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ORAL REVALIDA CLINICALS > CHRONIC KIDNEY DISEASE > Flashcards

CHRONIC KIDNEY DISEASE Flashcards

1
Q

Define CKD

A

Abnormality of kidney STRUCTURE & FUNCTION with an eGFR of 60 mL/min/1.73 square meters for a minimum of 3 months regardless of the cause

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2
Q

What are pre-renal causes of CKD?

A

HF, Cirrhosis

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3
Q

What are intrarenal causes of CKD?

A

Intrenal:

  1. RENAL VASCULAR CAUSES - Hypertension, Renal Artery Stenosis
  2. GLOMERULAR DISEASES - Nephrotic, Nephritic Syndromes
  3. TUBULOINTERSTITIAL DISEASE - Polycystic Kidney Disease
  4. NEPHROTOXIC SUBSTANCES - Lead, Cisplatin
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4
Q

Enumerate Nephrotoxic Substances

A 
Cisplatin
Methotrexate
Lithium 
NSAID
Diphenhydramine 
Beta Lactam
Rifampin
Sulfonamide
Benzodiazepines (rhabdomyolysis)

Chinese herbals with aristocholic acid

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5
Q

Enumerate Post renal causes of CKD

A

Prostatic Disease

Repeated Episodes of Pyelonephritis

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6
Q

Markers of kidney damage that should be present for >3 months:

A
  1. Albuminuria - magic number 30 mg for AER and ACR
    Albumin excretion rate ≥ 30 mg/24 hours, or
    Albumin to creatinine ratio (ACR) ≥ 30 mg/g
  2. Decreased GFR <60 mL/min/1.73m2 (GFR categories G3a-G5)
  3. Urine Dipstick & Sediment - BROAD WAXY CAST
  4. Abnormality detected thru HISTOLOGY
  5. Structural abnormalities detected thru IMAGING (On abdominal ultrasound, CKD can cause scarring —> makes kidney SMALL & ECHOGENIC)
  6. History of KIDNEY TRANSPLANT
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7
Q

Define Oliguria

A

UO of <400 mL/day

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8
Q

Signs & Symptoms of CKD

A

Edema
Oliguria (<400 mL/day)
Fatigue
Weakness
Anorexia
Hypertension (Na retention, inc RAAS activation, SECONDARY PARAHYPERTHYROIDISM)
Anemia - Kidney not making enough erythropoietin, in those undergoing hemodialysis —> regular blood loss
Iron Deficiency Anemia - diet low in Iron, blood loss, impaired absorption of iron

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9
Q

What could cause HTN in CKD?

A

Na retention, inc RAAS activation, SECONDARY PARAHYPERTHYROIDISM

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10
Q

What could cause gross Hematuria in CKD?

A

IgA nephropathy

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11
Q

What is CKD-MBD?

A

CKD-Mineral & Bone Disorder
Metabolic changes —> HYPERPHOSPHATEMIA, HYPOCALCEMIA
Skeletal Abnormalities
Extra-skeletal Calcifications - coronary artery calcifications

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12
Q

How does CKD cause hypocalcemia? And hyperphosphatemia?

A

Kidneys unable excrete phosphate —> hyperphosphatemia —> improper conversion of 25-hydroxyvitamin D to 125-dihydroxyvitamin D (calcitriol which is the active form of vitamin D) —> low levels of calcitriol —> hypocalcemia —> INCREASE PARATHYROID HORMONE —> SECONDARY PARATHYROIDISM (large hypertrophied PTH)

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13
Q

Symptoms of Hyperkalemia?

A

Palpitations, Paresthesias, Muscle Weakness

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14
Q

What acid imbalance happens on CKD?

A

METABOLIC ACIDOSIS

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15
Q

What symptoms of UREMIA can be present in CKD?

A

Uremia - accumulation of Uremic Toxins —> heart brain affected as well
Nausea, Vomiting, Weight Loss
Fatigue
Pruritus* (skin)
Bleeding & Easy Bruising* (platelet disruption)

(HEART) Uremic Pericarditis - chest pain, pericardial friction rub

(BRAIN) Uremic neuropathy - confusion, ASTERIXIS*, MYOCLONUS, DISTAL SYMMETRICAL PLOYNEUROPATHY & PARESTHESIAS, SEIZURES & COMA, SEXUAL DYSFUNCTION

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16
Q

What does a bubbly urine suggest?

A

Proteinuria

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17
Q

Important to ask sa ROS ng CKD

A

(+) edema - Na+ retentio

(+) Signs of uremia like weight loss, n/v, pruritus, muscle cramps,

(+) abnormal bleeding

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18
Q

What to look for PE sa CKD patient?

6 items ito

A
  1. VS - high BP (Na+ retention)
  2. Signs of dehydration
  3. FUNDOSCOPY*** - DM and HTN retinopathy
  4. ABDOMINAL EXAMINATION*** bruits/palpable masses
  5. Extremities - EDEMA, MUSCLE WEAKNESS, ASTERIXIS
  6. PROSTATE SIZE/POTENTIAL PELVIC MASSES THAT CAN CAUSE OBSTRUCTION
19
Q

Diagnostic plan: Why important to request Serum BUN, Creatinine?

A

To obtain eGFR value which is important in staging CKD?

20
Q

Diagnostic plan: Why important to request Urinalysis?

A

***BROAD WAXY CAST - indicative of CKD

Microscopic hematuria - GBM disorder as an underlying cause of CKD

RBC casts, dysmorphic - GN as an underlying cause

Granular and renal tubular epithelial cells - may point parenchymal diseases as cause of CKD

21
Q

Diagnostic plan: Why important to request ANA, C3 and anti-dsDNA

A

SLE as an underlying cause of CKD

22
Q

Diagnostic plan: Why important to request CBC?

A

To check for anemia since there is decreased EPO production in patients with CKD

23
Q

Diagnostic plan: Why important to request check Calcium, Phosphate and Parathyroid Hormone levels?

A

To check for metabolic bone disease caused by CKD

24
Q

Diagnostic plan: Why important to request Renal Ultrasound?

A

Renal ultrasound verifies the:
presence of 2 kidneys
Size of kidneys
And rules out any obstruction that might have caused CKD

25
Q

In CKD, both kidneys are bilaterally contracted except

A

DM nephropathy, HIV assoc nephropathy, PKD, Amyloidosis

26
Q

Ultrasound findings in Renal ultrasound

A

Reduced cortical thickness <6 mm
Reduced length
Increased renal cortical echogenicity (loss of corticomedullary differentiation)

27
Q

Diagnostic plan: Why important to request Kidney Biopsy?

When is it not advised?

A

Kidney Biopsy if GN is considered as a cause of CKD

CI: 
bilaterally contracted kidneys, 
uncontrolled  hypertension, 
active UTI, 
bleeding diathesis, 
UTI
28
Q

Diagnostic plan: Why important to request ABG?

A

Metab Acidosis

29
Q

Diagnostic plan: Why important to request Serum Electrolytes?

A

To determine abnormalities from deranged renal function

30
Q

Management for Volume Overload

A 
Loop Diuretics (FUROSEMIDE) may add METOLAZONE
—> if no response, adjust dose
Dietary Salt Restriction
Dialysis if volume is intractable
31
Q

Management for Salt-Losing Nephropathy?

A

Sodium-rich diet or salty supplementation

Water restriction if with hyponatremia

32
Q

Management for Hyperkalemia

A

Kaliuretic Loop Diuretic (FUROSEMIDE)

K-binding resins (CALCIUM RESONIUM) - promotes potassium loss in the GI tract

33
Q

***Which medications to avoid for hyperkalemia???

A

Avoid potassium-retaining medications (ACEIs, ARBs)

Go for CCBs of B Blockers

34
Q

Mgt for Metabolic Acidosis

A

Alkali Supplementation

Dialysis if intractable

35
Q

Mgt for Disorders of Ca and PO4 Metabolism

target PTH level?

A

Optimal management of secondary hyperparathyroidism and osteitis fibrosa is prevention

Achieve a target PTH level of between 150 and 300 pg/mL

Achieve a target PTH level of between 150 and 300 pg/mL

PTH suppressant - CALCITRIOL
Note: very low PTH levels are associated with adynamic bone disease, fracture and ectopic calcification

Phosphate-binding agents: CALCIUM CARBONATE (taken with meals)

36
Q

What is the target BP in CKD patients with DM or proteinuria >1g/24h???

What is the FIRST LINE THERAPY?
What is the DRUG OF CHOICE?
Contraindications of DOC

A

<130/80 mmHg
First line therapy: SALT RESTRICTION
DOC: ACEIs or ARBs – slow the decline of kidney function

CI: hyperkalemia and AKI with ischemic renovascular disease

37
Q

Before starting choice of Antihypertensives in patients with CKD what must be done?

If baseline goal is not met… shift to which medication?

A 
Before starting, get the baseline CREATININE
POTASSIUM levels (Hyperkalemia CI ng ARBs and ACEIs

Monitor Creatinine for 1week, GFR reduction should not be 30% from baseline!

K levels should not be >5.5

Non-dihydropyridine CCBs (Diltiazem and Verapamil)
Superior ANTI-PROTEINURIC and RENOPROTECTIVE effects compared to the dihydropyridines → Alternative if ACEIs/ARBs are contraindicated

38
Q

What is the management of the Hemostatic Abnormalities in CKD?

What are the hemostatic abnormalities?

TARGET HEMOGLOBIN CONCENTRATIONS

A

HEMOSTATIC ABNORMALITIES: bleeding & anemia
ANEMA
1. Recombinant erythropoiesis-stimulating agents (ESA) (epoetin alpha, epoietin beta)
2. BT generally avoided but if ESA fails
3. Iron Supplementation oral or IV
4. Vit B12 and Folate

target hgb concentration*** 100-115 g/L!!!!!
Not normal levels, because there is an increased risk of MI and stroke if high Hgb levels

BLEEDING
Abnormal bleeding time and coagulopathy may be reversed temporarily with the ff: Desmopressin DDAVP

Optimal dialysis - usually corrects prolonged bleeding time
((Ok di ko na mamememorize to pero ayun 100 to 115 g/dL ang target hemoglobin concentration))

normal hemoglobin concentration is
MALE: 14 to 18 g/dl
FEMALE: 12 to 16 g/dl

39
Q

Which class of medications would warrant their maintenance doses needing adjustment?

WHICH DRUGS ARE AVOIDED????

A

Antibiotics, Antihypertensives, anti-arrhythmics needing adjustment

METFORMIN, MEPERIDINE, NSAIDs, GALODINIUM (Nephrotoxic Contrast Agents)

40
Q

CUT OFF GFR FOR METFORMIN ADMINISTRATION

A

<45% GFR!!!!!!!!!!!!!!!!!

Stage G3a

41
Q

G stages

A

1, 2, 3a, 3b, 4, 5

90, 60, 45, 30, 15, below 15

42
Q

Fun fact: GFR decreases ________mL/min/year after the age of ______

A

1 mL/min/yr after the age of THIRTY!!!!!!!!!

43
Q

INDICATIONS FOR DIALYSIS (AEIOU)

A

Acidosis, Electrolyte Imbalance (Hyperkalemia), Intoxication, Overload (volume), Uremia

GFR <15mL/min/1.73m2 (DIABETICS)

BUN >100 mg/dL
Oliguria
Slow-type of dialysis

ORAL REVALIDA CLINICALS (4 decks)

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