Chronic Kidney Disease

Question 1

3 Definitions

Answer 1

eGFR <60 for >/3 mo
OR
Kidney Damage >/3 mo: persistent proteinuria (significant + dip 2/3 OR +ACR done 2-8w apart) 
OR 
abnormal urinary sediment 
OR 
abnormal imaging

Question 2

5 Symptoms

Answer 2

Fatigue
Anorexia 
Nausea / Vomiting
Edema
Oliguria
Anemia
Pruritis

Question 3

5 Risk Factors

Answer 3

Age
BMI
DM 
HTN 
Vascular disease 
Glomerular disease (autoimmune, malignant, systemic infection, renally excreted drugs, neoplasia) 
Tubulointerstitial disease (UTI, stones, obstruction, drug toxicity) PCKD 
Smoking

Question 4

5 Factors that affect GFR

Answer 4

Extreme Weights
Muscle Mass
Amputation 
Paralysis
Specific Diets (high / low protein)
Meds that affect Cr excretion
Illness
Pregnancy

Question 5

Who do you screen and how often? Is age alone a reason to screen?

Answer 5

Q 1 -2 years (q yearly for DM)
Age > 18 AND First Nations, Inuit, Metis
HTN
DM
Age 60-75 w/ CVD
Age alone is NOT a reason to screen

Question 6

Diagnostic criteria? How often do you repeat the test?

Answer 6

eGFR: <60 then repeat in 3 mo or sooner if rapid decline
Adjust for black patients by x 1.21
Urine Albumin-creatinine Ratio: >/3 repeat 1-2x over next 3 mo

Question 7

List 5 DDx / Reversible causes

Answer 7

Acute Illness
Dehydration
AKI
NSAIDS
BPH / Retention

Question 8

After diagnosis, how often / what do you check for disease progression?

Answer 8

Measure Cr 2x, 2-6 weeks apart

Question 9

5 complications / co morbidities

Answer 9

AKI
anemia
HTN
LVH
CHF / Volume Overload
Hypocalcemia
Hyperkalemia
Hyperparathyroid
Hyperphosphatemia
Metabolic Acidosis 
Malnutrition
Drug Toxicity

Question 10

List 5 additional measurements and labs do you order after diagnosis?

Answer 10

1. BP (cause)
2. BW
   FBG (cause)
   Cr, BUN
   Extended Lytes (Ca, Pho, Mg) (complication)
   CBC, Ferritin, TIBC (complication)
   Serum protein electrophoresis + Bence jones proteins
3. Urinalysis:
   Hematuria + proteinuria (glomerular)
   Proteinuria (>+1 protein) -> investigate further with albumin / cr ratio of 1st am void (2/3 ACR >/3mg/mmol within 3 mo confirms CKD)

Question 11

What imaging would you consider? Why?

Answer 11

Kidney Ultrasound: r/o hydronephrosis, stones, cysts

Question 12

5 Lifestyle Interventions

Answer 12

Smoking cessation
Healthy weight (nutrition, exercise)
Diet modification if eGFR<60 (not on dialysis)
Limit sodium (<2g/day or <5g salt/day), protein (0.8g/kg/day), phosphate (0.8g/day), calcium (1.5g/d), potassium (1.5g/d)
Moderate alcohol consumption

Question 13

Preferred medication for CKD + HTN

Answer 13

Acei / ARB

Question 14

Steps to treat and monitor if CKD stage 3 + proteinuria. What is an acceptable increase in Cr, lytes? What is an acceptable K+ level? What are indications to stop the drug?

Answer 14

ACEi / ARB controversial
Consult nephrology
Monitor Cr, BUN, lytes weekly until baseline
An increase fo 20 - 30 % is acceptable
K+ of 5.5 is acceptable if stable
If K+ > 5.5 or Cr > 30% baseline stop drug

Question 15

When do you NOT use an ACEi / ARB in CKD?

Answer 15

With no proteinuria

Question 16

What are target BP for HTN in CKD

Answer 16

<120 SBP

Question 17

Is a statin indicated in CKD?

Answer 17

Yes, it is a statin indicated condition

Question 18

What is the DM target?

Answer 18

A1c < 7%

Question 19

How often is Cr, ACR, K monitored?

Answer 19

Measure Cr at least q 6 mo
ACR q6-12 mo
Measure K w/ med / clinical change (target < 5.5)

Question 20

What must be monitored annually when eGFR < 30

Answer 20

annual CBC, iron, Ca, Pho, Albumin

Question 21

What further steps must be taken to minimize further renal injury?

Answer 21

Renally Dose Medications

Avoid NSAIDs, Aminoglycosides, Lithium, contrast media

Question 22

List 5 Sick Day Medications list (to avoid if unable to maintain hydration)

Answer 22

SADMANS:

Sulfonylureas, ACEI, Diuretics, Metformin, ARB, NSAIDs, SGLT2i

Question 23

What vaccinations are recommended?

Answer 23

Pneumococcal vaccine q 5 yr

Flu vaccine q yearly