GFR 3 months Renal failure: GFR<15 or need for dialysis/transplant Causes Hypertension Diabetes Glomerulonephritis Polycystic Kidney Disease Chronic Obstruction Infection - Chronic Pyelonephritis Medications - Analgesics
CKD Stages Stage 1: normal - eGFR >90 ml/minute/1.73 m 2 with other evidence of chronic kidney damage. Stage 2: mild impairment - eGFR 60-89 ml/minute/1.73 m 2 with other evidence of chronic kidney damage. Stage 3a: moderate impairment - eGFR 45-59 ml/minute/1.73 m 2. Stage 3b: moderate impairment - eGFR 30-44 ml/minute/1.73 m 2. Stage 4: severe impairment - eGFR 15-29 ml/minute/1.73 m 2. Stage 5: established renal failure (ERF) - eGFR less than 15 ml/minute/1.73 m 2 or on dialysis. -Persistent microalbuminuria, proteinuria or haematuria (after exclusion of other causes - eg, urological disease). -Structural abnormalities of the kidneys, demonstrated on ultrasound scanning or other radiological tests - eg, polycystic kidney disease, reflux nephropathy. -Biopsy-proven chronic glomerulonephritis.
Examination WIPER – wash hands, intro, patients name/dob, explain + consent, reposition Inspection Around the bed Nutritional status – wasting? Excoriations Cushing Syndrome Hands Flapping tremor (uraemia) Nails – leukonychia (hypoalbuminaemia in nephrotic syndrome), koilonychia (Fe deficiency anaemia in nephritic syndrome Pulse BP Arms: AV fistula – expose both arms fully, palpate and auscultate
Examination - Fistula Used in haemodialysis Surgical procedure to connect artery side to end with ligation of distal vein Higher pressure and increased flow Use 6-8 weeks post formation Active: palpable thrill, audible bruit, access marks Types: Radio-cephalic, Ulnar-basilic, brachio-cephalic Implications: body image, clothing, avoid trauma, no bp/blood taking Complications: infection, stenosis, thrombosis, bleeding, failure Steal syndrome: distal tissue ischaemia
Examination Head & Neck Eyes – conjunctival pallor Mouth/tongue – gingival hypertrophy (immunosuppression) Neck – JVP, scar (parathroidectomy) Abdo Inspection Distension Scars Hockey stick/Rutherford Morrison Previous peritoneal dialysis Back Palpation – LIF mass Percussion Auscultation (renal bruits) Peripheral oedema
Polycystic Kidney Disease 50% will get ESRF Can also get cysts in liver, pancreas, brain, and arterial blood vessels Autosomal dominant PKD1 mutation on Chrom 16 (85%) PKD2 mutation (15%) Autosomal recessive Tend to present younger May need nephrectomy if severe Associated with: mitral valve prolapse, SAH
Hyperparathyroidism Renal osteodystrophy: 1. Osteoporosis 2. Hyperparathyroidism 3. Osteomalacia 4. Osteosclerosis “pepperpot lesions & rugger jersey spine” – sclerotic end plates and lucent central areas