine

Front 13

Explain the creatinine blood test

what is the normal levels of blood creatinine?

What is the severe level?

Back 13

Higher blood levels of creatinine would indicate a lower GFR when the kidney is less able to excrete waste products.

Normal:

0.6-1.2 mg/dL for men

0.5-1.1 mg/dL for women

Severe: >10.0 mg/dL, need for dialysis

Front 14

The creatinine clearance is also useful marker of kidney function.

What is it?

What is the normal value?

Back 14

Creatinine clearance is amount passed in the urine in 24 hours

normal: 500-2000 mg/24 hours

Front 15

what is urea?

Back 15

urea is a waste product formed from the breakdown of proteins that is normally excreted in the urine

Front 16

what is BUN level test?

what is the normal value of BUN?

Back 16

BUN= Blood Urea Nitrogen

Urea levels are usually expressed as BUN relative to blood creatinine:

BUN-to-creatinine ratio

Normal values:

BUN level = 6-20mg/L

BUN-to-creatinine ratio = 10-20

ratio higher than 20 considered as kidney injury, disease

Front 17

what may the results of BUN-to-creatinine ratio test suggest?

Back 17

The high results (the ratio higher than 20) may be when blood flow to the kidney is low; such as severe dehydration or heart failure

Front 18

what is albumin? what is the role?

Back 18

Albumin is a major protein in the human body (synthesized by the liver), comprising ~55-60% of total human plasma protein.

Many hormones, drugs, and other molecules are carriedin the bloodstream bound to albumin, from which they must be released to exert biologicalactivity

Front 19

what is the normal serum albumin?

Back 19

around 3.5 g/dL

Front 20

what is micro-albuminuria?

what is macro-albuminuria?

Back 20

Microalbuminuria is when theamount of albumin that leaks into the urine is between 30 and 300 mg per 24 hours.

When itis >300 mg per day, it is referred to as macroalbuminuria indicative of serious nephropathy.

Front 21

What is ACR?

what is the normal and abnormal levels?

Back 21

The urine albumin to creatinine ratio (ACR) [mg/gm per 24 hours]

Normal: <30 mg/g for the albumin to creatinine ratio

avalue> 30 mg/g may be a sign of early kidney disease.

Front 22

what is hyperkalaemia?

How does it relate to CKD?

Back 22

Hyperkalaemia: accumulation of K+ in the blood

It can produce range of symptoms including malaise and cardiac arrhythmia

Hyperkalaemia can develop in advanced CKD when GFR falls at point where the kidneys have a significantly decreased ability to excrete K+

Front 23

What is hyoerphosphatemia?

How does it relate to CKD?

Back 23

Hyperphosphatemia can occur due to reduced urinary phosphate excretion when GFR is decreased.

Hyperphosphatemia increases cardiovascular risk

Front 24

What is Hypocalcaemia?

How does it relate to CKD?

Back 24

Hypocalcaemia can occur due to

1,25 dihydroxyvitamin D3 (calcitriol) deficiency.

Calcitriol is the active metabolite of vitamin D normally synthesized in the kidneys under the control of parathyroid hormone (PTH).

Thisconversion would be compromised when kidney function is significantly impaired

Front 25

How does the body get Vitamin D?

Back 25

[synthesized in the skin or ingested in food]

Front 26

what is metabolic acidosis?

Back 26

Metabolic acidosis can develop due to accumulation of sulphates, phosphates, and uric acidin the blood - also due to decreased production of ammonia from proximal tubule cells.

Thiscan alter enzyme activity and also increase excitability of cardiac and neuronal membranes.Oral sodium bicarbonate supplements may be used in the management of metabolic acidosis

Front 27

How does iron deficiency anaemia relate to kidney damage?

Back 27

Iron deficiency anaemia: - mainly caused by reduction in renal erythropoietin synthesis.

Front 28

what is urine sediment abnormalities?

Back 28

CKD may also be associated with abnormal sedimentspresent in the urine. Material including red cells, cellular debris (tubular epithelial cells),crystals, fat and filtered proteins can be present (proteinurea). Histological examination of thesediments can provide useful information on the possible origins of the pathology. Urinedipsticks that can detect red or white blood cells or bacteria are also available.

Front 29

how is artherosclerosis related to kidney damage?

Back 29

Patients with CKD are more prone to develop atherosclerosis andcardiovascular disease than the general population.

Front 30

What are the imaging test available to detect kidney damages?

what are they useful at?

Back 30

- Renal ultrasonography: usuful for kidney abnormality, size, obstructions (stones), cysts, tumors

- Retrograde ureteroscopy: by inserting a cytoscope into the uretha and bladder. useful for renal stones

- CT scanning: by computer based X-ray. better define renal stones, cysts, tumors or renal trauma

- MRI: by powerful magnet and radiowaves. Useful in patients who cannot receive IV contrast agent.

- Xray: Renal opaque kidney stone can be detected

- Renal radionuclide scanning: by using redioactive 99m-TC, useful to comfirm renal blood flow

Front 31

what are main targets of treating CKD and why?

Back 31

The aim of CKD is to decrease or arrest the progression to stage 5.

- control blood pressure

- treatment of hyperlipidaemia with statins

- treatment of original underlying kidney disease

The most common cause of death in people with CKD is cardiovascular disease such as stroke and cardiac disease rather than renal failure.

Front 32

what are the first choice of antihypertensive drug treatments for patients with CKD?

Back 32

- ACE Is (angiotensin converting enzyme inhibitors) ; Enalapril, coptopril, lisinopril

- ARBs (Angiotensin 2 receptor antagonists);

valsartan, losartan, olmesartan

Front 33

what do you need to monitor during the treatment with use of ACEIs and ARBs?

Back 33

Serum K+ needs to be closely monitored since both can cause hyperkalaemia

Front 34

what treatment can we use to improve the life quality of CKD?

what do you need to monitor?

Back 34

treatment with IV iron and ESA.

ESA(erythropoetic stimulating agent)

Erythropoetin to normalise Hb can reduce symptoms such as fatigue.

Close monitor of Hb and serum ferritin (iron binding protein) is needed

Front 35

what treatment can we use to control the serum phosphate levels in CKD patients?

Back 35

Phosphate binders such as lanthanum carbonate or sevelamer carbonate that bind phosphate in the GI tract.

expensive

Front 36

what is RRT?

when do you need such therapy?

what are the disadvantages of RRT?

Back 36

Renal Replacement Therapy

when CKD reaches stage 5.

types are;

- haemodialysis

- peritoneal dialysis

- renal transplant

RRT can dramatically improve patient's symptoms and prolong life, but the life quality can be affected/

Transplantation increases patient survival but complications arising from the surgery can sometimes cause early mortality

Front 37

what is Dialysis?

what are the types of dialysis available?

Back 37

透析

Haemodialysis

Peritoneal dialysis;

APD (automated peritoneal dialysis ) and

CAPD (continuous ambulatory peritoneal dialysis)

Front 38

what is haemodialysis?

Back 38

It is an established method whereby waste products (such as urea and creatinine) and free water, which build up in the blood can be removed in the absence of adequate kidney function.

Front 39

where is harmodialysis carried? how often?

what is the method?

Back 39

The treatment is carried out in hospital, up to 3 times/week

Method:

1. I/V catheter is introduced in one of the large veins in the neck or groin

1a. Alternatively, arteriovenous fistula is created linking an artery and vein at the wrist or inner elbow.

2. two needles are placed in the fistula in different places, then connected to the artificial kidney machine.

3. Blood flow out from the fistula to the machine, and returns back to the fistula via other tube and needle/

4. patient sits/ lies down during treatment, which can usually take up to 3-4 hours to complete

Front 40

what is groin?

Back 40

脚の付け根、股間

Front 41

what is fistula?

Back 41

a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body.

Front 42

In order to carry out haemodialysis, what additional treatment required?

Back 42

Haemodialysis requires anticoagulation or antithrombotic treatment to prevent clotting of the external blood circuit.

This can be achieved with systemic anticoagulation therapy or in patients with bleeding risk, regional trisodium citrate anticoagulaton or heparin-grafted dialyser membrane can be used.

Front 43

Explain the mechanism and principle of haemodialysis?

Back 43

The basic principle of haemodialysis is using a machine that pumps the patient’s blood outthrough a dialyser, continuously fed with a saline dialysate solution, ‘cleans’ it, and thenpumps it back into the patient’s circulation.

The ultrapure water used in haemodialysis has tobe carefully purified and filtered before use.

The dialyser itself essentially consists of twocompartments (blood and dialysate) separated by a specialised semi-permeable membrane(cellulose or polymer) with variable pore-size; a pressure gradient is then established to drivefluid from the blood from one compartment to another through the membrane pores.

Moderndialysers have an ‘autoclean’ facility which allows regeneration and disinfection of thedialyser membrane and compartments to allow for multiple-use by the same patient.

Front 44

what are the dietary advice while on haemodialysis?

Back 44

- reduce potassium intake

- reduce phosphate intake

- reduce salt

- restriction of fluid intake depending on the patient's kidney function

Front 45

what are the high in potassium food?

Back 45

green vegetables such as spinach, parsley

Garlic

Seaweed

dry fruits

Front 46

what are the high in phosphate food ?

Back 46

protein rich food such as diary products, fish, meat, eggs

food additive as preservatives

Front 47

what is home haemodialysis?

what are the adv and dis adv?

Back 47

For patients that find it difficult to travel to a dialysis centre three times aweek

(intensive home haemodialysis[IHD]). Short intensive sessions of 1.5-2 hours may be given 5-7 days a week depending onthe patient.

Occasionally, nocturnal home dialysis can be offered, 6-10 hours/night while thepatient is asleep, 3-6 nights a week.

IHD is associated with improved survival and a greaterquality of life, compared to the standard hospital haemodialysis and peritoneal dialysis. Italso has reduced costs compared with in-centre conventional haemodialysis, and puts less ofa burden on the facility. However, such treatments may not be available in all areas.

Front 48

what is peritoneal dialysis?

Back 48

Peritoneal dialysis (PD) is an alternative treatment for patients with severe CKD.

The processuses the patient's peritoneal ‘barrier membrane’ [lining the walls of the abdominal cavity andenclosing the digestive organs in the abdomen] across which excess body fluids anddissolved waste substances are exchanged fromthe blood into the peritoneal dialysis solution.

The fluid is introduced through a permanentindwelling catheter inserted into the abdominal cavity and drained out either after every nightwhile the patient is asleep (8-10 hours) or viaregular exchanges throughout the day (4-6 hours).

Front 49

what is the adv and dis adv of peritoneal dialysis?

Back 49

PD has comparable risks to haemodialysis but is cheaper to run, and avoids regular visits to a medical facility. The main complication of PD is possible infection due to the permanent abdominal catheter. In some patients, the peritoneum does not filter 9 waste products into the dialysis solution efficiently to be of use. Also, excessive amounts of dextrose can be absorbed from the dialysis solution overnight; a mini-cycler machine can be used to empty and fill the abdomen 3-5 three to five times during the night while the patient sleeps.