12 - CKD Flashcards
National kidney foundation (NKF) defines CKD as?
Evidence of renal damage based on: - abnormal UA (protein, heme) Or - structural abnormality by US Or - GFR <60 mL/min
For >3 months
Stages of CKD?
1: GFR >90
- damage
2: GFR 60-89
- mild
3: GFR 45-59
- mild - moderate
4: GFR30-44
- moderate - severe
5: GFR < 15
- ESRD
Chart on slide 8
KDIGO guidelines
CKD definition?
Abnormalities of kidney structure of function persistent > 3 months
KDIGO guidelines CKD classification?
Based on GFR and albuminuria
MC risk factors for CKD?
DM HTN Vascular disease FHx of CKD >60yo
Maj outcomes of CKD?
CVD Complications of Impaired renal function - anemia - DO of mineral metabolism - 2ndary hyperparathyroidism ESRD
Major causes of CKD?
Primary glomerular diseases Secondary glomerular diseases Tubulointerstitial nephritis Cystic disease Obstructive nephropathies Vascular disease
Examples on slid 12
Pathophys of CKD?
L clearance of certain solutes principally excreted by the kidney results in their retention in body fluids
Reduction in renal mass (nephron destruction)
- hypertrophy of remaining nephrons
- hyper-filtration
Symptoms of CKD?
Develop slowly and are nonspecific
Early stages - asymptomatic
Symptomatic once GFR <5-10
CKD physical findings
Chronically ill-appearing HTN Dermatologic manifestations Uremic fetor Mental status changes
What are mee’s lines?
Seen with the dermatologic manifestions of CKD
They are finger nail changes
Pic on slide 19
What is uremic fetor?
Urinous breath
Halitosis
UA findings for CKD?
Broad, waxy casts (stasis)
Persistent proteinuria
- persistent proteinuria - (CKD no matter the GFR)
CKD serum findings?
H BUN/Cr (persistent) L GFR (<60) Anemia Metabolic acidosis Hyperphosphatemia Hyperkalemia Hypocalcemia
Caution when using serum creatinine to track CKD because?
Serum creatinine may remain normal until there has been a severe decline in GFR
imaging with CKD?
US - small (<9-10cm)
Radiology - evidence of renal ostedostrophy
- phalanges of hands
- clavicles
Complications of uremia
- Cardiovascualr - (50% of deaths in pts w ESRD)
- Disorders of mineral metabolism
- Hematologic
- Hyperkalemia
- Acid-base disorders (metabolic acidosis)
- Neurologic
- Endocrine disorders
CKD cardiovascular complications?
HTN
CHF
Uremic pericarditis
MC CKD complication?
HTN
Lifestyle changes for HTN pts?
Decrease salt (2g/day)
Diuretic - Thiazide/loop
ACEI/ARB
Goal BP <140/90 mmHg
CKD and CHF?
A chain of events
CKD causes HTN (RAAS stimulation), volume overload, anemia
- Lead to higher cardiac workload
- accelerated atherosclerosis
contributes to LVH and HF
uremic pericarditis presentation?
S/s - pleuritic chest pain/fever
PE - pulsus paradoxus and friction rub
ECG - low voltage, electrical alternans
CXR - enlarged cardiac silhouette
Pericarditis is?
An absolute indication for hemodialysis and hospitalization
CKD pts (esp those w DM) will likely die from ?
CVD is much more likely than ESRD
CKD - look at heart
Heart disease - look at kidney
Low GFR and small kidneys have what effect on mineral metabolism?
Osteitis fiberosa cystica (H PTH)
Adynamic bone disease (L PTH)
Osteomalacia (L vit D)
MC mineral disorder from CKD?
Osteitis fibrosa cystica
- secondary hyperparathyrodism -> osteoclast stimulating effects of PTH
Why does CKD lead to bone problems?
Hserum phosphorus (hyperphosphatemia
L vitamin D -> (hypercalcemia)
H PTH (secondary hyperparathyrodism) -> Renal osteodystrophy (bone disease)
Tx for mineral metabolism do?
Hyperphosphatemia control
- phosphorus restriciton
- phosphorus binding agents
Hyperparathyrodism tx
- vit D
- Calcitriol
Hematologic complications of CKD?
Anemia - normochromic, normocytic
- low erothropoietin
- low iron absorption
Coagulopathy
- platelet dysfunction
- > petechia/purpura
- > bleeding
Dialysis effect on bleeding?
Improves bleeding time but doesnt normalize it
CKD and hyperkalemia?
Potassium balance remains intact until GFR < 10-20ml/Min (CKD stages 4-5)
Acute hyperkalemia needs?
- Cardiac monitoring
- IV calcium chloride or gluconate
- Insulin w glucose
- Bicarbonate
- Sodium polystyrene sulfonate
Chronic Hyperkalemia needs?
- Dietary potassium restriction
- Sodium polystyrene PRN
Damaged kidneys lead to what acid-base do?
Inadequate acid (H+) excretion -> metabolic acidosis
Acid-base d/o tx?
Maintain/normalize serium bicarb level: >21 mEq/L
- alkali suppliments
Keep pH >7.20
Neurologic complications?
Uremic encephalopathy - GFR <5-10
Peripheral neuropathies
Endocrine complications of CKD?
H insulin (hypoglycemia)
L libido and ED (common)
CKD management
Tx underlying cause - esp DM Meds - ACEI/ARB, statin, diuretics Consult - CKD clinics (goal - stay off dialysis) Pt eduction - smoking Diet restrictions - protein - salt/water - k+ - phosphorous
CKD pts need to be evaluated by?
Nutritionist
Once CKD -> ESRD pts need?
RRT - renal replacement therapy
- hemodialysis
- peritoneal dialysis
- kidney transplant
Indications for RRT?
GFR <5-10 Uremic symptoms (pericarditis, coagulatpathy etc) Fluid overload Refractory hyperkalemia >7 Severe metabolic acidosis (pH <7.2) Neurologic symptoms BUN >100
Problems w hemodialysis?
Vascular access complications
- infection, thrombosis, aneurysim
3 sessions/wk - 3-5 hrs each (15hrs/wk)
What is peritoneal dialysis?
Peritoneal dialysis is a type of dialysis that uses the peritoneum in a person’s abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood.
types of peritoneal dialysis?
CAPD - continuous ambulatory peritoneal dialysis
- MC type
- pt swaps bags out throughout the day
CCPD - continusous cyclic peritoneal dialysis
- machine works at night
Which type of kidney transplant is best?
Living donor is much better
1 yr survival
- 95% living donor
- 89% deceased
5 yr
- 80% living donor
- 66% deceased
Life expectancy for dialysis pts?
5 yr survival?
- 40%
Average life expectancy 3-5 yrs (though sometimes up to 25 yrs)
Causes of death for CKD pts?
Cardiac disease (50%)
Infection
Cerebrovascular disease
Malignancy
Bottom line for CKD pts?
Medical care is based on delaying/halting CKD progression
With CKD pts always?
Be cognizant of necessary dose adjustments when prescribing meds
Dont worry
Urine good hands
