Chronic Kidney Disease Flashcards
Chronic Kidney Disease Definition
Damage to kidney
or
GFR less than 60 for more than 3 months
Stage 1 CKD
Kidney damage with Normal GFR
- GFR greater than 90
Stage 2 CKD
Kidney damage with mild reduced GFR
- GFR 60-89
Stage 3 CKD
Moderate Reduced GFR
- 3a: GFR 45-59
- 3b: GFR 30-44
Stage 4 CKD
Severe Reduced GFR
- GFR 15-29
Stage 5 CKD
Kidney Failure / End Stage Renal Disease
- GFR less than 15 or DIalysis
CKD Staging Via ACR
ACR = Albumin:Creatinine Ratio
A1: Normal/mild increase
- ACR is less than 3.0
A2: Moderate increase
- ACR 3.0-30
A3: Severe increase
- ACR is greater than 30
How to assess CKD (abbreviation)
C: Cause
G: Glomerular Filtration
A: Albuminuria Category
How to evaluate for causes of CKD
Physical Exam
Nephrotoxic Drugs
Medical History
Family History
Social History
Symptoms and Signs (Systemic Disease)
Symptoms and Signs (Urinary Tract Abnormal)
Lab Tests
What are the major causes of CKD
1: Type 2 Diabetes
#2: Hypertension
What is the leading cause of death in CKD patients
Cardiovascular Disease
CKD
- Overview
Hypertension + T2DM causes Glomerulosclerosis
- Loss of nephron mass
- Proteinuria
- Glomerular Hypertension
CKD (Hypertension)
- How does it occur
Mainly driven by RAAS system leading to kidney injury
Vasculature
- Endothelial damage
- Endothelial cell damage
Glomerulus
- Glomerular hypertension
- Glomerular cell hypertrophy
Tubule
- Tubular damage
- Tubular cell injury
Interitem
- Inflammation
- Oxidative stress
RAAS System response to low BP
- Low BP
- JG Cells in Kidney stimulate release of renin
- Angiotensinogen from liver is converted by renin into Angiotensin I
- ACE converts Angiotensin I into Angiotensin II
- Angiotensin II acts on adrenal cortex to produce aldosterone and acts on arterioles to constrict
- BP increases
Angiotensin II role
- Vasoconstriction
- Increase blood pressure
- Increases filtration of plasma protein, leads to renal scarring
How does Diabetic Neuropathy affect CKD
Glomerular Hyperfiltration
Altered Glomerular Composition
Renal Hypertrophy
Glomerular Hypertension
Proteinuria
–> All of this leads to glomerular scarring
Progression factors of CKD
Hyperglycemia
Hypertension
Smoking
Obesity
Proteinuria
Proteinuria and CKD
Proteinuria is a strong risk factor of cardiovascular mortality
- High proteinuria = Higher risk of end stage renal disease
- Glomerular Dysfunction –> Glomerular Hyperfiltration
Persistient Proteinuria and Transient and CKD
Persistient proteinuria is an indicator of kidney damage and renal disease
Transient proteinuria can be an indicator of some sort of underlying issue (UTI, heavy exercise, dehydration, pregnancy)
Symptoms of CKD
- Edema/Fluid Overload
- Glomerular Hyperfiltration causes too much proteins to go through. Reduction in kidneys filtering ability. Fluid buildup - Pruritus
- Waste is retained leading to itching - Restless Leg
- Electrolyte abnormalities - Anemia
- Kidneys do not produce erythropoietin
CKD Lifestyle Management
- Exercise
- Weight Loss
- Smoking Cessation
- Low Sodium Diet
- Limit Protein Intake in CKD G3-5 (Do not do if patient is metabolically unstable)
- Limit alcohol
ACEi Drugs
Perindopril
Ramipril
Lisinopril
ARB Drugs
Candesartan
Irbesartan
Valsartan
When are ARBs and ACEi recommended
Always use in diabetic patients (unless contraindicated)
For non diabetic patient used if ACR is greater than 3.0 (proteinuria) (unless contraindicated)
ACEi and ARBs mechanism
Reduces hyperfiltration
Reduce glomerular hypertension (less stress on glomerulus)
Reduce/stabilize proteinuria
Renoprotective
- Benefits are independent from BP lowering effects
ACEi and ARBs considerations
Do not use in AKI (Due to hemodynamic effect)
Contraindications:
- Pregnancy
- Angioedema history
- Bilateral renal artery stenosis
ACEi and ARBs Adverse Effects
ACEi
- Dry cough
ACEi and ARB
- Angioedema
ACEi and ARB monitoring
Start with low dose and taper slowley
Will get worse first before patient gets better
- Serum Creatinine will spike up (due to decrease in GFR)
Be careful of potassium (hyperkalemia)
Proteinuria
- Treatment
ARBs and ACEi
Can use Spironolactone in some patients (Be careful of hyperkalemia)
Diltiazem and Verapamil have some effectiveness (Calcium Channel Blockers)
SGLT-2 Inhibitor Drugs
Empagliflozin
Dapagliflozin
Canagliflozin
SGLT-2 Inhibitor Mechanism
Renoprotective
Prevents reabsorption of glucose
- Lowers plasma concentration of glucose by excreting it
Reduces sodium reabsorption
- Sodium gets delivered to macula densa, glomerular feedback is restored, blood flow in kidney is reduced , decreases glomerular hyperfiltration, reducing intraglomerular pressure
SGLT-2 Inhibitors effects on patients with diabetes vs no diabetes
Reduction in glucose reabsorption mainly benefits DM Patients
Reduction in intraglomerular pressure benefits both DM and non-DM patients
- Dapagliflozin
SGLT-2 Inhibitors Considerations
Initiate as an add on therapy to ACEi and ARBs for patients with T2DM and CKD
- When GFR is greater than 20
- Reasonable to keep using even if GFR falls under 20
Do not initiate in patients undergoing dialysis
SGLT-2 Inhibitor Adverse Effects
Genital Mycotic Yeast Infections (Due to excrerion of sugars)
UTI
Increased urination and thirst
Diabetic Ketoacidosi
- Occurs during acute illness (should put therapy on hold in this case)
Non-Steroidal Mineralocorticoid Receptor Antagonist drugs
Steroid MRA = Spironolactone
Non-Steroidal MRA = Finerenone
Non-Steroidal Mineralocorticoid Receptor Antagonist considerations
Can be added on to ARB/ACEi + SGLT-2 Inhibitor
- In patients with persistient albuminuria (ACR greater than 30)
- In patients with normal potassium
Renal and CV benefits for patients with
CKD + T2DM + Greater than 25 GFR
GLP-1 considerations
Used to manage glycemic control in patients not responding to metformin or SGLT-2 inhibitors
CKD and reducing CV risk
Statins
- Prescribe for all patients older than 50 with CKD
- Prescribe for patients 18-49 if at moderate-high risk of CV disease
ASA
- Secondary prevention of atherosclerotic cardiovascular disease and ischemic CV disease
CKD SIckday management
If patient is ill and unable to replenish their fluids hold the following nephrotoxic drugs
Sulfonylurea
ACEi
Diuretics
Metformin
ARBS
NSAIDs
SGLT2 Inhibitors
