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Clin Med II > Chronic Kidney Disease > Flashcards

Chronic Kidney Disease Flashcards

1
Q

What is the Epidemiology of Chronic kidney disease?

A
  • Approx. 26 million Americans have CKD and millions of others are at increased risk for CKD
  • Chronic kidney disease globally resulted in approx. 956,000 deaths in 2013 up from 400,000 deaths in 1990
  • Black Americans are 3 times more likely to experience kidney failure
  • Hispanics are 1 Β½ times more likely to experience kidney failure
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2
Q

What is Acute Kidney Disease?

A
  • Rapid loss of kidney function (hours to days)
  • Commonly reversible
  • Usually caused by dehydration, blood loss, medication, IV contrast, obstruction
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3
Q

What is

Chronic Kidney Disease?

A
  • Progressive loss of renal function that persists for more than 3 months
  • Commonly irreversible
  • Usually caused by long-term diseases such as DM, HTN
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4
Q

How does the Kidney Function?

A
  1. Regulation of water, minerals and acid-base status
  2. Removal of metabolic waste products from the blood and their excretion in the urine
  3. Removal of foreign chemicals from the blood and their excretion in the urine
  4. Secretion of hormones (Erythropoietin, renin, Vit D)
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5
Q

What is the Pathophysiology of CKD?

A
  1. Underlying etiology (DM,HTN) causes hyperfiltration and subsequent nephron damage
  2. Hyperfiltration = increased flow through glomerulus and thus GM HTN and over time leads to hypertrophy of remaining viable nephrons
  3. Adaptations become maladaptive as the increased pressure and flow predisposes to distortion of glomerular architecture, sclerosis and loss of remaining nephrons
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6
Q

What is Glomerular Filtration Rate (GFR)?

A
  • Measure of how well the kidneys are removing wastes and excess fluid from the blood
  • Calculated from the serum creatinine level using your age, weight, gender and body size
  • The normal value for GFR is 90 or above
  • A GFR below 60 is a sign that the kidneys are not working properly
  • A GFR below 15 indicates that a treatment plan for kidney failure, such as dialysis or a kidney transplant is needed
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7
Q

What is the Estimated GFR (glomerular filtration rate)?

A

-Cockcroft-Gault Equation:
CrCl = (140 – age) X (IBW)
Scr X 72

  • Modification of Diet in Renal Disease Study (MDRDS) Equation:
    1. 86 π‘₯ γ€–(π‘ƒπ‘π‘Ÿ)γ€—^(βˆ’1.154) x γ€–(π‘Žπ‘”π‘’)γ€—^(βˆ’0.203)
  • Multiply by 0.742 for women
  • Multiply by 1.21 for African Americans
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8
Q

What are the symptoms of CKD?

A
  • No symptoms typically until stage 3 or 4
  • Anemia
  • Fatigue/weakness
  • Decreased appetite with progressive malnutrition
  • Nausea/vomiting
  • Sleep problems
  • Decreased mental sharpness/encephalopathy
  • Muscle twitches and cramps
  • Swelling of feet and ankles
  • Pruritis
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9
Q

What are the Clinical Manifestations Advanced Stages of Uremic Syndrome?

A

Symptomatic manifestations associated with Azotemia = the accumulation of urea and other nitrogenous compounds and toxins caused by the decline in renal function

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10
Q

What are the Complications of progressive chronic kidney disease?

A
  • Anemia
  • Metabolic acidosis
  • Derangements in vitamin D, calcium and phosphorus metabolism
  • Volume overload
  • Hyperkalemia
  • Uremia
  • Cardiovascular consequences
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11
Q

What is the Approach to the patient with new renal dysfunction?

A
  • Consider pre-renal, renal, post-renal etiologies
  • Careful history (contrast exposure, meds, dehydration)
  • PE
  • Serum creatinine (GFR)
  • Urine dipstick; microscopy & spot protein
  • Renal ultrasound (consider other imaging)
  • Urinalysis
  • Consider checking for multiple myeloma (serum protein electrophoresis, urine protein electrophoresis)
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12
Q

What is Serum Creatinine Laboratory Data?

A
  • Waste product that develops from normal wear and tear on the body muscles produced at fairly constant rate and excreted unchanged by kidneys
  • Normal levels vary depending on age, race, body/muscle size
  • A creatinine level of greater than 1.2 for women and greater than 1.4 for men may be an early sign that the kidneys are not working properly
  • As kidney function decreases, creatinine level rises
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13
Q

What is Blood Urea Nitrogen

Laboratory Data?

A
  • Measures the amount of nitrogen in your blood that comes from the waste product urea
  • Urea is made when protein is broken down in your body.
  • A normal BUN level is between 7 and 20
  • As kidney function decreases, the BUN level rises
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14
Q

What is CKD

Laboratory Data?

A

-24hr urine test
(Compares the urine creatinine to the blood creatinine to show how much blood the kidneys are filtering out each minute)

-Urinalysis (UA)
(Protein (albumin))

-Urine Microscopy
(Cells/casts/crystals)

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15
Q

What is Hematuria?

A
  • > 3 RBCs per high-power field on at least 2 occasions
  • Conditions that can cause hematuria
    Urologic malignancy
    Urinary tract infection (UTI)
    Can be seen in interstitial nephritis
    Glomerulonephritis causes
    Coagulopathy
    Colic
    HSP, SLE nephritis
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16
Q

What is Proteinuria?

A
  • > 150-160 mg/24hr
  • > 1-2gram/24hr signifies underlying kidney abnormality, usually glomerular
  • > 3.5 g/24hr is consistent with nephrotic range proteinuria
  • 24hr urine collection vs random β€˜spot’ urine sample (Urine protein/Urine Creatine ratio)
  • For spot urine < 0.2 is normal
17
Q

What is Anemia?

A
  • Occurs secondary to decreased production of EPO by the kidney
  • After work-up for anemia, if no other explanation is found, then CKD is declared to be the cause
  • EPO-stimulating agents should be provided if Hgb falls <10 mg/dL (goal 11-12 mg/dL) *higher goals are associated with increase mortality
18
Q

What is Vitamin D Deficiency?

A
  • Secondary to decreased production of 1,25-OH vitamin D (active form/short half life) as kidney is responsible for 1-hydroxylation process
  • Only measure 25-OH vitamin D as they represent the storage form (normal is > 30 mg/mL)
19
Q

What is Metabolic acidosis?

A
  • Secondary to decreased bicarbonate reabsorption and generation by kidneys
  • Treat with bicarbonate supplementation after bicarbonate falls < 18 mg/dL (target 22 mg/dL)
20
Q

What is Bone disease?

A

Secondary to abnormalities in the complex interaction between vitamin D, phosphorus, calcium and PTH

21
Q

What is Uremia?

A
  • Hundreds of toxins accumulate
  • Urea and creatinine are elevated and used as surrogate markers for toxins
  • Systemic inflammation increases
22
Q

What are the Risk Factors to the development of CKD?

A
  • Hypertension
  • Diabetes mellitus
  • Autoimmune disease
  • Older age
  • African ancestry
  • Family history
  • Previous episode of acute kidney injury
  • Proteinuria
  • Abnormal urinary sediment
  • Structural abnormalities of the urinary tract
23
Q

What are the Most common causes of ESRD?

A
  • Diabetic glomerular disease (44%)
  • Hypertensive nephropathy (28%)
  • Glomerulonephritis (6%)
  • Autosomal dominant polycystic kidney disease (2%)
  • Other cystic and tubulointerstitial nephropathy
24
Q

What is Diabetes Mellitus?

A
  • Leading cause of ESRD
  • Approx. 26 million Americans have diabetes
  • 2014 CDC reported that about 40% of US adults will develop diabetes
  • More than 224,000 people are currently living with kidney failure caused by diabetes
  • Intensive insulin therapy to maintain hbA1c level <7.0% reduces progression of kidney disease
25
Q

Treatment for Diabetes Mellitus?

A
  • Primary prevention
  • Tight glucose control
  • Diet/exercise
  • *BP control <130/80, lowering the BP delays the onset of microalbuminuria
26
Q

What is Diabetic Nephropathy?

A
  • Diabetic patient with the development of renal injury
  • First sign – microalbuminuria
  • Most common co-morbidity – hypertension
  • Recommendations of ACEI/ARB treatment even in a normotensive patient with Diabetic Nephropathy due to renal protective properties
27
Q

What is treatment for Diabetic Nephropathy?

A
  • ACEI/ARB’s – renal protective qualities

- Diuretic – addition of a second agent to aide in BP control

28
Q

What is Hypertension?

A
  • Second leading cause of ESRD
  • HTN accelerates the progression of CKD
  • Controlling blood pressure slows down the decline in GFR
  • Inhibiting RAAS is effective in lowering blood pressure and reducing microalbumiuria
29
Q

What is treatment for Hypertension?

A

-Salt and water restriction
(2-4g/d salt restriction to avoid CHF/edema (extra fluid))

  • Weight loss
  • Pharmacological therapies
  • Goal of therapy = halt progression to hypertensive nephropathy
30
Q

What is Hypertensive Nephropathy?

A
  • Develops in patients with proteinuria and hypertension

- Lowering BP Goals in a patient with CKD and HTN

31
Q

What is treatment for Hypertensive Nephropathy?

A
  • Current guidelines advise caution with use of ACEI/ARB’s in the presence of renal impairment
  • Evidence that these drugs are effective in reducing progression of CKD and reducing mortality/morbidity in patients with heart failure
  • Recommend use of ACEI/ARB’s in stages 1-3 and those with proteinuria
32
Q

What is Chronic Kidney Disease Treatment?

A
  • Primary Prevention
  • Treat underlying disorder
  • Dialysis
  • Transplant
33
Q

When do you Refer to a Nephrologist?

A
  • GFR < 30ml/min (CKD Stages 4 and 5)
  • Rapidly progressive CKD
  • Poorly controlled hypertension despite four agents
  • Rare or genetic causes of CKD
  • Suspected renal artery stenosis
34
Q

When to Dialyze?

A
  • Acidosis
  • Electrolytes: hyperkalemia, hyperphosphatemia, hypocalcemia, rarely hyponatremia
  • Ingestions: overdose
  • Overload: volume overload, especially on many IVs + anuria
  • Uremia: many symptoms - CNS (asterixis, seizure, coma), platelet dysfunction (GI bleed, bleeding diathesis, coagulopathies), infectious risk, pleuritis/pericarditis (friction rub), pericardial effusion
35
Q

What is Dialysis?

A
  • Process for removing waste and excess water from the blood, and is used primarily as an artificial replacement for lost kidney function in people with ARF or CKD (stage 5)
  • Dialysis is regarded as a β€œholding measure” until a renal transplant can be performed or as supportive measure in those with acute kidney injury where a transplant unlikely/unecessary
36
Q

What is Hemodialysis?

A
  • Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane
  • This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer
  • This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several liters of excess fluid during a typical 4-hour treatment
37
Q

What is Peritoneal Dialysis?

A
  • Peritoneal dialysis, a sterile solution containing glucose (called dialysate) is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a partially permeable membrane
  • Diffusion and osmosis drive waste products and excess fluid through the peritoneum into the dialysate until the dialysate approaches equilibrium with the body’s fluids
  • Then the dialysate is drained, discarded, and replaced with fresh dialysate
  • This exchange is repeated 4-5 times per day; automatic systems can run more frequent exchange cycles overnight
  • Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis
38
Q

When is time for a kidney transplantation?

A
  • end-stage renal disease (ESRD), regardless of the primary cause
  • This is defined as a glomerular filtration rate <15ml/min/1.73 sq.m.
  • The majority of renal transplant recipients are on dialysis (peritoneal dialysis or hemofiltration) at the time of transplantation
  • Individuals with chronic renal failure who have a living donor available may undergo pre-emptive transplantation before dialysis is needed.

Clin Med II (9 decks)

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