Approach to CKD Epi and Staging

Question 1

3 lab tests needed to evaluate CKD

Answer 1

Biochemistry: creatinine + GFR
Urinalysis: dipstick and microscopy
Proteinuria measurement: ACR or PCR
+/- imaging (US)

Question 2

When does the eGFR equation perform poorly?

Answer 2

Extremes of body size (body builders, amputees, cachectic elderly)

Question 3

CKD definition

Answer 3

Abnormality of kidney function or structure that is present for > 3 months
1. Persistently abnormal kidney function (GFR < 60) due to intrinsic disease of the kidneys
OR
2. Normal function but persistent structural/functional abnormality with either markers of kidney damage, pathologic abnormalities, or kidney transplant

Question 4

GFR cut offs (G1-G5)

Answer 4

G1: 90+
G2: 60-89
G3a: 45-59
G3b: 30-44
G4: 15-29
G5: < 15

Question 5

5 main risk factors for CKD

Answer 5

HTN
Diabetes
Atherosclerotic coronary, cerebral, or peripheral vascilar disease
Fam hx of kidney disease
High risk ethnicity (FN, south asians, pacific islanders)

Question 6

Hints for a chronic kidney problem

Answer 6

Look at old creatinine/eGFR results
Small kidneys on ultrasound (scarred) - or rarely large (polycystic)
Elevated PTH
Anemia
Presence of uremic symptoms

Question 7

4 reversible factors from a change in eGFR

Answer 7

Volume depletion
Infection
Meds (NSAIDs, IV contrast dye, diuretics, etc)
Obstruction

Question 8

What are normal values for

1. ACR
2. PCR

Answer 8

1. < 3.0

2. < 15.0

Question 9

Normal or abnormal?

1. Hyaline casts
2. Cellular casts
3. Granular casts
4. Epithelial cells
5. Renal tubular epithelial cells
6. Bacteria

Answer 9

1. Normal
2. Abnormal (always)
3. Abnormal in large numbers
4. Normal
5. Abnormal in large numbers
6. Abnormal if WBCs also present, otherwise more likely contamination

Question 10

Some common causes of CKD

Answer 10

HTN
Diabetes
Ischemic/vascular
GN
Polycystic kidney disease
Drug induced
Pyelonephritis
Reflux

Question 11

Uremic syndrome symptoms

Answer 11

Typical symptom onset with GFR < 30
Solute retention symptoms: fatigue, cold intolerance, nausea, anorexia, metallic taste, wasting, pruritus, restless legs, leg cramps, constipation
Fluid retention symptoms: edema, SOB, pulmonary edema

Question 12

General treatment strategies

Answer 12

BP control (ACEIs/ARBs are good for the kidneys)
Glycemic control if diabetic
Na and protein diet restriction
Avoiding volume depletion
Lifestyle (weight loss, exercise, smoking cessation)
Vaccinations

Question 13

BP control with CKD 1/2/3 line meds

Answer 13

1st line: ACEi or ARB (avoid combo)
2nd line: long acting CCB
3rd line: diuretic

Question 14

Effect of
1. NSAIDs
2. ANP, prostaglandin
3. ANP, AII, NE
4. ACEI/ARB
on what arteriole and what is its effect on GFR

Answer 14

1. Vasoconstrict afferent arteriole, decrease GFR
2. Vasodilate afferent arteriole, increase GFR
3. Vasoconstrict efferent arteriole, increase GFR
4. Vasodilate efferent arteriole, decrease GFR