Approach to Patients witch CKD

Question 1

Chronic kidney disease (CKD) is defined as

Answer 1

eGFR <60 mL/min or kidney damage that persists for at least 3 months

Question 2

What is a significant limitation of urine dipstick?

Answer 2

Measures concentration only, and can give falsely negative results in dilute urine

Question 3

Define GFR

Answer 3

Volume of serum cleared by the kidneys per unit of time

Question 4

Creatinine is produced from … and excreted by …

Answer 4

Muscle & kidneys

Question 5

Normal creatinine

Answer 5

Men - 0.6 - 1 mg/dl
Female - 0.8 - 1.3 mg/dl

Question 6

Serum creatinine levels are influenced by

Answer 6

Muscle mass, recent dietary intake (cooked meat), concomitant drug therapy

Question 7

The main risk factors for progression of renal disease include:

Answer 7

Smoking, high blood pressure, hyperglycemia in diabetic patients

Question 8

How does smoking impact the progression of renal disease?

Answer 8

Accelerates the rate of progression

Question 9

Why are ACE/ARBs recommended in CKD?

Answer 9

Whether or not hypertension is present they are utilized to slow the rate of kidney disease progression in patients with proteinuria
- works by decreasing pressure in the kidneys

Question 10

What and when to monitor with ACE/ARBs?

Answer 10

Blood pressure, potassium, and creatinine with initiation and after each dose change.
Check labs in 2-4 weeks

Question 11

What percent of creatinine increase is expected when initiating ACE/ARBs and when should you expect to see it?

Answer 11

An increase of ~30% is ok, you should see this in the first two weeks, and it should stabilize in 2 to 4 weeks.
- Discuss discontinuing medication with the attending if the creatinine is higher than 30%

Question 12

If there is a significant rise in creatinine when initiating ACE/ARBs what should you assess for?

Answer 12

Renal artery stenosis via renal artery duplex

Question 13

Utilizing an ESA with hemoglobin =>13 g/dl is associated with

Answer 13

No benefit
CVA
Increased risk of cardiovascular complications
Death

Question 14

The cause of iron deficiency is multifactorial but include:

Answer 14

Reduced absorption of iron
Blood loss from frequent blood draws or GI loss
Reduced nutritional intake

Question 15

Ferritin’s serum levels reflect

Answer 15

Iron storage

Question 16

What is the TSAT?

Answer 16

Total iron binding compacity

Question 17

What is the TSAT goal?

Answer 17

=> 30%

Question 18

How should ferritin be interpreted when assessing for iron deficiency anemia and why?

Answer 18

Cautiously
Ferritin increases with inflammation and CKD patients often exhibit chronic inflammation

Question 19

TSAT of <20% is indicative of

Answer 19

Low iron availability

Question 20

Describe the relationship between ESA and iron deficiency?

Answer 20

Iron deficiency can lead to decreased effectiveness of ESA therapy

Question 21

How often should iron therapy be monitored?

Answer 21

Every three months

Question 22

What labs should you order when monitoring iron therapy?

Answer 22

TSAT and ferritin

Question 23

Hyperphosphatemia is associated with

Answer 23

Increased risk of vascular calcification and left ventricular hypertrophy in ESKD

Question 24

Hyperparathyroidism is associated with

Answer 24

Bone disease

Question 25

Why does the PTH range increase with CKD?

Answer 25

As CKD progresses, the bone becomes resistant to the actions of PTH and so the target PTH range increases

Question 26

In non-dialysis CKD patients what is the recommended first-line treatment for elevated PTH?

Answer 26

Vitamin D

Question 27

How does CKD progression affect 25-D /1,25D and PTH?

Answer 27

Serum levels of 1,25D may be reduced and PTH suppression may be inadequate

Question 28

What drug class is cinacalcet?

Answer 28

Calcimimetic

Question 29

What does cinacalcet do?

Answer 29

Increases the sensitivity of calcium receptors on the parathyroid gland to calcium, resulting in decrease PTH secretion

Question 30

How does chronic metabolic acidosis affect bone health and CKD?

Answer 30

Results in increased resorption of bone, an increased rate of progression of CKD

Question 31

What is the effect of dialyzer blood flow rate on clearance?

Answer 31

The volume of blood cleared of urea increases as blood flow rate increases

Question 32

What is the effect of dialysis solution flow rate on clearance?

Answer 32

Faster dialysis solution flow rate increases the efficiency of diffusion of urea however it is usually modest.

Question 33

What is the optimum dialysis solution flow rate?

Answer 33

1.5-2 times the blood flow rate

Question 34

Kt/V urea goal

Answer 34

> 1.2 or 1.2-1.4 depending on the attending