Chronic Kidney Disease Flashcards
What are the major functions of the kidneys?
Excretion of waste
Fluid balance
Electrolyte balance
pH balance
Calcium homeostasis
REgulation of RBC production
What is End stage renal disease defined as?
GFR < 15mL/min
need dialysis or kidney transplant o live
What is used to classify CKD?
GFR and Albuminuria
How long must an abnormaility in kidney structure or function be present that has health implications exist to be CKD
3 months or longer
What are risk factors of CKD?
diabetes
high BP
heart and blood vessel disease
obesity
family history
abnormal kidney structure
older age
smoking
How to symptoms and signs of CKD develop?
slowly; nonspecific hard to notice as it can be asymptomatic, can’t feel pain in kidneys.`
What does rhabdomyolysis cause in kidneys?
tubular necrosis
What is the GFR of G1?
> 90 mL/min
Normal/ high
What is the GFR of G2?
60-89 mL/min
Mildly decreased
What is the GFR of G3a?
45-59 mL/min
midly to moderately decreased
What is the GFR of G3b?
30-44 mL/min
moderately to severly decreased
What is the GFR of G4?
15-29 mL/min
severely decreased
What is the GFR of G5?
<15 mL/min
Kidney failure
What is the albumin:Creatinine ratio of A1?
< 30 mg/g
normal to midly increased
WHat is the albumin: creatinine ratio of A2?
30-300 mg/g
moderately increased
What is the albumin: creatinine ratio of A3?
> 300
severely increased
What paramaters are needed to diagnose CKD without signs of damage to the kidneys?
A GFR of < 60mL/min for atleast 3 months
Can CKD be diagnosed with a GFR > 60mL/min?
Yes, if evidence of kidney damage; proteinuria present for at least 3 months
What is needed if their is a loss of renal functions resulting in the build up of toxins?
Dialysis; Kidney transplant
What are symptoms of toxin build up?
Fatigue, weakness, shortness of breath, loss of apetite, cold intlerance
What are some signs of toxin build up?
Edema, weight gain, urine output change, abdominal distension, foaming of urine
At what GFR do thiazide diuretics lose their effectiveness?
less than 30 mL/min
What is ESRD?
End stage renal disease; kidneys permanently fail to worke
What are the treatment options for ESRD?
Dialysis treatment; peritoneal and hemodialysis
Kidney transplant is “curative” option
What kidney transplant makes up ~20% of kideny transplants and has a lower risk of rejection and improved survival rates as well as quality of life, lower treatment costs, and avoidance of dialysis?
Pre-emptive kidney transplant
How can hypertension contribute to CKD?
Increased glomerular pressure leading to damage
increased ANG2 promoting tissue remodeling
glomerular dysfunction leading to protein leakage
What are first line agents for Hypertension CKD?
ACEI or ARBs usually paired with a diuretic
How does proteinuria contribute to CKD progression?
Promotes additional loss of nephrons via direct cellular damage.
T or F. Proteins are toxic to tubular cells.
True
What can additional damage from proteinuria lead to?
Cause increased production of inflammatory cytokines and damage can lead to scarring, structural change, and progressive loss of renal function.
How can proteinuria be identified?
Albumin to creatinine ratio
Protein dipstick
Blood levels can decline in severe proteinuria
How can daibetes impact CKD?
Glycated products can damage kidney structure directly
How can CKD progression be slwoed in daibetes?
Glucose control
What is the leading cause of death in all stages of CKD?
Cardiovascular disease
What are non-traditionalrisk factors that appear to accelerate risk of atherosclerotic cardiovascular disease?
Anemia
High phosphate, high PTH
Generalized inflammaton
What lower baseline correlates with overall reduced risk for ESRD?
SCr; lower albumin excretion
What is a first line agent for CKD in patients with diabetes and nephropathy?
ACEI / ARBs
At what GFR does hyperkalemia become a serious problem?
below 5mL/min
What are some options for hyperkalemia treatment?
K-wasting diuretics
Potassium-binding resins
Sodium polystyrene sulfonate
Calcium polystyrene sulfonate
Minimal use of K-sparing diuretics/ medications
Altering diet; less K intake
How does Sodium polystrene sulfonate work?
Binds K in GI tract in exchange for Na
Onset of effect is slow, not an emergency treatment
What is the dosing of Sodium polystrene sulfonate? Dosage forms?
15-60 g per day, 100mg Na per 1 g drug
Powder, suspension, or recatal suspension
How does Calcium polystrene sulfonate work?
Binds K in GI tract in exchange for Ca
What is the dosing for calcium polystrene sulfonate?
15g, 3-4 times a day
What is an issue with both Na/Ca polystrene sulfonates?
Borh have potential to bind to other orally administered medications
What would be the emergency treatment for hyperkalemia?
Hemodialysis
where is 80-90% of bicarbonate produced?
Kidneys
What is the effect of CKD on bicarbonate?
Less production, causing metabolic acidosis from increased protons in the body
What 2 factors are seen in CKD that cause acidosis?
diminshed capacity to excrete acid and diminished capacity to produce base
What is the acid produced through metabolism?
Carbon dioxide
What increases with carbon dioxide?
Hydrogen; protons
What does Carbon dioxide retention in the lungs cause?
Respiratory acidosis
How do the kidneys excrete “fixed acids”
Secretion of H ions that combine with NH3 to form NH4+ that is then secreted into tubular lumen
what are 2 examples of fixed acids?
Lactic acid
Ketones
What do NH3 and Co2 combine in the liver too?
Urea
What characteritics does urea have that make it ideal for excretion?
odourless and highly soluble in water making it easily excreted
What are the effects of pH, bicarbonate, and PaCO2 in metabolic acidosis?
pH decrased
bicarbonate decreased
PaCO2 normal
What are the effects of pH, bicarbonate, and PaCO2 in respiratory acidosis?
pH decrased
bicarbonate normal
PaCO2 increased
What are the effects of pH, bicarbonate, and PaCO2 in respiratory alkalosis?
pH increased
bicarbonate normal
PaCO2 decreased
What are the effects of pH, bicarbonate, and PaCO2 in metabolic alkalosis?
pH increased
bicarbonate increased
PaCO2 normal
at what GFR is metabolic acidosis no longer “mild”
<20mL/min
What is the risk of using sodium bicarbonate to manage bicarbonate levels?
Sodium load becomes a risk
How do the kidneys play a role in Ca homeostasis?
Through its role in activating Vitamin D
With low Ca serum levels what else does the kidnet fail to excrete?
phosphate
How can Ca/phosphate disorders be managed in CKD?
Decrease in phosphorous in diet
phosphate binding agents (sevelamer)
Calcitriol
what does low Ca cause the parathyroid gland to excrete?
PTH
How does PTH effect the kidneys?
Promote renal tublar Ca reabsorption
Promote phosphate excretion
stimulate production of 1,25 - dihydroxyvitamn D
What does PTH stimulate in the bone?
Promotes catabolism of bone to release Ca and phosphorous into bloodstream
What does the combination of low Ca and reduced Vitamin D level cause?
Increased PTH release.
As PTH increases only Ca source is bone causing accelerated bone loss
What vitamin D product does not require activation; is already active?
Calcitriol
What major structural changes happens to the glomerulus in diabetic patients?
change of podocytes
expansion of mesangial matrix
renal vascular damage
What does EPO regulate?
stimulation of bone marrow to ONLY produce more RBC’s
NO lymphocytes or hormones
What happens to the hematocrit in CKD patients?
Decreased; decreased RBC’s
What is often given for anemia in CKD along with EPO replacement?
Iron supplements
at what GFR can anemia often begin at?
when GFR falls below 30-45mL/min
Why anemia treatment closely monitored (hemoglobin levels)
Increased RBC production can result in hypertension or thrombosis
What can happen if there is poor disease recognition?
lapses in patient saftey
what pharmacokinetics and pharmacodynamics need to be considered in CKD?
increased volume distribution in moderate to severe CKD
Metabolite accumulation
non-renal clearance
loading dose
maintenance dose
serum drug monitoring
