#19 Press - Chronic Kidney Disease

Question 1

What is the overall prognosis for a patient with Acute Kidney Injury?

Answer 1

generally reversible

Question 2

You suspect your patient has a decreased glomerular filtration rate. What would you use to confirm?

Answer 2

Creatinine based formula

CKD Epi

Question 3

How would you stage a patient with a GFR of 45?

Answer 3

Stage 3

GFR 30-59

Question 4

How would you manage a patient with uremia?

Answer 4

dialysis
renal transplant
treat anemia

Question 5

What is the overall prognosis of a patient with chronic kidney disease?

Answer 5

Generally not reversible
- onset over months to years
Need three values over time.

Question 6

What is the appearance of the kidney in a person with chronic kidney disease?

Answer 6

Small kidneys
increased echogenicity
(if large - Diabetic nephropathy)

Question 7

A patient’s labs come back with a GFR less than 60. What comorbidities are they likely to have?

Answer 7

Anemia
Secondary hyperparathyroidism (2*HPTH)
Malnutrition
Acidosis
Hypercalcemic
Cardiovascular (LVH)

Question 8

Which measure would you use to determine stage, GFR or creatinine?

Answer 8

GFR

Question 9

At what GFR rate is CKD diagnosed?

Answer 9

Under 60 mL/min/1.73m^2

Question 10

HG comes in for a visit complaining of frequency and nocturia. During the history you discover he has been taking large amounts of ibuprofen for his knee pain. The urinalysis comes back with mild proteinuria. What is the ddx?

Answer 10

Chronic interstitial nephritis

Question 11

During a physical exam of a 60 year old, you notice a femoral and carotid bruit. After labs you diagnose him with ischemic nephropathy. What is the etiology?

Answer 11

renovascular disease
Risk factors: white, smoker, over 50
Difficult to control HTN
-may have recurrent pulmonary edema

Question 12

A patient comes in with acute hypertension and otherwise unexplained renal insufficiency. They are currently on an ACE inhibitor. What would you suspect?

Answer 12

Ischemic nephropathy

Due to blocking of efferent arterioles

Question 13

HY comes in with a diverticular disease and valvular disorder. She also has a history of UTIs. She has a decline in GFR. You send her in for an ultrasound to look for what genetic defect?

Answer 13

ADPKD
Defect of chromosome 16 resulting in abnormal formation of cysts
Beware of intra-cerebral berry aneurysm Get MRA

Question 14

When patients come into your office, what risk factors are you looking for developing CKD?

Answer 14

HTN
Cardiovascular
DM
>60Y
Family history
Recurrent UTIs
Drugs - NSAIDS, antibiotics, contrast agents

Question 15

OE just completed a 24 hour protein collection. How would you classify OE if his albumin was 190 mg/day?

Answer 15

Microalbuminuria (30-300 mg/day) more sensitive

[Macro >300mg/day]

Question 16

What is the best way to quantify proteinuria?

Answer 16

uP/uCr ratio

If p/cr = 0.500 (500 mg/day)–> proteinuria

Question 17

The dipstick proteinuria came back positive but your nurse says it is may be a false positive. What do you suspect she noticed on labs?

Answer 17

Alkaline urine (pH>7.5)
or
Gross hematuria present
[False negative –>light chain protein or dilute urine]

Question 18

The urinalysis results come back with trace urine. Would you be concerned?

Answer 18

It would depend on how much urine is being produced by the patient. If the amount is 15 mg/dl and the patient is producing 2 liters a day that is 300 mg which is abnormal.

Question 19

What can you do to slow progression of CKD?

Answer 19

control BP 140/90

Reduce proteinuria

Question 20

What is the guideline for managing LDL levels in a CKD patient?

Answer 20

less than 70

Question 21

When would you initiate the work up of anemia in CKD?

Answer 21

Stage 3 CKD
Less epo –> anemic
Hgb

Question 22

Your patient with CKD is being evaluated for anemia. What would you want to know?

Answer 22

Hgb, Hct, RBC indices, reticulocyte count
Iron Evaluation:
- serum iron
- TIBC
- percent transferrin saturation
- Serum ferritin
Test for occult blood in stool

Question 23

How would you differentiate primary and secondary hyperparathyroidism?

Answer 23

Both have elevated PTH
1* - hypercalcemic
2* - hypocalcemic

Question 24

What is your PTH goal for stage 3 CKD?

Answer 24

35-70 pg/mL

Question 25

How would you manage a patient with hyperparathyroidism?

Answer 25

In CKD, resrict dietary phosphate, phosphate-binding agents, supplement with Vit D, calcimimetics (sensipar) turn PTH off

Question 26

What type of acid/base balance is usually found in CKD?

Answer 26

Metabolic acidosis

Goal: HCO3 >22mmHG

Question 27

What constitutes uremia?

Answer 27

GFR 10-15
More than one:
Renal failure, lethargy, anorexia, dysgeusia, pericarditis, neuropathy, N/V, pruritis, dyspnea

Question 28

When would you start dialysis?

Answer 28

AEIOU (Acidosis, Electrolytes, Intoxicants, Overload, Uremia)
GFRDM
non-DM
Symptoms of uremia