A.36 Chronic Renal Failure Flashcards

Question

A. 36 Chronic Renal Failure Uremic Neurological Symptoms

Answer 1

Asterixis - An irregular, high-amplitude tremor of the hand that occurs when the arm is outstretched and the wrist and fingers are dorsiflexed. Most commonly a sign of encephalopathy Signs of uremic encephalopathy Seizures Somnolence Coma Peripheral neuropathy → paresthesias

Answer 2

Anemia Leukocyte dysfunction → ↑ risk of infection ↑ Bleeding tendency caused by abnormal platelet adhesion and aggregation

Answer 3

Kidney OUTAGES: hyperKalemia renal Osteodystrophy Uremia Triglyceridemia Acidosis (metabolic) Growth delay Erythropoietin deficiency (anemia) Sodium/water retention (consequences of chronic kidney disease)

Answer 4

Order initial laboratory studies. Determine if the patient meets the criteria for CKD. Stage CKD according to the CGA classification. Order further tests (e.g., electrolytes, CBC) to establish if complications are present. Rule out AKI or acute on chronic kidney injury. Identify the etiology of CKD and possible contributing factors. Perform a comprehensive chart review, history, and physical examination. Consider an initial renal ultrasound for all patients with CKD. Consider further investigations for specific underlying causes of CKD. If any indications for acute dialysis are identified, proceed with urgent renal replacement therapy.

Answer 5

The diagnosis of CKD requires the persistence of eGFR < 60 mL/min/1.73 m2 and/or of a marker of kidney damage for more than 3 months

Answer 6

Glomerular Filtration Rate (GFR): A measure of how well the kidneys filter blood, expressed in mL/min/1.73 m². Serum Creatinine: A waste product in the blood that reflects kidney function; elevated levels indicate reduced kidney function. Urine Albumin: Measurement of albumin in urine; used to assess kidney damage (e.g., albuminuria). Blood Urea Nitrogen (BUN): Another waste product in the blood that can indicate kidney function. Electrolyte Levels: Measurement of sodium, potassium, calcium, and phosphorus levels in the blood, which can be affected by kidney function

Answer 7

Serum markers: ↑ creatinine and BUN (alternatively, ↑ cystatin C) Glomerular filtration rate: ↓ eGFR

Answer 8

↑ Spot UACR: used to determine the albuminuria category for CKD staging. ↑ Spot urine protein-to-creatinine ratio (UPCR): Nephrotic-range proteinuria may be seen. Urine dipstick: may show hematuria or proteinuria Urine microscopy: may show abnormal urine sediment, e.g., the presence of waxy casts

Answer 9

First-line imaging technique for the assessment of kidney structure Consider obtaining for all patients to further support the diagnosis and help determine the etiology. Findings that suggest chronic kidney damage include: ↓ Kidney length (< 10 cm) ↓ Parenchymal and/or cortical thickness ↑ Cortical echogenicity Cysts Calcifications

Answer 10

Symptoms of diabetes mellitus Age > 35 years and/or the presence of other risk factors for type 2 diabetes mellitus Nephrotic syndrome or nephrotic-range proteinuria - may be seen in diabetic nephropathy HbA1C

Answer 11

Evidence of extrarenal disease (e.g., clinical features of SLE, anti-GBM disease, pauci-immune glomerulonephritis) History of IV drug use Nephritic syndrome or nephrotic syndrome Urinalysis abnormalities (any of the following): Nephritic sediment Nephrotic sediment Nephrotic-range proteinuria Serology, e.g.: ANA ANCA anti-GBM antibody Viral serology (e.g., HIV, HBV, HCV)

Answer 12

Treatment-resistant hypertension Abdominal bruit heard over the flank or epigastrium Evidence of other atherosclerotic diseases (e.g., CAD, PAD) dx Duplex ultrasonography of the renal arterie

Answer 13

History of a chronic inflammatory condition (e.g., IBD, RA) or chronic infectious disease (e.g., tuberculosis, osteomyelitis) History of plasma cell dyscrasia Evidence of other organ involvement (e.g., macroglossia, restrictive cardiomyopathy, hepatosplenomegaly, malabsorption measure: Serum protein electrophoresis Urine Bence Jones protein Serum and urine free light chains

Answer 14

Slow the progression of CKD The goals of treatment are to delay the progression of CKD and prevent and manage complications. Treat the underlying causes of CKD (if identified). Start comprehensive management. Provide recommendations regarding nutrition and vaccinations, and adjust current medications as required. Primary prevention of ASCVD. Assess for evidence of metabolic complications Monitor for CKD progression and continuously evaluate the need for advanced care.

Answer 15

Fluid intake: Ensure appropriate fluid intake and avoid dehydration. Protein and energy consumption Mediterranean diet, ↑ fruit and vegetable intake Protein restriction (e.g., 0.55–0.60 g/kg/day) in patients with CKD category G3–G5 Electrolytes Sodium restriction (< 2.3 g/day): for individuals with CKD category G3–G5 Potassium intake adjustment: avoidance of high-potassium foods in patients with CKD category G4–G5 to reduce the risk of hyperkalemia Phosphorus intake adjustment: as needed to maintain serum phosphate levels in the normal range Micronutrients: Consider multivitamin supplementation for patients with inadequate dietary vitamin (e.g., vitamin D) intake.

Answer 16

Nephrotoxic Substances A property of a substance to impair renal function. Nephrotoxic substances include certain metals (e.g., lead, mercury, and cadmium salts), radiocontrast agents, and organic solvents (e.g., hydrocarbons). Many drugs also have nephrotoxic properties at high doses and/or after long-term use (e.g., aminoglycosides, amphotericin B, vancomycin, lithium, cyclophosphamide, cyclosporine, NSAIDs).

Answer 17

Nonoperative (hemodialysis or peritoneal dialysis) Indications include: Hemodynamic or metabolic complications that are refractory to medical therapy, e.g.: Volume overload or hypertension Metabolic acidosis Hyperkalemia Serositis: e.g., uremic pericarditis Other symptoms of uremia: e.g., signs of encephalopathy Refractory deterioration in nutritional status Operative: kidney transplantation

Answer 18

Perform for all patients (untreated CKD is an ASCVD risk-enhancing factor). Includes: Diabetes mellitus screening Screening for hypertension Screening for lipid disorders ASCVD risk calculation (e.g., using pooled cohort equation)

Answer 19

Systolic blood pressure (SBP) target SBP < 120 mm Hg is recommended (if tolerated). Consider higher targets (e.g., < 130–140 mm Hg) for selected patients. Pharmacological therapy Consider for patients with SBP above target, particularly if they are in albuminuria categories A2–A3. First-line therapy: RAAS inhibitors (i.e., ACEI or ARB) Benefits: nephroprotection and reduced proteinuria Risks: may cause hyperkalemia and/or an initial decline in GFR Consider combination therapy (e.g., RAAS inhibitor PLUS a calcium channel blocker and/or a thiazide diuretic) For patients with an initial SBP ≥ 20 mm Hg above target For patients who do not reach the target while on monotherapy at the optimal dose

Answer 20

Second-line agents include: Loop diuretics or thiazide diuretics - Diuretics are often needed to achieve blood pressure control in patients with advanced CKD given a tendency for increased sodium and water retention. Thiazides are usually preferred given their proven cardiovascular benefits. However, loop diuretics may be more effective in patients with eGFR < 30 mL/min/1.73 m2. Calcium channel blockers (CCBs) - Non-dihydropyridine CCBs (e.g., verapamil) may reduce proteinuria. Beta-blockers: usually reserved for patients with cardiovascular comorbidities - Beta-blockers may be inferior in preventing ASCVD in patients with CKD compared to RAAS-inhibitors, diuretics, and CCBs. However, they may be indicated in patients with comorbidities, such as angina, myocardial infarction, or systolic heart failure with reduced ejection fraction. Aldosterone receptor antagonists: usually reserved for treatment resistant hypertension - Use with caution as they may cause hyperkalemia and/or GFR decline, especially in patients with low baseline eGFR.

Answer 21

Goal: reduction of ASCVD risk Fasting lipid panel (↑ triglycerides are common) Statin therapy; indications include: Prevention of ASCVD in patients with CKD Start for all patients ≥ 50 years of age. - For patients ≥ 50 years of age with eGFR < 60 mL/min/1.73 m2 (i.e., eGFR category G3–G5), initial combination therapy with statin/ezetimibe is also appropriate. Consider for patients 18–49 years of age with concomitant diabetes mellitus and/or 10-year ASCVD risk > 10%.

Answer 22

Pulmonary edema - Due to an inability in patients with very low GFR to clear excess fluids Hyperkalemia - May be triggered by excessive dietary potassium, nonadherence to diuretic therapy, or a new medication or medication interaction (e.g., ACE inhibitors, potassium-sparing diuretics) Infection Bacteremia secondary to UTI or pneumonia IV catheter-related infection Hemodialysis catheter-related infection Peritoneal dialysis-associated peritonitis Drug toxicity - Due to impaired renal excretion and the effect of changes in volume status and plasma protein binding on volumes of distribution

Answer 23

Pathophysiology: ↓ synthesis of erythropoietin → ↓ stimulation of RBC production → normocytic, normochromic anemia Laboratory findings ↓ Hemoglobin (Hb) MCV is usually normal. Consider erythropoietin-stimulating agents (ESAs): for patients with Hb < 10.0 g/dL

Answer 24

CKD-MBD refers to abnormalities in mineral and/or bone metabolism in CKD. Renal osteodystrophy refers specifically to issues with bone metabolism due to CKD. Pathophysiology - CKD results in hypocalcemia via different mechanisms. ↓ Renal excretion of phosphate → hyperphosphatemia → calcium phosphate precipitation in tissues → ↓ Ca2+ ↓ Renal hydroxylation of vitamin D → ↓ 1,25-dihydroxyvitamin D → ↓ intestinal Ca2+ absorption → ↓ Ca2+ Chronically decreased calcium levels can cause secondary hyperparathyroidism, which can progress to tertiary hyperparathyroidism. Histological classification Secondary hyperparathyroidism: high turnover bone disease or osteitis fibrosa cystica (metabolic bone disease) Osteomalacia: defective bone mineralization Mixed uremic bone disease: secondary hyperparathyroidism with osteomalacia Adynamic bone disease: decreased bone formation without osteomalacia Clinical features (may be asymptomatic initially) Musculoskeletal Fractures Bone and periarticular pain Muscular weakness and pain Extraskeletal Focal vascular calcification (atherosclerotic plaques) Diffuse vascular calcification (medial calcific sclerosis and calcific uremic arteriolopathy) Diagnostics Laboratory studies: frequent monitoring with a mineral and bone disorder panel Consider bone mineral density testing for patients with CKD category G3–G5. Treatment (under specialist guidance): The goal is to normalize phosphate, calcium, and PTH levels. Treatment of hyperphosphatemia, e.g.: Dietary phosphate restriction Phosphate binders (e.g., sevelamer) Treatment of hyperparathyroidism, e.g.: Cholecalciferol or ergocalciferol supplementation for vitamin D deficiency or insufficiency Calcitriol (not routinely recommended) Calcimimetics (e.g., cinacalcet) Parathyroidectomy (last-line therapy)

Answer 25

CKD = Independent risk factor for CAD, HF, arrhythmia Left ventricular hypertrophy is common Hyperkalemia + ACEi/ARB = risk of arrhythmia Troponin can be elevated chronically in CKD (especially hs-TnT) CKD alters drug clearance – watch contrast nephropathy, digoxin, antiarrhythmics, NOACs

Answer 26

Troponin can be chronically elevated in CKD. Look at the delta (serial rise), ECG, symptoms. Don't jump to STEMI.

Answer 27

No! Up to 30% rise is expected and acceptable. Only stop if: Hyperkalemia Severe drop in GFR Volume depletion

Answer 28

Secondary hyperparathyroidism. ↓Calcitriol → ↓Ca → ↑PTH, compounded by hyperphosphatemia.

Answer 29

They're renoprotective – reduce intraglomerular pressure and progression of CKD.

Answer 30

Hyperkalemia with ACEi Digoxin clearance Troponin misinterpretation NOAC use and GFR thresholds

Answer 31

Small kidneys, stable labs over months, anemia, PTH changes

Answer 32

A Anemia (↓EPO) B Bone disease (CKD-MBD) A Acidosis (metabolic) D Dyslipidemia H Hypertension O Overload (fluid/Na) M Malnutrition E Electrolyte issues (K, Ca, PO₄) S Sodium/water retention or Secondary hyperparathyroidism

Answer 33

ACEi/ARB Blood pressure <130/80 Check labs (K, Ca, PO₄, Hb) Dietary control (Na, protein, K, phosphate) EPO & Vitamin D analogs