22 - CKD 1 Flashcards
Normal GFR levels
Adjusted for BSA
Males
130 mL/min/1.73m2
Females
120 mL/min/1.73m2
To Accurately Asses GFR, Use a substance that is most ideal:
Freely filterable across glomerular membrane
Neither absorbed nor secreted by renal tubules
NOT metabolized nor produced by kidneys
EX:
inulin / iothalamate / iohexol
CrCl
Estimation of GFR & Factors that Affect
End product from muscle catabolism
directly related to muscle mass, extremes are NOT accurate
OVERESTIMATES GFR
by 15-20% (CrCl > GFR)
Factors Affecting SrCr:
Age / Gender / Race
Diet / Body Habitus / MEDS
Cockroft Gault Equation
- *Uses CrCl to ESTIMATE GFR** (Overestimates)
- *most commonly used, but least accurate**
- *(140 - age) x (wt in kg)** x (0.85 if female)
- *(72 x SCr**)
Definition of CKD
Defined 3 ways:
Cause
GFR Category
Albuminuria
Abnormal Function
(decrease in GFR < 60 mL/min/1.73 m2)
OR
Structure of Kidney for > 3 months
Albuminuria > 30 mg/day
Presence of hematuria or Red Cell Casts in urine sediment
Electrolyte and other abnormalities due to tubular disorders
Abnormalities detected by histology
Structural abnormalities by imaging
History of KIDNEY TRANSPLANTATION
Risk Factors for CKD
DM
HTN / Proteinuria / AKI
Immunological Disorders / OBESITY
SMOKING / High protein diet / Metabolic Acidosis
AA / Native American / MALE / Older age
HyperPHOS / HyperURICEMIA / Obstruction
Pregnancy / FAMILY HISTORY of DM/CKD/ESRD
CAUSES of CKD
Primary Causes:
DIABETIC NEPHROPATHY** & **HyperTensive Nephrosclerosis
Less frequent:
Primary Glomerular Disease = IgA nephropathy
Secondary Glomerular Disease = Lumpus Nephritis
HIV / Transplantation
Tubulointerstitial / vascular / cystic / herdetiary DISEASE
Diabetes & CKD
Damage done DIRECTLY through:
Hemodynamically
RAAS activation
Increased: Vasoconstriction of E-ferrent Arteriole
Increased: Glomerular HYPERfiltration
Podocyte destruction -> Albuminuria
Inflammation
Induces TNF-a + IL1/6/18
Also mediated by RAAS
Proteinuria
What defines:
MICROalbuminuria vs MACROalbuminuria
Large proteins –> can NOT pass through glomerulus filter
DESTRUCTION of PODOCYTES + Filtration Barrier
allow for proteins to leak out into glomerular filtrate
VVV
overwhelms proximal tubule to reabsorb this
MICROalbuminuria = 30-300 mg/day
MacroAlbuminuria = >300 mg/day
How to assess
PROTEINURIA
Measure:
SPOT URINE TEST / Early Morning Urine Sample
Assess:
ALBUMIN / CREATININE RATIO = P/C Ratio
albumin = most important protein loss
Damage if total:
P/C ratio > 200 mg/g
Treatment for PROTEINURIA
- *ACE-I_ / _ARB**
- *renoprotective, give even if normotensive**
- not in combination with one another*
INHIBIT vasoconstriction of E-ferrent Arteriole
Also important to: REDUCE NA INTAKE
- *+Aldosterone Antagonist may help**
- but increase in K*
DO NOT combine with DIRECT renin inhibitor (aliskiren)
second line is non-diphydropyridine CCBs
HTN & CKD
Failure of:
Primary Protection via Autoregulatory Responses
Changes in:
- *Extrarenal** & Renal Vasculature
- breakdown of ELASTIC FIBERS* in arterial circulation
NEPHROSCLEROSIS
Narrowing of pre-glomular arteries & arterioles –> decreased glomerular blood flow
- *GLOMERULOSCLEROSIS**
- *Glomerular HTN & HYPERfiltration**
KDIGO
Staging of CKD
G1-G5
Also based on Albuminuria
<30 = normal
30-300 = Micro
300> = Macro
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Signs of CKD
Edema / ANEMIA
Decreased Urine Output / FOAMING of urine
Abdominal Distention
Electrolyte Abnormalities:
K / Na / Phos / Ca
Uric Acid / Metabolic Acidosis
Symptoms of CKD
CHF, HTN // Fatigue, weakness, SOB
Mental confusion, N/V Itching
Cold intolerance // Hypoglycemia
Loss of appetite and malnutrition, weight gain
Peripheral neuropathies // HL
Sexual dysfunction, loss of menstruation
Muscle weakness, renal osteodystrophy
Uremia - Uremic Syndrome
Uremia
Azotemia associated with Clinical S/Sx
1) Diminished Excretion of E- & water
2) Decreased excretion of uremic toxins (organic solutes)
3) decreased synthesis of renal hormones
4) Maladaptive changes due to compensation
Uremic Syndrome
SYMPTOMS
resulting from the accumulation of nitrogenous waste products
secondary to RENAL FAILURE
Nephrotic Syndrome
Defined as:
Urine Albumin > 2200 mg/day
or
Urine protein Excretion > 3000 mg/day
Generally:
GFR is 10-15 when patients complain of symptoms
- *INCREASE SCr + BUN**
- Decrease* GFR
Prognosis of CKD
Dependent on:
CAUSE of kidney Disease
TIME of Diagnosis
DEGREE of Albuminurea
Presense of other comorbid conditions
Earlier seen by nephrologist = BETTER outcomes
GFR < 30 // Albuminuria
Progression / HTN / Hereditary / Kidney Disease
Dialysis for CKD
When on Dialysis / RRT:
Mortality rate is SIGNIFICANTLY HIGHER than other CKD stages
6-8x higher vs non-ckd patient
Cardiovascular Complications = TOP REASON for increased risk of death
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G3b CKD
What GFR level?
Moderate to SEVERE
30-44
GFR mL/min/1.73m2
G4 CKD
What GFR level?
SEVERELY Decreased
15-29
GFR mL/min/1.73m2
G5 CKD
What GFR level?
KIDNEY FAILURE
<15
GFR mL/min/1.73m2
G3a CKD
What GFR level?
Mild-Moderate decrease
45 - 59
GFR mL/min/1.73m2