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01 Family Medicine > AKI & CKD > Flashcards

AKI & CKD Flashcards

AAFP Board Review lecture: Acute Kidney Disease & Chronic Kidney Disease

1
Q

Name 4 functions of the kidney

A

Hormone secretion

Regulates blood pressure

RBC production- Erythropoietin

Calcium and phosphorous regulation

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2
Q

If a UA is positive for blood but no RBCs are present what should you consider?

A

Hemolysis

Rhabdomyolysis

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3
Q

What proteins are measured on a UA?

A

Only albumin

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4
Q

What UA finding likely indicates UTI?

A

Positive leukocyte esterase (highly sensitive, more likely to be sole indicator of UTI)

Positive nitrite is highly specific

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5
Q

What would you consider if UA showed WBCs but no bacteria?

A

Urethritis
Prostatitis
Interstitial nephritis (eosinophils)

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6
Q

Which type of casts can be normal and which are always abnormal?

A

Can be normal: hyaline and granular casts

Always abnormal: 
RBC casts (glomerulonephritis)
WBC casts (pyelonephritis)
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7
Q

What is the normal range of 24 hour urine protein excretion? pregnant v. non pregnant

What range indicates nephrotic syndrome?

A

<150 mg/24 hours if non-pregnant
<300 mg/24 hours if pregnant

3g/24 hours => nephrotic syndrome

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8
Q

What are the ranges for normal microalbumin/creatinine ratio v. microalbuminuria v. macroalbuminuria?

A

Normal: <30 mg/g

Micro: 30-300 mg/g

Macro: > 300 mg/g

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9
Q

What are the most common causes of death in patients with renal problems (AKI/CKD)?

A

Infection complications

Cardiopulmonary disease

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10
Q

What is the KDIGO criteria for AKI?

A
  • Increase in serum Cr of >=0.3 in 48 hours
  • Increase in serum Cr of >= 1.5 times baseline within the prior 7 days
  • Urine volume <0.5 mL/kg per hour for more than 6 hours
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11
Q

What is the most common cause of AKI?

A

Acute tubular necrosis

followed by prerenal causes

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12
Q

List some examples of prerenal AKI

A

Dehydration, bleeding

Shock, CHF (cardiorenal), cirrhosis (hepatorenal), thromboembolic disease

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13
Q

Name some causes of Acute Tubular Necrosis

A 
Hypotension, sepsis
Ischemia
Surgery, burns
Toxins
Rhabdo
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14
Q

Name some causes of Acute Interstitial Nephritis

A

Drugs
Autoimmune
Infection
Infiltrative diseases

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15
Q

What are some clinical signs of Acute Interstitial Nephritis?

A

Fever
Rash
Elevated serum and urine eosinophils

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16
Q

How to treat Acute Tubular Necrosis?

A

No therapy available to hasten recovery

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17
Q

How to treat Acute Interstitial Nephritis?

A

Remove offending agent if possible

+/- steroids (may be beneficial)

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18
Q

Name some drug classes that have increased risk of Acute Interstitial Nephritis

A 
PPIs
NSAIDs
Sulfonamides
Allopurinol
Thiazides, Furosemide
Pheytoin
Cephalosporins
Ciprofloxacin
Penicillin
Rifampin
Cimetidine
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19
Q

Name some causes of Intrarenal AKI

A

Multiple myeloma

Hypercalcemia

Tumor lysis syndrome

Acute phosphate nephropathy (ex: phosphate containing bowel prep for colonoscopy)

Glomerular disease

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20
Q

Clinical signs of glomerular intrarenal AKI?

A

Fever, rash, arthritis, edema

RBC casts, hematuria, proteinuria

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21
Q

Nephritic v. Nephrotic syndrome clinical findings

A

Nephritic:
RBCs and RBC casts in urine
HTN
mild proteinuria

Nephrotic:
Massive proteinuria
Edema
hypoalbuminemia
hyperlipidemia
hypercoagulable state
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22
Q

Nephritic or nephrotic?

Post infectious glomerulonephritis

A

Nephritic

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23
Q

Nephritic or nephrotic?

IgA Nephropathy

A

Nephritic

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24
Q

Nephritic or nephrotic?

Minimal change disease

A

Nephrotic

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25
Q

Nephritic or nephrotic?

Rapidly progressive glomerulonephritis

A

Nephritic

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26
Q

Nephritic or nephrotic?

Diabetic nephropathy

A

Nephrotic

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27
Q

Nephritic or nephrotic?

Focal segmental glomerulosclerosis

A

Nephrotic

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28
Q

Nephritic or nephrotic?

Mesangial proliferative glomerulonephritis

A

Nephrotic

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29
Q

Nephritic or nephrotic?

Membranoproliferative glomerulonephritis

A

Nephritic

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30
Q

Nephritic or nephrotic?

Membranous glomerulonephritis

A

Nephrotic

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31
Q

Nephritic or nephrotic?

Primary Amyloidosis

A

Nephrotic

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32
Q

Nephritic or nephrotic?

Henoch-Schonlein purpura

A

Nephritic

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33
Q

Nephritic or nephrotic?

Preeclampsia

A

Nephrotic

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34
Q

Nephritic or nephrotic?

Vaculitis

A

Nephritic

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35
Q

How to evaluate for postrenal AKI?

A

Renal US

*recovery is directly proportional to duration of obstruction

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36
Q

Signs to get a renal biopsy in patient with AKI?

A 
Oliguria
Rapidly worsening GFR
Ruled out pre and post renal causes
No clear intrinsic cause
May need confirmation of diagnosis before starting treatment (immunosuppressants)
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37
Q

Signs of contrast induced nephropathy?

A

Increase in serum creatinine >= 0.5 or 25% above baseline

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38
Q

Treatment of contrast induced nephropathy?

A

Usually reversible (1% -> dialysis)

Begins to improve in 3-7 days

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39
Q

Name some ways to prevent contrast induced nephropathy

A

Stop metformin 48 hours before

Isotonic IV hydration

Inconsistent evidence for urine alkalization, Acetylcysteine

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40
Q

How to interpret FENa?

A

<1% prerenal
1-2% intrinsic
>2-3% ATN

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41
Q

What should you use instead of FENa if a patient is on diuretics and why?

A

FeUrea: <35% prerenal, >50% ATN

diuretics induce Na excretion, looks like intrinsic renal

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42
Q

How can obstruction affect FENa?

A

early obstruction: <1%

chronic obstruction: >1%

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43
Q

What electrolyte disturbances can AKI cause?

A 
Metabolic acidosis
Hyperphosphatemia
Hyperkalemia
Hyper or hypo calcemia
Azotemia
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44
Q

How to calculate MAP and what is the goal?

A

(systolic + 2x diastolic)/ 3

Goal > 65

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45
Q

In patients with AKI and decreased or no urine output should diuretics be used to stimulate urine output?

A

No

Increased mortality, does not promote renal recovery

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46
Q

In patients with AKI and volume overload should diuretics be used to stimulate urine output?

A

Yes

Lasix 20-100 IV q6 as initial treatment

47
Q

What is the treatment of hyperkalemia?

A
  1. Calcium gluconate 10%, 10 ml IV - cardioprotection
  2. Insulin 10 u IV and glucose 25 g- shift K intracellular
  3. Inhaled beta agonists
  4. Patiromer (Veltassa) 8.4 - 25.2 g daily
  5. Sodium Bicarb 3 amps in 1L 5% dextrose
48
Q

When should bicarb be given in acidosis?

A

if serum bicarb <15 or pH <7.2

49
Q

What are the indications for dialysis in AKI?

A

Metabolic acidosis pH <7.1

Uremia- altered, pericarditis/pleuritis, neuropathy

Fluid overload refractory to diuretics

Hyperkalemia >6.5

Toxins- ethylene glycol, lithium

50
Q

Name some general principles of AKI prevention

A

Maintain hydration, avoid hypotension

Avoid nephrotoxic medications

Avoid unnecessary exposure to contrast

51
Q

Patients who have had an AKI are at higher risk for what 3 problems?

A

Developing CKD

Higher risk of ESRD

Higher risk of premature death

52
Q

What two cardiac conditions are patients with CKD at higher risk of?

A

Atherosclerotic CVD

Heart failure

*CVD is the cause of up to 50% of the deaths in pts with renal failure

53
Q

Where and why is renin released?

A

Released by the juxtaglomerular apparatus

Due to:
Fall in BP
Dec blood volume
Dec [Na] in distal tubule
Sympathetic stimulation
54
Q

What effects does Angiotensin 2 have?

A

Direct arterial vasoconstriction (efferent arterioles)

Aldosterone secretion from adrenal gland (Na retention)

Vasopressin release from post. pituitary (water retention at distal tubule)

55
Q

What effects do ACE inhibitors have?

A

Block conversion of angiotensin I to II

Increase levels of angiotensin I, renin and bradykinin

Lower arteriolar resistance

Increase venous capacity

Increase Na excretion

Enhance parasympathetic activity

56
Q

How do ACE inhibitors benefit CHF patients?

A

Reduce plasma norepinephrine levels:

  • reduce prevalence of cardiac arrhythmias
  • reduce sudden death
  • reduce cardiac remodeling that worsens CHF
57
Q

How may ACEi/ARBs change renal funtion?

A

Dilate efferent arteriole

  • Inc flow through glomerulus
  • Dec Cr excretion (increased serum Cr)
58
Q

How can you tell if an increase in Cr after starting and ACEi/ARB is a hemodynamic change v. structural change?

A

hemodynamic: If Cr increased 20-30% then stabilizes

Structural: >30% in Cr (d/c medication, work up causes of renal dysfunction)

59
Q

If Cr increases >30% after starting an ACEi/ARB, what causes might you think of?

A

Bilateral renal artery obstruction (also think about stenosis)

Low intravascular volume (dehydration, CHF)

Renal vasoconstriction (NSAIDS)

60
Q

True or False?

Patients with CKD are more likely to die of cardiovascular disease than to require dialysis

A

True

61
Q

What are the two main risk factors for CKD?

A

Diabetes
Hypertension

*Autoimmune, glomerular disease, cystic disease, toxins, family hx, lower urinary tract obstruction, infections, AKI, etc.

62
Q

What causes of CKD have the highest risk of developing ESRD and needing a transplant?

A

Diabetic kidney disease

HTN nephropathy

Chronic glomerulonephritis

Polycystic kidney disease

Chronic pyelonephritis

Renal calculi

63
Q

What is the KDOQI definition of CKD?

A 
Kidney damage for >3 months
-structural or functional
\+/- dec GFR
-abnormal testing, persistent albuminuria 
-Pathological abnormalities

or

GFR <60
+/- kidney damage

64
Q

GFR in CKD1

A

GFR >90 (normal) with kidney damage

65
Q

GFR in CKD2

A

GFR 60-89 (normal) but with other evidence of kidney damage

66
Q

GFR in CKD3a

A

GFR 45-59

67
Q

GFR in CKD3b

A

GFR 30-44

68
Q

GFR in CKD4

A

GFR 15-29

69
Q

GFR in CKD5 (ESRD)

A

GFR <15

70
Q

Albuminuria in CKD, stages?

A

A1 <30 mg/g

A2 30-300 mg/g (microalbuminuria)

A3 300 mg/g (macroalbuminuria)

71
Q

What are the baseline labs for CKD evaluation?

A

UA with microscopic

Random (or 24 hour) urine Cr/GFR

Random (or 24 hour) urine protein

CBC, CMP, Ca, Phosphorous

Uric acid

72
Q

What tests might you order in addition to the baseline labs for CKD evaluation?

A

Serum protein electrophoresis

Hep B and C, HIV

ANA

C3/C4

ANCA

Anti-GBM antibody

73
Q

What imaging may be helpful in CKD evaluation?

A

Renal US

CT kidneys and liver

MRI

Renal angiogram

Voiding cystourethrogram

74
Q

What are the indications to get a biopsy in CKD?

A

Persistent hematuria with low GFR or proteinuria

Nephrotic range proteinuria

CKD of unknown cause

75
Q

Who is at risk of developing Nephrogenic Systemic Fibrosis?

A

Patients with CKD4/5 (GFR <30), on dialysis, or with AKI who receive gadolinium contrast (MRI)

*gadolinium forms insoluble salts with anions and deposits in tissues leading to fibrosis

76
Q

What are some symptoms of Nephrogenic Systemic Fibrosis?

A

Skin plaques (itchy, painful, discolored)

Joint contractures

Fibrosis of organs

77
Q

What is the treatment of Nephrogenic Systemic Fibrosis?

A

None

Dialysis does not help

Avoid gadolinium if GFR <15

78
Q

Management of CKD 1 and 2?

A

Diagnose and treat comorbid conditions

Slow progression

CV risk reduction

Encourage patient self management

79
Q

Management of CKD 3?

A

Evaluate and treat complications

Slow progression

CV risk reduction

Encourage patient self management

80
Q

Management of CKD 4?

A

Refer to nephrology

Prepare for kidney transplant

Continue measure to slow progression and eval and treat comorbid conditions

81
Q

Management of CKD 5?

A

Transplant or dialysis

82
Q

How often should GFR be monitored in CKD?

A

At least yearly

More often if GFR <60 or fast progression

83
Q

Name some complications of CKD?

A

HTN

Anemia

Acidosis

Hyperkalemia

Metabolic bone disease

Cardiovascular disease

84
Q

What should be reviewed at all visits in patients with CKD?

A

Medications

  • renal dosing as GFR changes
  • Monitor side effects
  • D/c meds with adverse renal effects
85
Q

KDOQI HTN guidelines for CKD

BP goal?

A

If albumin/Cr ratio <30: BP <140/90

If alb/Cr ration >30: BP <130/80

86
Q

KDOQI HTN guidelines for CKD

Medication selection?

A
  • ACEi/ARB if DM or proteinuria
  • Include diuretics for most patients
  • Additional agents should be selected based on CVD indications
87
Q

KDOQI HTN guidelines for CKD

Use ACEi/ARB if?

A

Patients with DM kidney disease:
-Alb/Cr ratio >30 or GFR <60, +/- HTN

Patients with NON dm kidney disease:
-Alb/Cr ratio > 300 or urine alb >300 in 24 hours, +/- HTN

*ACEi/ARB can be used safely in most patients with CKD

88
Q

KDOQI HTN guidelines for CKD

Diuretic use?

A

Use thiazides if GFR >30
Use loops if GFR < 30

*Caution in K sparing diuretics due if GFR <30, taking ACEi/ARB, HyperK risk factors

89
Q

KDOQI HTN guidelines for CKD

Dietary Na goal?

A

Less than 2.4 grams/day of Na

90
Q

KDOQI Anemia guidelines for CKD

Definition of anemia?

A

Males: Hb <13.5

Females Hb <12

91
Q

KDOQI Anemia guidelines for CKD

Initial labs?

A

CBC (annually)

Absolute reticulocyte count

Ferritin

transferrin saturation

Iron

TIBC

92
Q

Serum iron, TIBC and Fe/TIBC in Anemia of chronic disease v. Iron deficiency anemia?

A

Anemia of chronic disease: Low Fe, TIBC low, Fe/TIBC normal (>15%)

Iron def: Low Fe, TIBC high, Fe/TIBC low (<15%)

93
Q

Treatment of anemia of chronic disease?

A

Treat underlying cause

Erythropoiesis- stimulating agents

Transfusion

94
Q

When to use erythropoiesis- stimulating agents?

A

Symptomatic anemia not improved by treating underlying cause

Hb <11 or <10 (if dialysis)

95
Q

What are some risks of Erythropoiesis- stimulating agents?

A

Increased mortality and risk of CV events (MI, CVA, CHF) in CKD patients

Increased mortality and risk of tumor progression in cancer patients

Increased thromboembolic events in surgery patients

Contraindicated in uncontrolled HTN

96
Q

KDOQI Anemia guidelines for CKD

Transfusion principles

A
  • Use transfusion judiciously (sensitivity affects future transplant ability)
  • No specific Hb trigger
  • EPO target Hb is not a transfusion trigger
97
Q

Causes of anion gap metabolic acidosis?

A

MUDPILES

Methanol
Uremia
DKA
Propylene Glycol
Iron and INH
Lactic acidosis
Ethylene Glycol
Salicylates
98
Q

What causes metabolic acidosis in CKD?

A

Decreased H+ excretion

Bicarb <22 associated with increased CKD progression and inc mortality

99
Q

Treatment of acidosis in CKD?

A

Goal: serum CO2 >=22

-Na bicarb (0.5-1 mEq/kg/day)
-Na citrate
-Ca acetate
Ca carbonate

100
Q

Pattern of Ca, PO4 and PTH in CKD?

A

Ca low
PO4 high
PTH high

*Secondary hyperparathyroidism

101
Q

What causes Secondary hyperparathyroidism in CKD?

A

Dec GFR -> phosphate retention

Decreased free Ca

Decreased 1,25 Vit D

102
Q

KDOQI dietary phosphorous guideline?

A

Less than 800-1000 mg/day if PO4 is elevated

Use PO4 binders if phosphate is uncontrolled despite diet

103
Q

Name 3 PO4 binders

A

Non Calcium containing:
Sevelamer (Renleva) 800- 1600 mg TID
Lanthanum (Fosrenol) 1500-3000 mg/day

Calcium containing:
Ca acetate (PhosLo) 1300-2600mg with meals

*non-calcium containing binders, better per KDOQI

104
Q

What is calciphylaxis?

A

Calcific uremic arteriolopathy
-Ca deposits in small vessels, skin, fat

CKD5 on dialysis patients most at risk

105
Q

What are the symptoms of calciphylaxis and treatment?

A

Extremity pain, non healing ulcers, infection

Tx: Na thiosulfate

*high 1 year mortality

106
Q

Explain screening for albuminuria, who? how often?

A

T1 DM: 1-5 years from initial diagnosis

T2DM: At diagnosis

If normal, screen annually

If positive, confirm with samples over 3-6 months (confirmed if 2/3 samples positive)

107
Q

What is the preferred test for albumin screening?

A

Random spot albumin/Cr ratio

Normal <30 mg/g
Microalbuminuria 30-299 mg/g
Macroalbuminuria >300 mg/g

108
Q

What are some ways to prevent progression of albuminuria?

A

Intensive blood glucose and blood pressure control

ACEi/ARB therapy

109
Q

If a patient has diabetes, normal blood pressure and alb/Cr ration is less than 30, should they be started on an ACEi/ARB to prevent CKD?

A

NO

If a patient has diabetes and normal blood pressure only start ACEi/ARB if they have an alb/Cr ratio >30 or GFR <60

110
Q

When should a patient with NON diabetic CKD get an ACEi/ARB?

A

If they have HTN or alb/Cr >300

111
Q

What is the dietary protein goal for CKD patients?

A
  1. 8- 1.0 g/kg/day in early stages

0. 8 g/kg/day in later stages

112
Q

When should CKD patients be referred to nephrology?

A

If they develop:

Complex, severe CVD

Anemia

Bone mineral disorder

Hyperkalemia (K >5.5 despite treatment)

Alb/Cr > 300 mg/g

Resistant HTN (on 3+ medications)

CKD stage 4 (GFR <30)

Unexplained decrease in GFR (>30%)

113
Q

What is the goal Hb for a patient on erythropoiesis- stimulating agents?

A

Hb goal should not exceed 11

01 Family Medicine (16 decks)

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