305 CKD Flashcards
Leading categories of CKD
Diabetic nephropathy
Glomerulonephritis
Hypertension associated CKD
Autosomal dominant Polycystic kidney disease
Where is urinary Potassium mediated
Aldosterone dependent secretion in distal nephron
True or false. Hyponatemia is commonly found in CKD
False.
When is Hyperkalemia and hyperchloremic metabolic acidosis present
CKD stage 1-3
Diabetic nephropathy
Tubulointerstitial disease
Part of the family of phosphatonin that promote renal phosphate secretion
FGF-23
Target PTH in CKD
150-300 pg/ml
Considered a risk factor for calciphylaxis
Warfarin use
Vascular occlusion in association with extensive vascular and soft tissue calcification
Calciphylaxis
Non calclun containing polymers
Sevelamer
Lanthanum
Primary cause of anemia in CKD
Insufficient production of EPO
Target hemoglobin in CKD
100-115 g/L
Causes skin discoloration in CKD
Deposition of urochromes
Most vexing dermatologic problem of CKD
Pruritus
Target FBC and HbA1c of CKD
FBS 90-130 mg/dl
HbA1c of less than 7%
Daily protein in CKD not on HD
0.6-0.8 g/kg/day with at least 50% high biologic value
Dietary protein in CKD patient on HD
0.9 mg/kg/ BW
Top 3 causes of CKD worldwide
Diabetes mellitus
Hypertension
Glomerulonephritis
Decline in CrCl in normal people? In diabetes?
Age 30, decline of EGFR by 1% per year
Diabetes: 10-12% decline per year
Target HCO3 in CKD
HCO3 of 22-26 meq
When AVF creation done? In diabetic? Other cause?
Diabetic: EGFR of 25 ml/min
Other causes: EGFR of 15 ml/min
Dietary protein in CKD
On ketoanalogue: 0.3 mg/kg/ BW
CKD with symptoms not on HD: 0.6 mg/ Kg/BW
CKD with no symptoms not on HD: 0.8 mg/Kg/BW
CKD on HD: 0.9-1.2 mg/kg/ BW
defined by structural or functional abnormalities of the kidney, with or without decreased GFR
Chronic kidney disease
When can label a patient with CKD
GFR less than 60 ml/min/1.73m2 for more than 3 months with or without kidney damage
when is the peak GFR
third decade of life
what is the annual decline in GFR after the peak
1 ml/min/year
True or false. Women have lover GFR than men
True.
6 mechanism of renal progression
- glomerular hypertension and proteinuria 2. proteinuria linked interstitial mononuclear and accumulation 3.cytokine and chemokine bath, 4. mononuclear cell infiltration 5.epithelial mesenchymal transition and 6. fibrosis
True or false. CKD progression is closely linked to both the GFR and the amount of the albuminuria
True.
Represents the stage of CKD where the accumulation of toxins, fluids, and electrolytes normally excreted by the kidneys leads to death unless the toxins are removed by renal replacement therapy
End stage renal disease
Two broad sets of mechanisms of damage in the pathophysiology of CKD
1.initiating mechanism specific to the underlying etiology and 2 hyperfiltration and hypertrophy of the remaining viable nephrons
helpful in monitoring nephron injury and response to therapy
measurement of albuminuria
replaced the 24 hour urine collection as measure pointing to glomerular injury
urinary albumin creatinine ratio (UACR)
UACR value that serves as marker for early detection of primary kidney disease
Above 17 mg in men and above 25 mg in women
True or false. UACR serves not only as maker for early detection of primary kidney disease but for systemic microvascular disease as well
True.
GFR categories. G1- G5
G1 normal eGFR more than 90 G2 eGFR 60-89 G3a eGFR 45- 59 G3b eGFR 30-44 G4 eGFR 15-29 G5 kidney failure eGFR less than 15
KDIGO persistent albuminuria. A1- A3
A1 normal less than 30 mg/d or 3 mg/mmol A2 30-300 mg/dl or 3-30 mg/mmol A3 more than 300 mg/d or 3 mg/mmol
True or false. Stage 1 and 2 CKD are usually asymptomatic and recognition often result from laboratory testing other than suspicion of kidney disease
True.
Leading categories of etiologies of CKD
diabetic nephropathy, glomerulonephritis, hypertension associated CKD, ADPKD, other cystic and tubulointerstitial nephropathy
True or false. When no overt evidence for a primary glomerular or tubulointerstitial disease process is present, CKD is frequently atttributed to hypertension
True.
three spheres of dysfunction manifested as pathophysiology of uremic syndrome
those consequent to the accumulation of toxins that normally undergo renal excretion, 2 those consequent to the loss of other kidney functions, 3. progressive systemic inflammation and its vascular and nutritional consequences
True or false. Hyponatremia is not commonly seen in CKD patient.
True.
How is hyponatremia treated in CKD patient?
Water restriction
True or false. Diuretic resistance with intractable edema and hypertension in advanced CKD may serve as an indication to initiate dialysis
True.
True or false. Decline in GFR is not necessarily accompanied by a parallel decline in urinary potassium
True.
What precipitates hyperkalemia in CKD
dietary potassium intake, hemolysis, hemorrhage, transfusion of stored red blooc cells, and metabolic acidosis
True or false. Hypokalemia is also not common in CKD patients
True.
True or false. Metabolic acidosis is a common disturbance in advanced CKD
True.
When is alkali supplementation recommended
sodium bicarbonate levels are below 20-23 mmol/L
When does bone manifestation of CKD occur
occurs when GFR falls below 60 ml/min
Pathophysiology of secondary hyperparathyroidism in CKD
- declining GFR leads to phosphate retention, 2. retained phosphate stimulate FGF-23 and PTH, 3. FGF-23 leads to decreased ionized calcium, further phosphate retention and low calcitriol
part of a family of phosphatonins that promotes renal phosphate excretion
FGF-23
Devastating condition seen in advanced CKD where there is evidence of vascular occlusion in association with extensive vascular and soft tissue calcification
Calciphylaxis
Considered a risk factor for calciphylaxis
warfarin treatment
What is the optimal management of secondary hyperparathyroidism and osteitis fibrosa
prevention
Calcium based phosphate binders
calcium carbonate and calcium acetate
Major side effect of calcium based phosphate binders
calcium accumulation and hypercalcemia
non calcium containing phosphate binders
sevelamer and lanthanum
what is the target PTH level
150- 300 pg/ml
Leading cause of morbidity and mortality in patients at every stage of CKD
cardiovascular disease
True or false. Cardiac troponin levels are frequently elevated in CKD without evidence of acute ischemia
True.
largest increment in cardiovascular mortality in dialysis patient
congestive heart failure and sudden death
most common complication of CKD
hypertension
Strongest risk factor for cardiovascular morbidity and mortality in patients with CKD
LVH and dilated cardiomyopathy
True or false. In epidemiologic studies, low blood pressure actually carries a worse prognosis than does high blood pressure
True.
True or false. Exogenous erythropoiesis- stimulating agents can increase blood pressure and the requirement for antihypertensive drugs
True.
When should blood pressure in CKD be lowered to 130/80 mmHg
in CKD patients with diabetes and proteinuria of more than 1 g per 24 hrs
Firs line of therapy for hypertension in CKD patients
salt restriction
Diagnostic of pericarditis
chest pain with respiratory accentuation accompanied by friction rub
Classic ECG finding of pericarditis
PR interval depression and diffuse ST segment elevation
True or false. Uremic pericarditis is an absolute indication for urgent initiation of hemodialysis or intensification of dialysis
True.
Stage anemia is first observed and when does it become universal
Anemia is observed as early as stage 3 CKD and universal by stage 4
Primary cause of anemia in CKD patients
insufficient production of EPO by the diseased kidney
Other causes of CKD
relative deficiency of EPO, diminished RBC survival, IDA, chronic inflammation, folate and vitamin B12 deficiency, hemoglobinopathy, hyperparathyroidism
what is the effect of blood transfusion to CKD patient waiting for renal transplant
frequent blood transfusion can lead to development of alloantibodies that can sensitize the patient to donor kidney antigens and make renal transplantation more problematic
What can temporarily reverse abnormal bleeding time and coagulopathy in patients with renal failure
desmopressin, cryoprecipitate, IV conjugated estrogen, blood transfusion and ESA therapy
derives from breakdown of urea to ammonia in saliva and often associated with an unpleasant metallic taste
uremic fetor
True or false. Because the kidney contributes to insulin removal from the circulation, plasma levels of insulin are slightly to moderately elevated in most uremic patients both in the fasting and postprandial states
True.
GFR associated with higher rate of spontaneous abortion
GFR less than 40 ml/min
True or false. Pregnancy may hasten the progression of kidney disease itself.
True.
Most vexing manifestations of the uremic state
Pruritus
pigmented metabolites in CKD
urochromes
Skin condition in CKD consisting of progressive subcutaneous induration in the arms and legs with history of exposure to gadolinium
nephrogenic fibrosing dermopathy
GFR when CKD patients should minimize exposure to gadolinium
GFR 30-59 ml/min
GFR when gadolinium should be avoided unless medically necessary
CKD stage 4-5 of GFR less than 30 ml/min
differential for unexplained CKD in patients aged above 35 with anemia, normal serum calcium
multiple myeloma
an indication for therapy with ACEI or ARBS
24h urine protein excretion more than 300 mg
Conditions where kidney size may be normal in the face of CKD
diabetic nephropathy, amyloidosis and HIV nephropathy
a discrepancy in kidney length suggests either a unilateral development abnormality or renovascular disease with arterial insufficiency
discrepancy of more than 1 cm
Reasons why kidney biopsy in patients with bilaterally small kidneys are not advised (3)
- technically difficult, 2. much scarring that underlying disease may not be apparent, 3. window of opportunity to render disease specific therapy has passed
Other contraindicati0on to kidney biopsy
uncontrolled hypertension, active UTI, bleeding diasthesis, severe obesity
important in slowing the progression of CKD
control of glomerular hypertension
surrogate for improved renal outcome
reduction in proteinuria
among calcium channel blockers, these agents exhibit superior antiproteinuri and renoprotective effects
verapamil and diltiazem
