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Are we alive? Ok. Uh I'm just gonna assume that this is live now. Ok, perfect. We're live. Great. Ok, so um hello everyone. Uh I'm Michael. Er and today I'm gonna be talking about uh chronic renal conditions and UTI S. Um So as II mentioned this earlier, but um feel free to drop any questions you guys have in the chats. Uh I don't think I'll be able to really look at them until the end of the presentation, but I will get round to them. So don't worry. Um I do understand as well that this is quite a, a long topic but I think it's very much worth um learning because these are very common conditions and could definitely come up from your exams. So it's very important. Oh, I'll say real quick. Can I just check, can everyone hear me? Can anyone uh can you just drop a message and chat if you can hear me? Ok, I'm just gonna, yep. OK, great, thanks. Great. OK. Um So yeah, without further ado let's uh just jump right into it. Um So this is gonna be the rough session structure whenever recovering conditions, it will vary based on how important I feel like the conditions are, but general will be trying to follow it in a logical order. Um Here are the conditions that we're going to uh be covering today. Um And, but first of all, let's start off with just a quick question just so we can kind of get our minds working. Um So a 65 year old male has a swollen face and ankles for the past two weeks. The patient has a 15 year history of type two diabetes mellitis. He reports feeling exhausted and run down recently and his temperature was found to be 37.3 with a BP of 100 and 53/99. And a heart rate of 70 physical examination shows that periorbital edema, bilateral pitting edema in the lower extremities and reduced light to touch sensation in the feet, which of the following laboratory values is most likely to be elevated in this patient. Um If you guys wouldn't mind, have a, have a go at this question. Uh I'll give you a couple of seconds for that. And, uh, if not, I'll just uh review the answers later. Ok. Have a quick answer, see if anyone's answered. Ok? No worries. Ok. Yeah, this is quite a tricky question. Um The answer was c uh, creatinine. Um, so chronic kidney disease. Um, and things to look out for in this question that would show um what uh disease we're dealing with is the swollen, face and ankles and the signs of edema that they have as well as being generally tired and having hypertension. And type two diabetes is also quite relevant because it's the most common cause for chronic kidney disease due to it causing diabetic nephropathy. Um So looking at the uh questions themselves, um albumin, calcium and sodium all would actually be reduced and not elevated in the patient albumin leaking out into the urine. So, being reduced, calcium, um being reduced because of the lack of Vitamin D production. Um and then sodium uh not being reabsorbed. So, there's also lower sodium. Um creatinine and urea would both be raised. Um However, creatinine would actually be raised more um because urea uh tends to fluctuate. Um and it's not very consistently produced. Whereas creatinine is and urea is also secreted by other means such as in the sweat. Whereas creatinine is primarily done in the the kidneys. And as a result, um with the loss of kidney function, creatinine increase would be a lot more dramatic than urea. And so it'd be the most likely to be elevated. It was quite a tricky question. They said, don't worry if you weren't able to get it. Um So, um thinking about what chronic kidney disease actually is, it essentially describes the chronic damage to the glomeruli. Um and this leads to um the kidney trying to rebuild itself, but it turns slightly abnormal in the structure And now, as a result, there's a gradual loss in kidney function as the more damage accumulates um as chronic kidney disease cos there's quite a lot. Um it's quite useful to think about what the actual um functions of the kidney are. And there's a helpful pneumonic a wet bed um to remind ourselves of what the kidneys do. So this is stands for acid base balances, water removal, ep O production, toxin removal, BP control, electrolyte balance and Vitamin D activation. A loss of acid base regulation would lead to a metabolic acidosis in CKD patients because bicarbonates aren't being reabsorbed and hydrogen ions aren't being um secreted anymore. Um A loss of water removal would lead to edema and fluid retention. Uh reduced epo production would lead to normocytic anemia. Um No, uh lack of toxin removal would lead to build up of urea leading to uremia and hyperphosphatemia as well. And a lack of BP control would lead to hypertension and cardiovascular disease. Um electrolyte imbalances would also be hyperkalemia, for example, which is typically uh potassium typically being um secreted from the kidneys. Uh and uh lack of Vitamin D activation would lead to hypocalcemia. Um So when you're thinking about questions, it's always used to always useful to think about what uh demographics the patients are as this will help kind of confirm or make you question whether your principal diagnoses is correct or not. Um KD is quite a common condition affecting about 9% of the, the uh the global um population. Um and it's more common in women, although uh it's also uh quite uh like highly occurring in men as well. So uh I wouldn't use that as a primary differentiator. Um The risk definitely increases with age though. So think about it in older people. Um and it's higher in black and Hispanic populations as well as people with a family history of renal disease. Um In terms of risk factors, you just want to think about what would essentially strain the glomerular apparatus. Um The most common one being diabetes mellitis. Um and this is the most common cause in about 30 to 50% of cases. Um due to diabetic nephropathy, which will cause damage to the um capillaries in the nephron hypertension is also uh a quite a common cause being the second most common. Um and would also lead to damage in the kidney Nephron. Um medications, glomerular diseases and systemic disease would also all cause it as well as obstructive neuropathies. Um And the reason for this would be that any stones would cause a backup of urine. Uh And so that there would be increased pressure in the kidneys, uh uh known as hydronephrosis and it would cause damage that way. Um So now looking at the presentation, um d in real practice, often goes unnoticed because the disease has often significantly progressed um until it's significantly progressed. Sorry, because the kidneys can compensate for diminished function. Um until then. Um but in your exams, essentially early signs may be um being generally unwell and fatigued, having changed um, urine patterns and hypertension and edema. Um Later on though, as uh kidney begins to shut down, uh you may get reduced urine output shortness of breath from fluid overload, uremia symptoms because of the build up of urea, as mentioned earlier. Um These may be nausea and vomiting, pruritus, which is essentially itchy, skin, appetite loss and cramps. Um You also may get poor from normocytic anemia, uh as well as frothy urine from the protein urea, uh and a whole host of systemic symptoms as these are also all affected by the kidneys. Um you can also get signs um of uh the causes of CKD. So, polycystic kidney disease can cause flank masses, er and bladder distention may be a sign of obstructive uropathy. Um So the key investigations uh in D you always want to think about um in terms of investigations, beds bloods, uh and then scans. So the most er easy tests first line to do would be bedside. Um and something easy would be a urine dipstick. Um With this, you can look out for hematuria, um which would rule out uh things like glomera nephritis and causes for CKD as well as excluding other differentials such as UTI S. However, it's important to bear in mind that urine dipsticks aren't really a good indicator of protein urea. And so instead it's best to use uh albumin to creatinine ratios collected from an early morning midstream urine sample. Um or you could also measure serum creatinine. And of this, calculate the eeg fr um as a kind of rough graph here to show you, um essentially, you can estimate a person's G fr based on their creatinine level. However, it is worth bearing in mind that creatinine levels uh do vary from individual to individual um as well as having factors that affect them, such as pregnancy, muscle mass and eating red meat. Um Also, it's quite useful to assess cardiovascular risk factors. Um such as BMI BP, HBA1C and lipid profiles just because cardiovascular events are actually the most common cause of death in CKD patients uh often before you get end renal failure. And the reason for that being is that the increase in pressure in BP and other strains on the vascular system would lead to more uh cardiovascular events. Um and this is a, a real problem in for the patients. Uh renal ultrasound scans are also useful if you suspect urinary tract stones or uh may be a cause or polycystic kidney disease, which would show up as um cysts on uh on a enlarged kidney. Um So C KD is classified into stages and it's very useful to think about it. It just looks like quite an intimidating