Chronic Kidney Disease Flashcards
Spectrum of pathophysiologic processes associated with abnormal kidney function and a progressive decline in glomerular filtration rate (GFR)
Chronic Kidney Disease
2 Broad Sets of Mechanisms of Damage in CKD
- initiating mechanisms specific to the underlying etiology
2. hyperfiltration and hypertrophy of the remaining viable nephrons
Risk Factors of CKD
- small for gestation birth weight
- childhood obesity
- hypertension
- diabetes mellitus
- autoimmune disease
- advanced age
- African ancestry
- a family history of kidney disease
- a previous episode of acute kidney injury and presence of proteinuria
- abnormal urinary sediment
- structural abnormalities of the urinary tract
Normal annual mean decline in GFR with age from the peak GFR (~120 mL/min per 1.73 m2) attained during the 3rd decade of life
~1 mL/min per year per 1.73 m2
Refers to the excretion of amounts of albumin too small to detect by urinary dipstick or conventional measures of urine protein
Microalbuminuria
Serves as a marker not only for early detection of primary kidney disease, but for systemic microvascular disease as well
urinary albumin to creatinine ratio (UACR)
MEN - > 17 mg albumin/g creatinine
WOMEN - > 25 mg albumin/g creatinine
Devised to predict the risk of progression to stage 5 dialysis-dependent kidney disease
Kidney Failure Risk (KFR) equation
Factors affecting the likelihood and rate of CKD progression
baseline eGFR and degree of albuminuria
primary renal disease
ongoing exposure to nephrotoxic agents
others: obesity, hypertension, age, ethnicity and laboratory parameters
Stage of CKD where the accumulation of toxins, fluid, electrolytes normally excreted by the kidney –> uremic syndrome
ESRD
Etiologies of CKD
Diabetic nephropathy Glomerulonephritis HPN associated CKD ADPKD Other cystic and tubulointerstitial nephropathy
Major risk factor for cardiovascular disease
Minor decrement in GFR or the presence of albuminuria
PATHOPHYSIOLOGY OF UREMIC SYNDROME (3 Spheres Of Dysfunction)
- accumulation of toxins that normally undergo renal excretion
- loss of other kidney functions such as fluid and electrolyte homeostasis and hormone regulation
- progressive systemic inflammation and its vascular and nutritional consequences
May serve as an indication to initiate dialysis in advanced CKD
diuretic resistance with intractable edema and hypertension
Common disturbance in advanced CKD – metabolic acidosis
NAGMA – early stage
HAGMA – later stage
Used to maintain euvolemia in CKD
dietary salt restriction and loop diuretics + metolazone
Treatment of hyperkalemia in CKD
dietary restriction of potassium
Kaliuretic diuretics
potassium-binding resins – calcium resonium, sodium polystyrene or patiromer
Considered a uremic toxin and high levels are associated with muscle weakness, fibrosis of cardiac muscle, and nonspecific constitutional symptoms
parathyroid hormone
Leading cause of morbidity and mortality in patients at every stage of CKD
cardiovascular abnormalities
Cardiovascular abnormalities
Ischemic Vascular Disease
Heart Failure
Hypertension and Left Ventricular Hypertrophy
Pericardial Disease
For the CKD patient not yet on dialysis or the patient treated with peritoneal dialysis
oral iron supplementation
Subtle clinical manifestations of uremic NEUROMUSCULAR disease usually become evident at
stage 3 CKD
PERIPHERAL NEUROPATHY becomes clinically evident after the patient reaches
stage 4 CKD
EARLY MANIFESTATIONS OF CNS COMPLICATIONS:
mild disturbances in memory and concentration and sleep disturbance
LATER STAGES:
neuromuscular irritability – hiccups, cramps, and twitching
ADVANCED UNTREATED KIDNEY FAILURE
asterixis
myoclonus
seizures
coma
Characterized by ill-defined sensations of sometimes debilitating discomfort in the legs and feet relieved by frequent leg movement
“restless leg syndrome”
Urine-like odor on the breath, derives from the breakdown of urea to ammonia in saliva and is often associated with an unpleasant metallic taste (dysgeusia)
uremic fetor
Quite common and one of the most vexing manifestations of the uremic state
pruritus
Skin condition unique to CKD patients which consists of progressive subcutaneous induration, especially on the arms and legs
nephrogenic fibrosing dermopathy
Diagnosis of CKD of long-standing duration
bilaterally small kidneys
EXCEPTION: diabetic nephropathy amyloidosis HIV nephropathy polycystic kidney disease
COMMONLY ACCEPTED CRITERIA FOR INITIATING PATIENTS ON MAINTENANCE DIALYSIS
• presence of uremic symptoms
nausea, vomiting, anorexia
altered mental status – lethargy, somnolence, malaise, stupor, coma, delirium
pericarditis
friction rub
chest pain
dyspnea
bleeding diathesis
uremic encephalopathy – asterixis (flapping tremor of the hand), tremor multifocal myoclonus, seizures
uremic fetor (breath smells like urine)
sallow skin (slightly yellow and/or slightly pale)
- presence of hyperkalemia unresponsive to conservative measures
- persistent extracellular volume expansion despite diuretic therapy
- acidosis refractory to medical therapy
- bleeding diathesis
- creatinine clearance or estimated glomerular filtration rate (GFR) <10 mL/min per 1.73 m2)
Relies on the principles of solute diffusion across a semipermeable membrane, movement of metabolic waste products takes place down a concentration gradient from the circulation into the dialysate
Hemodialysis
3 essential components to hemodialysis
dialyzer
composition and delivery of the dialysate
blood delivery system
Have the highest long-term patency rate of all hemodialysis access options
Fistula
The most common additives to peritoneal dialysis solutions
heparin
dialysis access is the preferred option if your veins are too small
AV graft
Absolute Indications for Renal Replacement Therapy
Pericarditis or Pleuritis
Progressive Uremic Encephalopathy or neuropathy w/ signs such as confusion, asterixis, myoclonus, wrist or foot drop, seizures
Bleeding diathesis attributable to uremia
Persistent metabolic disturbances that are refractory to medical therapy - hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia and hyperphosphatemia
Fluid overload refractory to diuretics
HPN poorly responsive to antiHPN medications
Persistent nausea and vomiting
Evidence of malnutrition
Relative Indications for Renal Replacement Therapy
anorexia and nausea
impaired nutritional status
increased sleepiness
decreased energy levels, attentiveness and cognitive tasking
Indication for Maintenance Dialysis
Uremic Symptoms - N/V, loss of consciousness, uremic pericarditis
Intractable HYPERKALEMIA
Persistent Volume Expansion despite Diuretics
Refractory ACIDOSIS
Bleeding Diasthesis
eGFR < 1.73 mL
