Chronic Kidney Disease Flashcards
Incidence
1 in 9 adults
Many unknown d/t asymptomatic
77% of risk factors are treated in primary care
Risk Factors
DM
HTN
Older age
CVD
fam hx of CRF
ethnic/racial minority
Screening
Patients should be assessed annually to determine whether they are at increased risk of developing chronic kidney disease based on clinical and sociodemographic risk factors.
Major Causes of CKD: Glomerulopathies
Primary Glomerular Disease:
Focal & segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
IgA nephropathy
Membranous nephropathy
Secondary Glomerular Disease:
Diabetic nephropathy
Amyloidosis
Postinfectious glomerulonephritis
HIV-associated nephropathy
Collagen-vascular diseases
Sickle cell nephropathy
HIV-associated membranoproliferative glomerulonephritis
Major Causes of CKD: Tubulointerstitial Nephritis, and Hereditary Diseases
Drug hypersensitivity
Heavy metals
Analgesic nephropathy
Reflux/chronic phylonephritis
Idiopathic Alport syndrome
Medullary cystic disease
Polycystic kidney disease
Major Causes of CKD: Obstructive Nephropathies
Prostatic desease
Nephrolithiasis
Retroperitoneal fibrosis/tumor
Congenital
Major Causes of CKD: Vasuclar Disease
Hypertensive nephrosclerosis
Renal artery stenosis
Symptoms
Fatigue
Weakness
Malaise
As uremia progresses:
Decreased libido
Menstrual irregulaties
Chest pain from pericarditis
Gastrointestinal: Anorexia, Nausea, Vomiting, Metallic taste in mouth, Hiccups
Neurologic: Irritability, Difficulty in concentrating, Insomnia, Subtle memory defects, Restless legs, Twitching
Physical Exam
Hypertension
Skin is yellow
Easy bruising
Cardiopulmonary signs: rales, cardiomegaly , edema, and a pericardial friction rub.
Mental status: decreased concentration—confusion-stupor—and coma
Assessment of Renal Function
Initial testing must include an estimation of the glomerular filtration rate and examination of the urine
GFR
Estimation of the glomerular filtration rate (GFR) gives an approximate measure of the number of functioning nephrons.
Reduction in GFR implies either progression of the underlying disease or the development of a superimposed and often reversible problem, such as decreased renal perfusion due to volume depletion.
Increase in GFR is indicative of improvement in renal function
Stable GFR in patients with renal disease implies stable disease.
Individual values not as important as trends (increasing, decreasing, stable).
Trend crt or estimated GFR
Dx Labs
UA micro (most important noninvasive dx test in RF)
Protein - presence should alert provider to perform 24hr urine collection for protein and creatinine clearance, pH, Concentration, Glucose, Hematuria, Pyuria
Baseline labs: Full chemistry panel (lytes, FBS, magnesium, phosphorus, ionized calcium, total protein and serum albumin, BUN, creatinine, liver enzymes) CBC Intact parathyroid hormone (PTH)
Screening for DM pts
All diabetic patients who are negative for protein on dipstick testing should have laboratory testing for microalbuminuria
Test at time of dx for type II and 2yrs after dx for type I
Dx Radiology
Renal u/s
Helical CT scan - preferred: with patients with flank pain and possible urolithiasis
Arteriography Renal Bx - performed percutaneously
Renal Bx
A renal biopsy is most commonly obtained when noninvasive evaluation has been unable to establish the correct diagnosis
The major indications for renal biopsy include:
Isolated glomerular hematuria with proteinuria
Nephrotic syndrome
Acute nephritic syndrome
Unexplained acute or rapidly progressive renal failure
Definition CKD in Adults
Evidence of structural or functional kidney abnormalities (abnormal urinalysis, imaging studies, or histology) that persist for at least three months, with or without a decreased GFR (as defined by a GFR of less than 60 mL/min per 1.73 m2).
The most common manifestation of kidney damage is persistent albuminuria, including microalbuminuria.
OR
Decreased GFR, with or without evidence of kidney damage.
Indications to Initiate Dialysis in Pts w/ CKD
Pericarditis or pleuritis (urgent indication)
Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, wrist or foot drop, or, in severe, cases, seizures (urgent indication)
Fluid overload refractory to diuretics
Hypertension poorly responsive to antihypertensive medications
Weight loss or signs of malnutrition
Persistent metabolic disturbances that are refractory to medical therapy. These include hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia, and hyperphosphatemia.
Persistent nausea and vomiting A clinically significant bleeding diathesis attributable to uremia (urgent indication)
Nephrology Referral
Patients with CKD should be referred to a nephrologist early in the course of their disease, preferably before the plasma creatinine concentration exceeds 1.2 (106 micromol/L) in women and 1.5 mg/dL (133 micromol/L) in men, respectively, or the eGFR is less than 60 mL/min per 1.73 m2.
Institution of Renoprotective Therapy
Protective tx = ACE-I, ARB and rigorous BP control
Protective therapy has the greatest impact if it is initiated before the plasma creatinine concentration exceeds 1.2 (106 micromol/L) and 1.5 mg/dL (133 micromol/L) in women and men, respectively, or the eGFR is less than 60 mL/min per 1.73m2. At this point, most patients have already lost more than one-half of their GFR.
Waiting until the disease progresses further diminishes the likelihood of a successful response but still should be attempted.
Renal Replacement Tx
HD - in-center or at home
PD - continuous or intermittent
Renal transplant - living or deceased donor
Renal Replacement Pt Education
guidelines recommend that patients with a GFR less than 30 mL/min per 1.73 m2 should be educated concerning these issues.
Kidney transplantation is the treatment of choice for end-stage renal disease.
A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. To facilitate early transplantation, a 2008 NKF/KDOQI conference suggested early education and referral to a transplantation center plus the identification of potential living donors
Referral
All CKD pts should be referred to nephrology
Refer to nutritionist at dx
