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Nephrology > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

Over 70% of cases of late-stage chronic kidney disease are due to: 2?

12% are due to:
3

A
  1. Diabetes
  2. Hypertension
  3. Glomerulonephritis
  4. Cystic diseases
  5. Other urological diseases
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2
Q

CKD definition according to the national Kidney Foundation?

2

A

GFR less than 60mL/min for greater than or equal to THREE months with or without kidney damage OR

Kidney damage for > or equal to THREE months with or without decreased GFR

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3
Q
  1. Reduction in renal mass leads to what?

2. This places a burden on the remaining nephrons and leads to what?

A
  1. hypertrophy of the remaining nephrons

2. progressive glomerular sclerosis and interstitial fibrosis

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4
Q

CKD Risk Factors 9

what are the two most important?

A
  1. Diabetes**
  2. Hypertension**
  3. Family history of CKD
  4. Patient population
  5. Autoimmune disease
  6. Drug toxicity
  7. System infection (Shock)
  8. Urinary obstruction
  9. Older age
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5
Q

Pathophysiology:

  1. Normal kidney contains
  2. With destruction of the nephrons, this causes what? 2
  3. What two things start to show measurable increase only after total GFR has decreased by 50%
  4. Plasma Cr value will approximately ______with a 50% reduction in GFR
A
  1. 1 million nephrons
    • hyperfiltration
    • compensatory hypertrophy
  3. Blood urea and Cr
  4. double
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6
Q

Initial Assessment of CKD:

5

A
  1. Confirm primary renal diagnosis
  2. Establish chronicity
  3. Identify reversible factors
  4. Detect co-morbid factors
  5. Establish a baseline database
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7
Q

Staging of CKD
National Kidney Foundation
5

A

Stage 1: Kidney damage with normal or increased GFR ( (>90mL/min)

Stage 2: Mild reduction in GFR (60-89mL/min)

Stage 3: Moderate reduction in FGR (30-59mL/min)

Stage 4: Severe reduction of GFR (15-29 mL/min)

Stage 5: Kidney failure (GFR less than 15mL/min or dialysis)

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8
Q

Which stages are often asymtptomatic?

Clinical manifestations appear in what stages?

A

1-3

4-5

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9
Q
  1. Can serum creatinine tell us all we need to know about GFR?
  2. Creatinine is secreted by _____ ______; and as renal function worsens the amount secreted ________.

3, Normal ranges for serum creatinine are misleading because they do not take into account the what? 4

A
  1. Serum creatinine alone is NOT an accurate measure of glomerular filtration rate.
  2. renal tubules
    increases
    • age,
    • sex,
    • race
    • weight of the patient.
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10
Q
  1. Measurement of Renal Function:
    What formula adjusts creatinine for age, weight, and gender?
  2. What is the equation?
    (for men and women?)
A
  1. The Cockcroft- Gault (CG)

CrCl (male)=([140-age] x weight in kg)/(serum Cr x 72)

CrCl (female)=CrCl (male) x 0.85

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11
Q

Staging of CKD

The National Kidney Foundation advises what two lab tests should be used together to assess kidney function?

A

GFR and Albuminuria levels be used together rather than separately to improve prognostic accuracy

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12
Q

What is an early parameter for measuring nephron injury and repair?

How do we measure this? 2

A

Microalbuminuria is a key parameter for measuring nephron injury and repair

  1. Early sign of kidney disease
  2. Urine dipsticks
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13
Q

What are the GFR stages?

6

A
  1. G1 >90 -Normal or high
  2. G2 60-90 -Mildly decreased
  3. G3a-45-59Mild-mod decreased
  4. G3b-30-44Mod to sev decrease
  5. G415-29-Severely decreased
  6. G5 less than 15- Kidney failure
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14
Q

What are the Albuminuria stages that are part of the staging of CKD?
3

A
  1. A1 less than 30- Normal-mild increase
  2. A2 230-300-Moderately increased
  3. A3>300-Severely increased
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15
Q

Azotemia is what?

Types? 3

What can it lead to if not treated?

A

Condition characterized by high levels of nitrogen-containing compounds in the blood

  1. Prerenal azotemia
  2. Primary renal azotemia
  3. Postrenal azotemia

Uremia

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16
Q
  1. WHat is uremia?
  2. Symptoms may not occur until how many nephrons are destroyed?
  3. Develops in which stages of CKD?
A
  1. Condition resulting from advanced stages of kidney failure in which urea and other nitrogen containing wastes are found in the blood.
  2. Symptoms may not occur until 90% of nephrons are destroyed
  3. More commonly develops in the later stages of CKD
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17
Q

Symtpoms of Uremia:

  1. General?
  2. Skin?
  3. ENT?
  4. Pulmonary?
  5. CV?
  6. GI?
  7. GU/GYN?
  8. Neuromuscular?
  9. Neurologic
A
  1. General: fatigue, weakness, breath “fishy odor”
  2. Skin: pruritus, easy bruising
  3. ENT: metallic taste in mouth, epistaxis
  4. Pulmonary: dyspnea, pulmonary edema
  5. CV: dyspnea on exertion, retrosternal pain on inspiration (pericarditis)
  6. GI: anorexia, N/V, hiccups
  7. GU/GYN: ED, amenorrhea
  8. Neuromuscular: restless legs, numbness and cramps
  9. Neurologic: irritability, inability to concentrate
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18
Q

Signs of Uremia:

  1. General?
  2. Skin:?
  3. ENT?
  4. Eye?
  5. Pulmonary?
  6. CV?
  7. Neurologic?
A
  1. General: sallow appearing, chronically ill
  2. Skin: pallor, ecchymosis, excoriations, edema, yellow
  3. ENT: urinous breath
  4. Eye: pale conjunctiva
  5. Pulmonary: rales, pleural effusion
  6. CV: hypertension, cardiomegaly, friction rub, displaced PMI
  7. Neurologic: stupor, asterixis, myoclonus, peripheral neuropathy
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19
Q

What labs would we order for uremia?

A
  1. Elevated BUN/Creatinine
  2. CBC
  3. CMP
  4. Serum albumin levels
  5. Lipid profile
    6, Urinalysis
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20
Q

Why would we order a CBC for labs for uremia?

What are we looking for with a CMP? 3

What are we looking for in the urinalysis?

WHy would we order a lipid profile?

A
  1. Look for Anemia
  2. Hyperphosphatemia
  3. Hypocalcemia
  4. Hyperkalemia
  5. Broad waxy cast cells
  6. Risk for CVD
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21
Q

LABS for Uremia:
Evidence of renal bone disease can be evidenced on:
4

A
  1. Serum phosphate
  2. 25-hydroxyvitamin D
  3. Alkaline phosphatase
  4. Intact parathyroid hormone (PTH) levels
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22
Q

Imaging for Uremia?

4

A
  1. Renal Ultrasound
    - Small echogenic kidneys bilaterally
  2. CT
  3. MRI/MRA
  4. Retrograde pyelogram
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23
Q

When is renal biopsy indicated?

Major complication of this surgery?

A

Generally indicated when renal impairment is present and the diagnosis is unclear after extensive work-up

Bleeding

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24
Q

Metabolic complications of Uremia? 2

A

Hyperkalemia

Metabolic Acidosis

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25
Q

WHy would you see Hyperkalemia in uremia?

3

A
  1. Especially when GFR drops below 10mL/min, kidneys have a decreased ability to secrete potassium
  2. Can be seen sooner with potassium rich diet
  3. Can get extracellular shift of potassium with acidemia and decreased insulin
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26
Q

Why would you get metabolic acidosis from uremia?

4

A
  1. Damaged kidneys are unable to excrete the 1 mEq/kd/d of acid generated by metabolism of dietary proteins
  2. This limits production of ammonia and limits buffering of H+ in the urine
  3. Excess hydrogen ions are buffered by large calcium carbonate and calcium phosphate stores in the bone.
  4. This contributes to the renal osteodystrophy of CKD
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27
Q

What are the cardiovascular complications of uremia?

4

A
  1. Hypertension
  2. Pericarditis: Can be complicated by tamponade
  3. CHF and Pulmonary edema
  4. Heart disease
    - Left ventricular hypertrophy
    - Ischemic heart disease
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28
Q

Hematologic Complications? 2

A
  1. Anemia

2. Coagulopathy

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29
Q
  1. What kind of anemia would you expect in uremia?
  2. What is this due to?
  3. What other deficiency is present as well?
  4. What is the coagulaopathy due to?
  5. How does this affect platelets?
A
  1. Normochromic, normocytic
  2. Due to decreased erythropoietin production
  3. Iron deficiency is present as well
  4. Due to platelet dysfunction
  5. Platelet counts are mildly decreased, but show abnormal adhesiveness and aggregation
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30
Q

Neurologic Complications

3

A
  1. Uremic encephalopathy
  2. Peripheral neuropathy
  3. Sub-arachnoid hemorrhage
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31
Q

Uremia Disorders of Mineral Metabolism 2

A
  1. Hypocalcaemia

2. Hyperphosphatemia

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32
Q

Disorders of calcium, phosphorus and bone are referred to as what?

A

Renal Osteodystrophy

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33
Q
  1. WHat leads to hypocalcemia in renal osteodystrophy?
  2. What does this stimulate?
  3. This all leads to what? 2
A
  1. hyperphosphatemia
  2. PTH is stimulated
    • Leads to “Osteitis fibrosa cystica”
    • High level of bone turnover
34
Q

Causes of Renal Osteodystophy?

4

A
  1. Ability to excrete phosphate is lost
  2. Decreased production of 1,25 dihydroxyvitamin D leads to decrease intestinal absorption of calcium
  3. Hypocalcemia triggers PTH production and release
  4. Secondary hyperparathyroidism leads to Ca mobilization from bone and increase renal phosphate excretion to maintain electrolyte homeostasis.
35
Q

Bone Complications of Uremia?

A

Osteomalacia

36
Q

WHat is Osteomalacia?

3

A
  1. Decreased renal conversion of 25-hydroxycholecalciferal to the 1,25-dihydroxy form
  2. Gut absorption of calcium is diminished
  3. Aluminum deposition in bone

All can cause bony pain and proximal muscle weakness

37
Q

Skin complications of uremia?

4

A
  1. Dry
  2. Yellow-brown color
  3. Fingernails become thin and brittle
  4. Uremic frost
38
Q

Effective CKD Management

3

A
  1. Appropriately screen and diagnose early CKD
  2. Be aware of CKD complications and Comorbities
  3. Consult nephrologist in a timely manner
  4. Delay or halt progression
39
Q

When trying to delay or halt CKD management what should we treat with?
8

A
  1. Treat underlying condition
  2. Aggressive blood pressure control
  3. Treat hyperlipidemia
  4. Aggressive glycemic control
  5. Avoid nephrotoxins
  6. Treat hypocalcemia
  7. Volume overload
  8. Metabolic acidosis
40
Q

WHat medications are we giving for the following:

  1. Aggressive blood pressure control?
  2. Treat hypocalcemia?
  3. Volume overload?
  4. Metabolic acidosis?
A
  1. ACE/ARB
  2. Calcium supplements
  3. Loop diuretics
  4. Oral alkali supplements
41
Q

Recommendations for HTN Control/BP targets:

  1. HYPERTENSION WITHOUT CRF?
  2. HYPERTENSION WITH CRF &
    PROTEINURIA less than 1G/DAY?
  3. HYPERTENSION WITH CRF&
    PROTEINURIA >1G/DAY?
A
  1. less than 130/85
  2. less than 130/80
  3. less than 125/75
42
Q

WHat is the purpose of the CKD diet? 3

Why is this diet so important?

A

The purpose of this diet is to maintain a balance of

  1. electrolytes,
  2. minerals, and
  3. fluid in patients who are on dialysis.

The special diet is important because dialysis alone does not effectively remove ALL waste products. These waste products can also build up between dialysis treatments.

43
Q

Most dialysis patients urinate very little or not at all. Therefore, what is very important?

Why is this important?

A

fluid restriction between treatments is very important.

Without urination, fluid will build up in the body and lead to excess fluid in the heart, lungs, and ankles.

44
Q

Dietary Management

4

A
  1. Protein restriction
    - 1 gram/kg /day
  2. Salt and Water restriction
    - Reduce overload
  3. Potassium restriction
  4. Iron supplements
45
Q

Who to Screen?
Potential Risk Factors for CKD:
Clinical factors? 3

Socio-demographic factors? 4

Three other possible risk factors? 3

A

Clinical Factors

  1. Diabetes
  2. Hypertension
  3. First degree relative of patient with hypertension, diabetes or CKD
Socio-demographic Factors
US ethnic minority status:
1. African American
2. American Indian
3. Asian
4. Pacific Islander
  1. Metabolic syndrome and
  2. smoking may also be risk factors for CKD
  3. Undetected CKD has also been shown to be frequent in patients >65 years, with associated CV risk factors and normal plasma creatinine
46
Q

What should we screen? 4

A
  1. GFR
  2. proteinuria,
  3. albuminuria
  4. microalbuminuria

can reveal a decrease in kidney function when GFR’s are normal

47
Q

CKD Treatment Overall

11

A
  1. Restriction of daily protein to 1g/kg/d
  2. Daily caloric intake of 40-50cal/kg/d
  3. Fluid restriction
  4. Control of HTN, Diabetes, Lipids
  5. Sodium restriction to 2-4g/d
  6. Potassium restriction
  7. Calcium and Phosphorus control
  8. Management of metabolic acidosis
  9. Management of anemia
  10. Vascular access for dialysis
  11. Transplantation
48
Q

Appropriately screen and diagnose early CKD

8

A
  1. Diabetics
  2. Hypertensive
  3. 1st degree relative of patient with HTN, Diabetes, or CKD
  4. Older age
  5. African American
  6. Native American
  7. Asian
  8. Pacific Islander
49
Q
  1. Indications for dialysis? 3

2. Hemodialysis is how often?

A
    • Hyperkalemia
    • Severe metabolic acidosis
    • pericarditis
  2. Three times/week
    Takes 3-5 hours
50
Q

Dialysis parts?

3

A
  1. Vascular access
    - Arteriovenous shunt
    - Can be used 6-8 weeks or more after surgical construction.
  2. Prosthetic graft
  3. Temporary indwelling catheters
    - PICC lines
51
Q

WHat are complications with the prothetic graft?

3

A

-Infection,
thrombosis,
aneurysm formation
-Staphylococcus aureus is common organism

52
Q

Problems during hemodialysis?

3

A
  1. Hypotension
  2. N/V
  3. Muscle cramps
53
Q

Peritoneal dialysis:

  1. WHat is the dialyzer?
  2. Continuous cyclic peritoneal dialysis utilizes a cycler machine to do what?
  3. WHat does this permit?
  4. What does it minimize?
  5. What is better cleared?
A
  1. Peritoneal membrane
  2. to automatically perform exchanges
  3. Permits greater patient autonomy.
  4. Minimizes the symptomatic swings observed in hemodialysis patients.
  5. Phosphates are better cleared
54
Q

Pertineal dialysis complications:

What is the main complication and what symtpoms (5) are involved with these?

A

Complication is peritonitis

  1. Nausea
  2. Vomiting
  3. Abdominal pain
  4. Fever
  5. Diarrhea or constipation
55
Q

What organism is common with peritonitis?

A

Staph Aureus is most common organism

56
Q

Kidney Transplantation: considerations for transplant?

4

A
  1. Patient must have a condition for which transplantation is considered an effective treatment
  2. Patient must have severe and progressive disease
  3. Patient must be willing to accept the risks of surgery and subsequent medical treatment
  4. Patient must be physically and emotionally capable of undergoing surgery and subsequent medical treatment
57
Q

KIDNEY TRANSPLANTATION
Requirements?
8

A
  1. Pre-transplant exam
  2. Chest xray
  3. Complete medical and surgical history
  4. EKG
  5. Ultrasound with Doppler examination
  6. Blood tests
  7. Pulmonary function test
  8. Viral testing – hepatitis, CMV, EBV, HIV
58
Q

Pretransplant Evaluation
What do we have to test for Histocompatibility?
4

A
  1. Blood typing
  2. Tissue typing
  3. Crossmatch Testing
  4. Panel Reactive Antibody (PRA)
59
Q

Which Recipients are excluded from transplant?

5

A
  1. Age >70:
  2. High risk patients for major surgery:
    -severe cardiovascular disease, etc
    High risk patients for:
  3. cancer,
  4. acute or chronic infections, etc
  5. Surgical impediments:
    -calcified vessels,
    -bladder diseases (neurogenic, BPH) etc.
60
Q

What kind of pts are two high risk for surgery? 1

What kind of surgical impediments exclude a pt from surgery? 2

A
  1. severe cardiovascular disease, etc
    • calcified vessels,
    • bladder diseases (neurogenic, BPH) etc.
61
Q

Recipient preparation tests

7

A
  1. General biochemistry
  2. Hematology
  3. Viral studies (HBsAg, HCV, HIV, CMV, EBV, HSV) Ab’s or DNA accordingly.
  4. Hormones (PSA, CEA, AFP, CA 9-19, CA 125, etc)
  5. Imaging (US abdomen, Plain Abdomen & pelvis, Chest x-ray)
  6. Specialized evaluation (ECG, cardiac echo, stress test, urodynamics, etc)
  7. Any other test or Specialized evaluation if indicated.
62
Q

Pre-transplant immunosuppression should include:

24 hours before treatment? 2
1 hour before treatment? 1

All recipiants are started on what? 2

A

24 hours before Tx:

  1. Steroids (prednisone) 5mg/kg/ (in divided doses)
  2. Mycophenolate Mofetil 500-1000 mg BD

1 hour before Tx: 3. basiliximab (Simulect) 20mg iv (stat)
(To be repeated on day 4 after tx).

All recipients are started on Gancyclovir and Broad Spectrum Antibiotic Prophylaxis before surgery

63
Q

Recipients:

1. When are immunosuppressants changed after surgery?

A

7-10 days to desired levels

64
Q

Donor Preparation tests?

7

A
  1. General biochemistry
  2. Hematology
  3. Viral studies (HBsAg, HCV, HIV, CMV, EBV, HSV) Ab’s or DNA accord.
  4. Hormones (PSA, CEA,CA 9-19, CA 125, AFP, etc)
  5. Urine (routine, culture, 24 hour protein, creatinine clearance)
    Imaging (US, IVP, MRA, chest x-ray)
  6. Specialized evaluation (ECG, cardiac echo, stress test, etc)
  7. Any other test or Specialized evaluation if indicated.
65
Q

What makes a donor excluded from transplant?

3

A
  1. Age >70 years:
  2. Carriers of chronic infections: HIV, Hep. B, Hep C, etc.:
  3. Carriers of chronic diseases: diabetes, cancer, amyloidosis, vascular patients, autoimmune diseases, renal dysfunction, etc.:
66
Q

Medical (pathology) immediate or chronic Complications

6

A
  1. Rejection: Hyperacute /acute/chronic (CAN)
  2. Infection: viral/ bacterial/ mycotic/ opportunistic
  3. Cardiovascular: CAD/ CHF/ CVA/HTN
  4. Cancer: skin/ blood/ solid organs
  5. Diabetes / cataract/ hirsutism/ alopecia/ gum hypertrophy/ obesity/ impotence/ etc
  6. Drug toxicity
67
Q

Follow up schedule for Tx patients:

5

A
  1. 1st month: 3 times a week
  2. 1-3months: once a week
  3. 3-6months: once every 2 weeks
  4. 6 months-2 years: once a month
  5. 2 years and over: every 2 months
68
Q

Follow up schedule after transplant should include:

8

A
  1. Hematology
  2. General biochemistry
  3. Urine (MSU, 24 hr collection)
  4. Drug level monitoring
  5. Detailed Clinical examination
  6. Diagnostic imaging (when necessary)
  7. Biopsy (when necessary)
  8. Special attention to: cardiovascular disease, neoplastic disease, infection and parathyroid function
69
Q

What are the clinical signs of kidney rejection?

5

A
  1. Malaise
  2. Fever
  3. Oliguria
  4. Hypertension
  5. Graft tenderness
70
Q
  1. What does diagnosis of kidney rejection depend on?
  2. What triggers further evaluation?
  3. What do we have to rule out?
  4. What will we see?
  5. What procedure will we do to make sure?
A
  1. Diagnosis hinges on serial creatinine measurements
  2. Elevation of 20% over baseline triggers further evaluation
  3. Rule out non-immunologic causes
  4. Renal scarring
  5. Percutaneous biopsy
71
Q

Diabetes and HTN are the most common causes of renal failure?
8

A
  1. Autoimmune disorders
  2. Birth defects (polycystic kidney disease)
  3. Certain toxic chemicals
  4. Glomerulonephritis
  5. Injury or trauma
  6. Nephrolithiasis
  7. Problems with arteries to or inside of the kidneys
  8. Pain medications and some antibiotics
72
Q

CKD leads to what?

This condition affects most body systems and functions, specifically? 3

A

ESRD/Uremia

  1. Blood pressure control
  2. Red blood cell production
  3. Vitamin D and bone health
73
Q

Symptoms of early CKD may include:

6

A
  1. Appetite loss
  2. General ill feeling and fatigue
  3. Headaches
  4. Itching and dry skin
  5. Nausea
  6. Weight loss without trying to lose weight
74
Q

Symptoms that may develop as kidney function gets worse:

12

A
  1. Abnormally dark or light skin
  2. Bone pain
  3. Brain and nervous system
  4. Breath odor
  5. Easy bruising, bleeding or blood in stool
  6. Excessive thirst
  7. Frequent hiccups
  8. Decreased libido
  9. Amenorrhea
  10. SOB
  11. Sleep problems such insomnia, restless leg & obstructive sleep apnea
  12. Edema of the feet and hands
75
Q

Causes of CKD may be seen on:

5

A
  1. Abdominal CT scan
  2. Abdominal MRI
  3. Abdominal ultrasound
  4. Renal biopsy
  5. Renal ultrasound
76
Q

Treatment of CKD?

A

Control HTN (keep initially at or below 130/80)

Ace inhibitors
ARB

77
Q

Prevention of CKD?

6

A
  1. No tobacco
  2. Meals that are low in fat and cholesterol
  3. Regular exercise
  4. Lower lipids if needed
  5. Control glucose, HgbA1c
  6. Avoid salt or potassium
78
Q

Vaccinations for all with CKD:

5

A
  1. H1N1 vaccine
  2. Hepatitis A vaccine
  3. Hepatitis B vaccine
  4. Influenza vaccine
  5. Pneumococcal polysaccharide vaccine (PPV)
79
Q

Possible complications of CKD?

15

A
  1. Anemia
  2. Myalgias and joint pain
  3. Changes in glucose
  4. Peripheral neuropathy
  5. Dementia
  6. Pleural effusion
  7. High phosphorous levels
  8. Cardiac and vessel complications
  9. Hyperkalemia
  10. Hyperparathyroidism
  11. Hepatic damage
  12. Malnutrition
  13. Miscarriages and infertility
  14. Seizures
  15. Edema
80
Q

Cardiac and vessel complications of CKD?

5

A
  1. CHF
  2. CAD
  3. HTN
  4. Pericarditis
  5. Stroke

Nephrology (15 decks)

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