Chronic kidney disease Flashcards
Kidney anatomy
Retroperitoneal in the costovertebral angle (CVA)
Capsule - outer layer, helium is the place with blood vessels and ureter sits, Medulla with pyramids, pelvis
Nephrons
Functional unit of kidney (about 1 millions)
Contains
i) Bowman capsule
Collect glomerular filtrate
ii) PCT
Reabsorption of 80% of electrolyte, 100% glucose and 70% of water
iii) Loop of Henle
Concentrates filtrate
iv) DCT
Juxtaglomerular cells - respond to drop in BP, blood volume or sodium and release renin
Glomerulus
Has fenestrations for particles to pass
Endothelial - connect with blood
Basement membrane - mesh-like connective tissue
Epithelial
Filtraction factors
Hydrostatic pressure (BP) that filters into the bowmans
Oncotic pressure + capsular hydrostatic pressure
Overall net hydrostatic pressure is stronger
Autoregulation
Too much blood pressure/flow = afferent constricts, efferent dilates to decrease GFR
Too little blood pressure/flow = afferent dilates, efferent constricts to increase GFR
LIMITATION =
Fails if the BP is below 65-70 mmHg
Hormone functions of the kidney
1) RAAS system - angiotensin 2 causes vasoconstriction, aldosterone for Na/H20 retention
2) Erythropoitein - hormone for RBC
3) Activate vitamin D
Abnormal kidney
Azotemia = accumulation of metabolic waste products in blood (eg. urea, creatinine)
Uremia = group of signs and sympotms of inadequate renal function
Oliguria - urine output less than 400 ml/day
Anuria - urine output less than 40 ml/day
AKI vs CKD
CKD - gradual onset, common cause id diabetic nephropathy and HTN
progressive and irreversible
Death from CVD
AKI - Sudden onset, common cause is acute tubular necrosis (ATN)
Reversible, cause of death is sepsis
Chronic kidney disease (CKD)
Progressive irreversible loss of nephrons
Diagnosed as under 60ml/min GFR for longer than 3 months
Hyperfiltration = remaining kidneys work harder (thatss why symptoms dont show until about 75%
of nephrons stop working)
Glomerulosclerosis = hyperfiltration cause fibrosis and scarring of the overworked nephron
Stages 1/2 likely asymptomatic
Albuminuria occurs in stage 2/3
3-4-5, 30-20-10 ml/min GFR
CKD signs and symptoms
ESRD = Final stage of kidney function
Uremia = fluid retention, electrolyte imbalance, waste product accumulation, hormone insufficiency, increase in blood lipoprotein, bone metabolism
Urea/creatinine rise = toxic
High potassium, phosphate, magnesium
Low calcium as phosphate binds to it + vit d not activated, PTH is released to resorb from bones
Sodium initially low, then comes high
Metabolic acidosis due to hydrogen not excreted and bicarb not reabsorbed
= Kaussmaul respiration
Anemia = no erytroipoitin
Platelet and wbc dysfunctional due to uremia toxicity
Kidney dosage
Note that drugs are usually excreted by the kidney. However when dyfunctional they dont excrete well and therefore the drugs can accumulate too toxic levels
Dosages must be decreased by physician
Captopril
ACE inhibitor
MOA - inhibits angiotensin 2 therefore no vasoconstriction and no water/Na retention
AE
- Dry cough because bradykinin not broken down
- First dose hypotension
- Hyperkalemia - aldosterone
- Angioedema, neutropenia
CI - pregnancy/breastfeeding, bilateral renal artery stenosis
Candesartan
ARB (like valsartan)
Note that ARNI is ARB+sacubitril (increases ANP)
MOA - block angiotensin 2 receptors
good thing is that bradykinin are broken down so no dry cough, however ACE have lower mortality rate than ARB
AE
- Like ACE except dry cough
- First dose hypotension
- Hyperkalemia
Atorvastatin (Lipitor)
HMG-CoA inhibitor
AE - generally well tolerates
HA, dizzy, GI
Mylo/rhabdomyolsis and hepatotoxicity which is rare
NC
Evening dose
Assess LFT, CK
Diuretics (cause im sick of writing them)
Furosemide - loop diuretic effecting loop of henle for diuresis even in low GFR
But cant be used in anuria
Lasix challenge - giving it even when oliguric
AE - hyponatremic, hyptension, hypokalemia, ototoxicity
Hydrochlorothiazide - works on DCT
Ineffective when CKD under 15-20 (stage 4)
AE - hyponatremic, hypokalemia, hypotension
Spironolactone - blocks aldosterone
ineffective when CKD under 30 (stage 3)
CI - anuria, addisons, hyperkalemia
AE - hyperkalemia, encrine like mentrual irregularity, deeper voice, gynecomastia
Erythropoietin (Epogen)
Hematopoietic agents
AE - HTN, CVD
CI in uncontrolled HTN
SC 3x a week, goal to have lower than normal Hgb because high risk of thrombotic events
Works in 2-3 weeks, peak in 2-3 months
Calcium carbonate (TUMS)
Binds to phosphate and excrete in stool for hyperphosphatemia
CI in hypercalcemia and severe cardiac disease
AE - constipation, GI irritation, renal calculi
DIGOXIN TOXICITY
NC - monitor blood work, 1 hour after meals as antacid as well
Kayexalate
Given in hyperkalemia to get rid of potassium by exchanging it for sodium
CI - bowel obstruction as excreted in stool
AE - constipation, N/V, diarrhea, digoxin toxicity
NC - hyperkalemia, GI assessment, sandlike texture
Ferrous sulfate
Iron preparation for RBC development (anemia caused by erythropiotin)
AE
Nausea, constipation
Epigastric pain
Black tarry stool (not melena)
NC - monitor HgB, GI
Calcitriol (Rocaltrol)
Vitamin D activation to increase absorption of calcium
CI in hyperphosphatemia (will just keep binding to calcium), hypercalcemia
Indication - renal osteodystrophy
Adverse effect - GI upset
Diabetic nephropathy
Proteinuria appears around 5-10 months
Must screen frequently
Risk of CKD
METAL CANS
Metal - eg. mercury, leads
C - Chemo
A - Antibiotics like aminoglycides
N - NSAIDs
S - Solvents (eg. ethylene glycol)
Lab work
Electrolyte and acid/base imbalance
Hyperkalemia
Hyponatremia early on and hypernatremia later
Hypocalcemia
Hyperphosphatemia
Metabolic acidosis
Esp in hyperkalemia
Hematological imbalance
Anemia (low erythropiotin)
Platelet dysfunction = increased bleeding, brusing
Leukocyte dysfunction = altered immune response
Neurological effects
Uremic encephalopathy - fatigue, decreased conc, seizures, coma
Uremic neuropathies - tremors, asterixis, paresthesia (also occurs in diabetes, use HgBA1C to differentite)
Assess LOC, palpate extremities
Hypo/Hyperreflexia can occur due to magnesium
High BUN, metabolic acidosis
Cardiovascular effects
HTN, anemia, fluid overload causes cardiorenal syndrome & HF
Accelerated artherosclerosis due to Ca/phosphate deposits
Peripheral edema
Uremic pericarditis = inflammation of pericardium sac that surrounds the heart
Chest pain and friction rub
Assess VS (temp for WBC dysfunction), JVP, dyspnea, edema, crackles, heart sounds, chest pain
EKG if needed
Respiratory effects
Dyspnea from fluid can cause pulmonary edema, pleural effusion, uremic pleuritis
Secondary infections (dysfunctional WBC)
Kussmaul breathing = metabolic acidosis
CXR, sputum, C&S, CBC
Gastrointestinal effects
Inflammation of mucosa
Uremic fetor - foul breath
Stomatitis
Metalic taste
N/V, Anorexia, hiccups
Constipation
Malnutrition
Uremic gastritis/colitis = bleeding/diarrhea
Genitourinary
Polyuria in early stage, oliguria, then anuria
Proteinuria, casts, hematuria, pyuria
Urinalysis, urine osmolarity, creatinine clearance
Integumentary
Pigment changes - yellowish colouration in yt ppl, darkening in black/bwon
Pruritis from decreased skin oils/turgor
Uremic frost = urea crystallizes on skin (rare)
Note that infections and bleeding can occur secondary to scrating
Renal diagnostics
Urea, creatinine
Urea:creatinine ratio (normally 10:1)
eGFR = Screening, NOT a diagnostic
Electrolyte
CBC - HgB, platelet, WBC
HCO3
Urine tests like
Urinalysis = pH, protein, glucose, blood
Creatinine clearance = 3-24 hr Urine (staging CKD)
Urine albumin: creatinine ratio
MSK effects
Renal osteodystrophy
Calcification in vascular walls = CVD disease
Muscle cramping and wakness
Loss of height, bone pain, spinal curvature
Dialysis indication
AEIOU
A - Acidemia (metabolic acidosis)
E - Electrolyte imbalances with EKG changes (hyperkalemia)
I - Intoxication from med or infection
O - Overload of fluid with no response to diuretic
U - Uremic complications like pericarditis, encephalopathy, GI bleeding
Hemodialysis
- No protein diet required
- In clinic 3x a week
- 3-4 hours
- Monitor VS and blood - hypotension, bleeding, infection risk
- Through arteriovenous fistula or central line (but temporary)
Arteriovenous fistula are sensitive and can burst - never do acu check or BP in the same arm
Peritoneal dialysis
-Catheter in the abdomen
- 30 min to 8 hours
- Increase protein intake due to protein loss in dialysate
- Keep access site clean, monitor infection, avoid constipation
- Monitor for outflow obstruction, infection, back/abdomen pain
