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Chronic Kidney Disease Flashcards

1
Q

Chronic Kidney Disease

A

A long-standing, progressive deterioration of renal function
○ Results from the decline of GFR over months to years
○ Renal insufficiency, may progress to renal failure or end-stage renal disease (ESRD)

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2
Q

Most common causes of CKD

A

● Diabetic nephropathy
● Hypertensive nephrosclerosis
● Glomerulopathies

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3
Q

Over 70% late stage CKD cases (Stage 5/ESRD) are due to ____

A

DM and HTN/vascular disease

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4
Q

Chronic Kidney Disease causes an increased risk of _____

A

CV disease

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5
Q

Kidney Resiliency

A

● Despite renal injury or progressive destruction to the nephrons, the kidney has
an innate ability to maintain GFR
○ The remaining healthy nephrons manifest hyperfiltration and compensatory
hypertrophy

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6
Q

Plasma levels of substances such as urea and creatinine will start to show
measurable increases only after total GFR has decreased to _____

A

50%

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7
Q

Chronic Kidney Disease Etiology

A

● May result from any cause of renal dysfunction of sufficient magnitude (Prerenal, intrinsic and postrenal)
● DM and HTN account for > 2/3 of cases

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8
Q

CKD may also result from abnormalities of kidney structure or function, if present for more than ___ months

A

3
○ Kidney damage or decreased
GRF < 60 mL/min/1.73m2

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9
Q

Why is staging for CKD important?

A

● Provides a baseline for monitoring
● Improves communication among
providers
● Helps anticipate/facilitate interventions at different stages of disease

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10
Q

T/F CKD In Stage 1 and 2 & reduced GFR alone is diagnostic for CKD

A

F
One of the following markers must also be present
● Albuminuria (> 30mg/24 hours or Albumin:Creat ratio (ACR) >30 mg/g)
● Abnormal urine sediment
○ i.e. hematuria or broad waxy casts (dilated, hypertrophic nephrons)
● Electrolyte abnormalities due to tubular disorder
● Histologic pathology
● Structural pathology on imaging
● Any h/o kidney transplantation – low threshold to monitor these patients

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11
Q

What Albumin:Creatinine ratio (ACR) is concerning for CKD?

A

> 30 mg/g)
Must also be present >3 months

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12
Q

Chronic Kidney Disease Screening

A

● Early detection may slow or prevent the progression to ESRD
● Testing involves checking for albumin in a urine sample and a blood test
(BMP/CMP)for creatine to estimate GFR

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12
Q

MDRD

A

(Modification of Diet in Renal Disease)
○ The most commonly used estimate equation
○ Estimates using body surface area
○ Uses a standardized serum creatinine assay
■ More accurate than creatinine clearance from 24 hr urine

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12
Q

Gold standard for GRF determination

A

○ Gold standard is inulin (but is cumbersome to navigate)
○ Creatinine used instead

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13
Q

CKD-EPI

A

(Chronic Kidney Disease-Epidemiology Collaboration)
○ Developed to provide a more accurate estimate of GFR among
individuals with normal or only mildly reduced GFR
○ More accurate of the two in groups with eGFR > 60
■ As accurate as MDRD in eGFR < 60

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14
Q

Leading cause of CKD

A

Diabetes

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15
Q

Diabetic Nephropathy =

A

albuminuria with known DM
○ Diabetic nephropathy can also cause secondary HTN due to abnormal
renal function
■ HTN can worsen existing renal microvascular disease

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16
Q

Diabetic Kidney Disease (DKD) =

A

albuminuria and/or decreased eGFR with DM
○ Does not indicate a specific kidney disease
○ Typically a clinical (or presumptive) diagnosis; renal biopsy is rare

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17
Q

3 major changes occur in the glomeruli caused by Diabetic Nephropathy

A
  1. Mesangial expansion (fibrosis within the kidneys) – directly induced by hyperglycemia
  2. Glomerular Basement Membrane (GMB) thickens
  3. Glomerular Sclerosis – caused by intraglomerular hypertension (more to come)
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18
Q

HTN negatively impacts both _____

A

CKD and CVD

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19
Q

Hypertensive Nephrosclerosis has two important effects

A
  1. Glomerular Ischemia: Chronic hypertension narrows pre-glomerular arteries and arterioles
    ■ Reducing blood flow, causing ischemic changes
  2. Glomerulosclerosis
    ○ Glomerular HTN → glomerular hyperfiltration → progressive glomerular sclerosis
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20
Q

CKD Presentation

A

● Asymptomatic in early stages – “Silent Disease”
● Hypertension is them most common finding
○ Partially due to impaired sodium excretion
■ ↓Na excretion → ↑ECF → ↑ Blood pressure
■ Later stages may present with sign of volume overload (hypervolemia)

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21
Q

Skin changes with CKD

A

○ Pale skin – Anemia
○ Bruising/hematoma – platelet dysfunction
○ Uremic Frost – Urea crystallization (fine white powder)
○ Calciphylaxis – Calcium deposits in vessels → ischemia → skin necrosis

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22
Q

Uremic Syndrome

A

● Anorexia
● Fatigue/weakness
● Nausea/vomiting
● Irritability/mental status changes
● Insomnia
● Generalized pruritus

23
Uremic syndrome warrants ____
immediate admission and nephrology consult Dialysis will be needed
24
Chronic Kidney Disease - Lab workup
○ CBC – check for anemia ○ CMP ■ BUN, Creat – high ■ Potassium – high ■ Bicarb (Carbon Dioxide) – low ■ Serum Albumin – low ○ Lipid panel – due to risk of CVD ○ Serum phosphate, Vit D, Alk Phos, and intact PTH to look for bone disease
25
Why can CKD patients be at a higher risk for osteoporosis?
An increase in serum phosphorus and decreased Vitamin D lead to hypocalcemia and a secondary hyperparathyroidism
26
Treatment Goals for CKD
1. Slow the progression of CKD - treat the underlying conditions (HTN and DM) 2. Diagnose/treat pathologic manifestations/complications of CKD ○ Anemia ○ Hyperphosphatemia ○ Hyperparathyroidism ○ Bone disease ○ Volume overload ○ Metabolic acidosis ○ Hyperkalemia 3. Planning for renal replacement therapy – Dialysis
27
BP Control with CKD
○ Use of ACEi/ARBs ■ Lower systemic BP and vasodilate efferent arterioles ■ Improve glomerular membrane permeability ○ Target <130/80 if albuminuria > 30 mg/g (category A2, A3) ○ Reduces risk of CVD and Left Ventricular Hypertrophy (LVH) ○ Low salt diet
28
If serum creatinine increases 30% or more from baseline, stop _____
ACEi/ARB
29
What do you need to monitor for when prescribing a ACE/ARB for BP control in CKD?
Close monitoring for renal deterioration and for hyperkalemia
30
Target A1C for glycemic control in CKD
<7%
31
Why is dietary protein restriction controversial in CKD?
○ Too much protein causes increased intraglomerular pressure and increases protein byproducts that kidney has to filter ○ Stage 1, 2, or 3 limited to 12-15% of caloric intake ○ 0.6-0.8 g/kg/day in patient with GFR <30 ○ Consult dietician
32
Lipid Lowering Agents recommendation in CKD
○ Recommended for adults 50+ years with eGFR < 60 who are not on long-term dialysis or kidney transplantation
33
How does Hyperphosphatemia occur in CKD? How is it treated?
○ Seen in stages 4-5 of CKD, ↓GFR → ↓ phosphate excretion = ↑ phosphorus ○ Treat with dietary phosphate binders and diet modification
34
How does Hypocalcemia occur in CKD? How is it treated?
○ ↑ phosphorus → ↓ calcitriol (Vit D) → ↓ absorption of Ca+ in intestines = ↓ serum calcium ○ Treat with Calcium supplements
35
How does Hyperparathyroidism occur in CKD? How is it treated?
○ Triggered by high phosphorus and low calcium ○ Treat with Vit D supplementation
36
Osteitis Fibrosa
(rare) in CKD ○ Due to secondary hyperparathyroidism ○ Localized area of weak bone (different than osteoporosis)
37
Anemia in CKD and how we treat it
– worsens as CKD advances ○ Uremia induced platelet dysfunction causes bleeding tendency ○ Treatment usually reserved for those on dialysis with Epogen
38
How does Volume Overload occur in CKD? And how is it treated?
○ Impaired Na+ excretion → fluid retention ○ Treat with loop diuretics
39
How does Metabolic acidosis occur in CKD? And how is it treated?
Kidneys cannot properly excrete the acids in the body so they build up ○ Treat with PO alkali supplementation (sodium bicarb)
40
How does Hyperkalemia occur in CKD? And how is it treated?
Reduced excretion of K in the tubules during CKD combined with increased intake allow potassium to build up in the body – usually not seen until GFR <25 ○ Most treatments improving CKD will help drive K+ back inside cell
41
Indications for Dialysis
○ Severe metabolic acidosis ○ Hyperkalemia ○ Uremic Encephalopathy ○ Intractable volume overload ○ Peripheral neuropathy – uremic neuropathy (90% of dialysis Pts) ○ GFR 5-10, irrespective of symptoms, cause of CKD, or comorbidities
42
Timely planning for long-term renal replacement therapy requires
○ Early patient education ■ Dialysis, transplant, palliative care ○ Placement for permanent vascular access ■ Fistula, graft, catheter, peritoneal ○ Referral for renal transplant
43
How does Dialysis work?
● Hemodialysis relies on the principles of solute diffusion across a semipermeable membrane, providing an artificial replacement for lost kidney function ○ Excess water and metabolic waste (nitrogen) from the blood are move down a concentration gradient into the dialysate ■ Control hyperkalemia, hyperphosphatemia, and metabolic acidosis
44
What is a Dialyzer?
● A dialyzers is a plastic tube with two compartments ○ Capillary tubes/fiber bundles – where the blood circulates ○ Dialysate compartment – where dialysate travels on the outside of the fiber bundles
45
What is Dialysate?
A water and electrolyte solution ○ Removes waste material from blood ○ Keeps useful material in the blood ○ Relies on concentration gradients, membrane permeability, and flow rates
46
The general composition of dialysate typically includes
○ Sodium ○ Bicarb ○ Calcium ○ Potassium ○ Magnesium ○ Glucose ○ Chloride
47
Blood Delivery System in Dialysis
● The blood delivery system is composed of the dialysis machine and the vascular access
48
Blood Delivery System – Vascular Access in Dialysis
Arteriovenous (AV) Fistula AV Graft Tunnel Catheter
49
Peritoneal Dialysis
● In peritoneal dialysis, 1.5-3 L of a dextrose-containing solution is infused into a peritoneal cavity and allowed to dwell for a set period of time, typically 2-4 hours ○ Icodextrin – Non Absorbable carbohydrate is also commonly used (17%)
50
The peritoneal membrane is the _____ in Peritoneal dialysis
“dialyzer”
51
Continuous ambulatory peritoneal dialysis (CAPD)
Dialysate is manually infused into the peritoneal cavity and exchanged 4-6 times during the day
52
Continuous cycling peritoneal dialysis (CCPD)
Cycler machine performs exchanges at night
53
Peritoneal Dialysis Complications
● Not a much volume removal ● Removes too much albumin ● Hyperglycemia ● Peritonitis ● Tunnel infection
54
Treatment of tunnel infections in Peritoneal dialysis
○ Topical abx, PO abx, silver nitrate ○ If antibiotic therapy isn’t sufficient, the catheter will need to be removed
55
Average wait time for kidney transplant is ____
3-7 years (median 4 years)
56
Long Term Outcomes of CKD
● Cardiovascular disease constitutes the major cause of death in patients with ESRD ○ Shared risk factors – DM, HTN, athersclerotic and arteriosclerotic vascular disease ● Recommendations for conventional cardioprotective measures

GU Exam 2 (4 decks)

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