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CKD FOR FINALS Dr H. Elcome, FY1 Dr K. Thompson, FY1 “ Long term disease of the kidneys, causing either albuminuria or reduced function (eGFR) ” Plan Case Aetiology History and Examination Investigations Management Conservative Medical Surgical Complications Learning objectives • • • • Recognising stigmata of CKD Investigations for CKD Management plan in CKD Pros/cons of RRT 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 Piriton Generalised aching in his joints and back Increased thirst A yellowing of the skin Case On Examination: BP 160/95 Jaundice with excoriated skin CV/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 Staging Stage eGFR 1 > 90 2 60-89 3a 3b 45-59 30-44 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. Excretion Filtration 2. Elimination Via the urine 3. Regulation BP Regulation RAAS Electrolyte balance Vitamin D Calcidiol->Calcitriol Erythropoietin History and Examination Anaemia Pallor, SOBOE, Malaise and lethargy Hypertension Signs of fluid overloading Excretion Pruritus, jaundice Electrolyte imbalance Potassium Sodium Headaches, nausea # due to osteomalacia Urinary symptoms Ask about immunosuppressants 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 sodium Reduce dietary potassium Management...Medical EPO Antihypertensives (ACEI, diuretic, CCB) Calcium supplements (PO4 binders) Vitamin D RRT -Haemodialysis -Peritoneal dialysis -Haemofiltration -Transplantation Dialysis Haemodialysis Semi-permeable membrane Time consuming Travel to hospital Requires AV fistulae Peritoneal Dialysis Permanent catheter 3L of fluid; uncomfortable Higher infection risk (SBP) Transplant Complications • • • • • • Anaemia Renal osteodystrophy Myopathy Neuropathy CVD Infection (immunocompromise) Questions?