17) Chronic kidney disease Flashcards
what are the most common etiology for CKD ?
diabetic nephropathy
hypertensive nephropathy
chronic GN
polycystic kidney disease
what is the pathophysiology of hypertensive nephrosclerosis ?
: chronic hypertension → narrowing of afferent arterioles and efferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia
arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis)
diagnosis of hypertensive nephroslerosis ?
Initially microalbuminuria and microhematuria
With disease progression, nephrosclerosis with macroalbuminuria (usually < 1 g/day) and
Biopsy: sclerosis in capillary tufts, arterial hyalinosis
typical findings in diabetic nephropathy include a thick basement membrane, an increased mesangial matrix, fibrosis, and round nodules within the glomeruli (Kimmelstiel-Wilson nodules.)
but hypertensive predominantly affect the afferent arterioles
what are the clinical featured of CKD?
often asymptomatic until later stages.
Hypertension
Peripheral edema
Pulmonary edema (usually interstitial pulmonary edema)
Clinical features of uremia
Fatigue, weakness, loss of appetite, headaches
Uremic fetor
Pruritus
Anemia
Uremic pericarditis
Friction rub on auscultation
Asterixis
Encephalopathy: seizures, somnolence, coma
Peripheral neuropathy: paresthesias
Gastrointestinal symptoms: nausea, vomiting
↑ Risk of infection: leukocyte dysfunction
↑ Bleeding tendency secondary to platelet dysfunction - abnormal aggregation and adhesion
Chronic kidney disease-mineral and bone disorder (CKD-MBD):
Etiology: mostly due to secondary
short supply of active vitamin D
hen the blood phosphorus level goes up and blood vitamin D level goes down, your body makes too much parathyroid hormone (PTH). High PTH levels cause calcium
Clinical features: weakness, fractures, bone pain, avascular necrosis
diagnostics ?
Blood ↑ Creatinine and BUN Electrolytes: hyperkalemia, hyperphosphatemia, hypocalcemia Monitor blood pH for metabolic acidosis ↓ Calcitriol levels ↑ Parathyroid hormone (PTH
↑ bleeding time caused by uremic coagulopathy
Anemia of chronic kidney disease: ↓
ultrasound - shrunk kidneys
renal biopsy
stages based on GFR ?
Glomerular filtration rate (GFR) (mL/min/1.73 m2)
1 > 90 Normal or high 2 60 to 89 3 30 to 59 Moderately decreased 4 15 to 29 Severely decreased 5 < 15 = kidney failure
==========
based on albuminuria
mg/day
A1 < 30 Normal
A2 30 to 300 Mildly increased (microalbuminuria)
A3 > 300 Severely increased (macroalbuminuria)
treatment for CKD ?
Diet
Salt restriction in patients with edema or hypertension
hyperkalemia = Discontinue drugs that increase serum potassium Avoid high-potassium foods insulin administration calcium gluconate sodium bicarbonate ion exchange resin - sorbisterit
acid-base disorders- metabolic acidosis correction - sodium bicarbonate for compensated
decompnesated - intravenous alkalisation with sodium bicarbonate
hyperphosphatemia is used calcium carbonate and calcium citrate, which actively binds phosphorus in the intestine and prevents its absorption.
if acute
or vitamin D analogs (calcitriol, paricalcitol) and calcimimets to improve mineral exchange and treat secondary hyperparathyroidism
Nephrotoxic substances avoidance NSAIDs Sulfonamide aminoglycosides, vancomycin Acyclovir
Strict blood pressure control
Vaccinations
All patients with CKD
Pneumococcal vaccine every 5 years
Influenza vaccine annually
End-stage renal disease
Dialysis until a renal transplant is available
Anemia of chronic kidney disease
Administer human recombiant synthetic EPO, possibly in conjunction with iron replacement depending on serum ferritin and transferrin values.
Metabolic diseases
Hyperlipidemia: statins
Actively bleeding or about to undergo a surgical procedure
Desmopressin (DDAVP): first-line therapy
Conjugated estrogens: for chronic control of bleeding
Correction of anemia
