Ckd causes Prerenal



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tarix16.02.2017
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#8596
CKD
Causes

  • Prerenal

  • Hypovolaemia = hemorrhage, D, diuretics, pancreatitis, DKA, sepsis, burns

  • Decreased CO = MI, massive PE, CHF

  • Severe LF (hepatorenal syndrome)

  • Renal artery obstruction = stenosis, thrombosis, embolisation

  • Renal

  • Loses ability to conc urine and conserve Na+

  • Causes:

  • Acute tubular necrosis = ischaemia, exogenous nephrotoxins (gentamicin, IV contrast), endogenous nephrotoxins (Bence Jones protein, uric acid, Mb)

  • Acute tubulointerstitial nephritis = drug hypersensitivity, infections

  • Large renal vessels = renal artery/vein thrombosis

  • Small renal vessels = vasculitis, malignant HT, haemolytic uraemic syndrome, TTP

  • Acute glomerulonephritis

  • Congenital = PCKD

  • Postrenal

  • Total urinary outflow tract obstruction – intraluminal, intrinsic, extrinsic


Stages

  1. Stage 1: eGFR > 90 ml/min + some sign of kidney damage on other tests

  2. Stage 2: eGFR 60-90 ml/min + some sign of kidney damage on other tests

  3. Stage 3a: eGFR 45-59 ml/min + moderate reduction in kidney function

  4. Stage 3b: eGFR 30-44 ml/min + moderate reduction in kidney function

  5. Stage 4: eGFR 15-29 ml/min + severe reduction in kidney function

  6. Stage 5: eGFR < 15 ml/min + established KF  dialysis/transplant needed


History

  • General = anorexia, confusion, weakness, malaise, headaches

  • Anaemia = lethargy, SOBOE

  • Skin = bruising, pruritis, pigmentation, oedema

  • GI = N+V, D

  • Bone = pain, #

  • Urine = nocturia, polyuria


Examination

  • General = oedema, skin pigmentation, jaundice bruising, myopathy, cachexia

  • Arm = AV fistula (buzzes)

  • CV = HF, uraemic pericarditis, peripheral vascular disease

  • Abdo = kidneys not palpable, renal artery stenosis, transplanted kidney, scars


Investigations

  • Bedside = urine dipstick, ECG (hyperkalaemia)

  • Bloods = U+Es (raised urea + creatinine), eGFR, FBC (normocytic anaemia), Bone (low Ca, high PO4), ESR

  • Imaging = USS, CT KUB, CXR

  • Special tests = biopsy


Management

  • Conservative = Na and K dietary restriction

  • Medical = antihypertensives (ACEI/ARB, diuretics, CCB), Vit D and Ca supplements, PO4 binders, Epo  haemodialysis, peritoneal dialysis, haemofiltration (ITU)

  • Surgical = AV fistula, renal transplant

  • Psycho = screen for depression/anxiety (HADS)

  • Social = family support, transport for hospital appts, carers, finance


Complications

  • Anaemia

  • Renal osteodystrophy

  • Myopathy

  • Neuropathy

  • CVD

  • Infection (SBP, immunocompromise)


Differentiation between ARF and CRF

  • Hx

  • Duration of symptoms

  • Previous urinalysis/measure of renal function

  • Normocytic anaemia, small kidneys on US and renal osteodystrophy = CRF


Tips for finals

  • Investigations = bedside, bloods, imaging, special tests

  • Management = bio-psycho-social approach

  • Bio = conservative, medical, surgical

  • Explaining RRT/transplant to a pt


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