In CKD, we want to reduce blood pressure to? 1. ) Normal Case? 2. ) With significant proteinuria?

1. ) Less than 140/80 2. ) Less than 130/80

Chronic Kidney Disease Flashcards by Joel Glotfelty

Chronic kidney disease is the presence of kidney damage for 3 months or more, usually detected as which lab value?

Urinary albumin greater than 30 mg/day

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There are three characteristic “failures” in chronic kidney disease. These are?

) Excratory failure (accumlination of excess nitrogen)
) Regulatory failure (abnormal conservation or excretion of fluids and electrolytes)
) Biosynthetic failure (inadequate production of ammonia, Vit. D, or EPO

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Measures the amount of plasma filtered across glomerular capilaries (mL/min)

GFR

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A normal GFR is?

120 ml/min/1.73 m2

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A product of muscle breakdown produced at a relatively constant rate

freely filtered by glomeruli
Minimal to no reabsorption
10% secretion

Creatinine

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Overestimates GFR slightly

Creatinine

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GFR declines with age, but creatinine tends not to change due to parallel decrease in?

Muscle mass

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What is the Schwartz equation for estimating GFR in children ages 1 to 17?

eGFR = 0.413 x height

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A cysteine protease produced by all cells that is completely filtered by the glomeruli

New method for GFR calculation
Not readily available

Cystatin C

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The BUN to creatinine ratio is usually 10-15:1. This ratio is disproportionally increase in which 6 situations?

Volume depletion, GI bleeding, Corticosteroid use, High protein diet, Obstruction, or any catabolic state

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BUN is disproportionally decreaed in which 3 situations?

Low protein diet, Liver disease, Malnutrition

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Increased glomerular permeability to macromolecules and is a marker of kidney damage when persistently elevated

Proteinuria in CKD

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Increased Urinary Albumin Excretion is a sensitive marker for CKD due to which three diseases?

DM, GN, and HTN

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A history of prior abnormal renal function/progression is of utmost importance in the evaluation of?

-i.e. prior abnormal urinalyses to distinguish from AKI

CKD

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In addition to prior history of kidney damage, two other important factors of evaluating CKD are?

GFR estimate (eGFR) and Albuminuria/Proteinuria

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Ultrasound of kidneys in CKD typically shows?

Small and echogenic kidneys

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What are 5 major laboratory findings in CKD?

Elevated BUN and creatinine, Anemia, Metabolic Acidosis, and Hypocalcemia/hyperphosphatemia

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In CKD, we may see a urinary sediment containing red blood cells, leukocytes, and casts, which may indicate

GN, tubulointerstitial disease, vascular disease, or urologic disorders

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In the progression of renal disease, we see endothelial damage in the form of detachment of

Glomerular epithelial cells

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In the progression of renal disease, we see production of

Cytokines

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This results in further nephron dropout setting up a cycle leading to

ESRD

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In CKD, we want to reduce blood pressure to?

) Normal Case?
) With significant proteinuria?

) Less than 140/80

2. ) Less than 130/80

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Have benefits beyond their degree of BP lowering and are more effective with low salt diet or addition of diuretics

ACE inhibitors

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In type II DM with CKD, we especially want to treat with

ARBs

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Is it recommended to use ACEi's and ARBs?

7-10 days following initiatin of ACEi or ARB, we need to check BMP for?

Creatinine, and K+

Inhibition of agiotension II (by use of ACE inhibitors) slows deterioration in CKD by? -This decreases proteinuria

Decreasing intraglomerular hypertension and changing glomerular barrier size

The benefit of ACEi's is mostly seen in patients with significant

Proteinuria

We want to recommend a low protein diet in CKD patients with GFR values of

Less than 30-60

May play a role in the hyperfilitration seen in recently giagnosed DM

IGF-1

In DM, we can prevent progression to CKD with? -Prevents transition to macroalbuminuria

RAS inhibition

A major risk factor for long-term loss of kidney function is?

Acute Kidney Injury (AKI)

An episode of AKI increases risk of developing CKD

Metabolic Acidosis is one thing that can cause CKD progression, we can slow this with

NaHCO3 suplementation

Normally, we filter about 25,000 mEq of Na per day and excrete about 100-150 mEq. So normal FENa is

Less than 1%

We need to excrete progressively larger fractions of filtered load to stay in balance on usual intake as

GFR decreases

In CKD, urine osmolarity may be fixed at

300 mOsm/kg

In CKD, we see an increase in stool excretion of

K+

K+, Na+, and Water restriction are all important in

CKD

In HYPERkalemia, we can stabilize cardiac conduction by treating with

Calcium Gluconate

In HYPERkalemia, we can help move K+ INTO cells, by treating with which three things?

Glucose and insulin, NEbuized albuterol, and HCO3-

We can also treat HYPERkalemia with cation exchange resins such as?

Kayexelate (Na+ polystyrene sulfonate), and Veltassa (patiromer)

Common in CKD when eGFR is less than 25ml/min -Due to decreased ammonia excretion

Metabolic Acidosis

In patient's with normal renal function, even a SLIGHT decrease in plasma HCO3- induces tubular cells to

Increase NH4 production and H+ secretion

For patient's withg CKD, we need to maintain HCO3- in normal range using non K+ containing HCO3- cupplements or citrate salts such as

Bicitra or Shohl's

In CKD, we can also see problems with bone and mineral metabolism due to

Hyperparathyroidism and renal osteodystrophy

A systemic disorder of mineral and bone metabolism due to CKD

Mineral bone disease

Characterized by abnormalities of Ca2+, phosphorus, PTH, Vit D, bone turnover, etc

Mineral bone disease

In serum of patients with Mineral Bone Disease, we will often see a

Lower serum Ca2+, Elevated serum PO4, and Elevated PTH

Secreted by osteocytes and promotes renal phosphate excretion

Fibroblast Growth Factor 23 (FGF 23)

Levels increased early in CKD, stimulated by elevated serum PO

FGF 23

Increases renal PO4 excretion, stimulates PTH, supresses 1,25 di(OH) Vit. D, diminishing PO4 absorption from intestine

FGF 23

What are the three major types of Mineral Bone Disease (MBD)?

Osteitis fibrosa cystica, Adynamic bone disease, Osteomalacia

Most common form of MBD due hyperparathyroidism and osteoclast simulating efects of PTH -high turnover type

Osteitis fibrosa cystica

Characterized by low turnover, spontaneously low PTH procution or iatrogenic suppression -Sometimes caused by aluminum toxicity

Adynamix bone disease

Lack of bone mineralization. In the past was associated with Al toxicity, hypovitaminosis D

Osteomalacia

Frequently asymptomatic, but may manifest as joint pain and stiffness, spontaneous tendon rupture, and predisposition to fracture

CKD MBD

We also see extra skeletal calcifications in

CKD MBD

With stage 3-5 CKD, our goals we want to: 1. ) Correct? 2. ) Control?

1. ) 25OH Vit D deficiency | 2. ) Control Phosphorus

We can treat with calcium carbonate and calcium acetate which are

Phosphate binders

Sevelamer carbonate; lanthanum carbonate; ferric | citrate (Auryxia); and sucoferric oxyhydroxide (Velphoro) are

Noncalcium phosphate binders

To help increase Vit. D, we can take which three things?

Calcitriol, Doxacaldiferol, and paricalcitol

Increases sensitivity of parathyroid calcium sensing receptor to suppressive effect of calcium

Cincacalet (ESRD)

Almost universal with severe CKD when creatinine is greater 2-3 mg/dl

Anemia

CKD anemia is classified as

Nomorchromic and normocytic

CKD anemia is multifactorial but the major component is decreased

EPO production

Binds to erythroid progenitors causing differentiation to erythrocytes

EPO

Impairs activity, nutrition, quality of life, and contributes to LVH, and high output CHF

Anemia

Pre-dialysis (mean hemoglobin 10.1), we can treat with

EPO stimulating agent

Worsened if hematocrit is raised too quickly

Hypertension

Our goal Hgb 10-12 g/dL because studies show that in CKD we have increased risk of stroke and higher CV with

Hgb above 13

Clinical manifestation of severe kidney failure characterized by accumulation of organic waste products normally cleared by the kidney

Uremia

The surrogate markers for uremia are

BUN/creatinine

We refer patient for transplant evaluation when GFR is

Less than 20

Nausea, anorexia, uncontrolled hyperkalemia, and uncontrolled volume overload are some indications for

Dialysis

What are 4 modalities for ESRD?

1. ) Hemodialysis 2. ) Peritoneal dialysis 3. ) Conservation management 4. ) Transplant