Chronic Kidney Disease

Question 1

Incidence

Answer 1

1 in 9 adults

Many unknown d/t asymptomatic

77% of risk factors are treated in primary care

Question 2

Risk Factors

Answer 2

DM

HTN

Older age

CVD

fam hx of CRF

ethnic/racial minority

Question 3

Screening

Answer 3

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.

Question 4

Major Causes of CKD: Glomerulopathies

Answer 4

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

Question 5

Major Causes of CKD: Tubulointerstitial Nephritis, and Hereditary Diseases

Answer 5

Drug hypersensitivity

Heavy metals

Analgesic nephropathy

Reflux/chronic phylonephritis

Idiopathic Alport syndrome

Medullary cystic disease

Polycystic kidney disease

Question 6

Major Causes of CKD: Obstructive Nephropathies

Answer 6

Prostatic desease

Nephrolithiasis

Retroperitoneal fibrosis/tumor

Congenital

Question 7

Major Causes of CKD: Vasuclar Disease

Answer 7

Hypertensive nephrosclerosis

Renal artery stenosis

Question 8

Symptoms

Answer 8

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

Question 9

Physical Exam

Answer 9

Hypertension

Skin is yellow

Easy bruising

Cardiopulmonary signs: rales, cardiomegaly , edema, and a pericardial friction rub.

Mental status: decreased concentration—confusion-stupor—and coma

Question 10

Assessment of Renal Function

Answer 10

Initial testing must include an estimation of the glomerular filtration rate and examination of the urine

Question 11

GFR

Answer 11

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

Question 12

Dx Labs

Answer 12

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)

Question 13

Screening for DM pts

Answer 13

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

Question 14

Dx Radiology

Answer 14

Renal u/s

Helical CT scan - preferred: with patients with flank pain and possible urolithiasis

Arteriography Renal Bx - performed percutaneously

Question 15

Renal Bx

Answer 15

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

Question 16

Definition CKD in Adults

Answer 16

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.

Question 17

Indications to Initiate Dialysis in Pts w/ CKD

Answer 17

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)

Question 18

Nephrology Referral

Answer 18

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.

Question 19

Institution of Renoprotective Therapy

Answer 19

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.

Question 20

Renal Replacement Tx

Answer 20

HD - in-center or at home

PD - continuous or intermittent

Renal transplant - living or deceased donor

Question 21

Renal Replacement Pt Education

Answer 21

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

Question 22

Referral

Answer 22

All CKD pts should be referred to nephrology

Refer to nutritionist at dx