Chronic Kidney Disease and Diuretics

Question 1

CKD definition

Answer 1

Defined as more than 3 months of one of the following:

1) GFR less than 60
2) urinary abnormalities (proteinuria/micro hematuria)
3) Structural abnormalities

Most commonly due to DM, HTN, and glomerulonephritis.

Another commonly tested cause is PCKD (autosomal dominant form is more common and is adult onset - autosomal recessive is in kids)

Question 2

History and physical for CKD

Answer 2

Generally asymptomatic until GFR is below 30, but patients gradually experience the signs and symptoms of uremia (anorexia, nausea, vomit, uremic pericarditis, uremic frost, delirium, seizures, coma)

Question 3

Dx of CKD

Answer 3

Common metabolic derangements:

1) Azotemia (high BUN and Cr)
2) Fluid retention (HTN, edema, CHF, pulmonary edema)
3) Metabolic acidosis
4) HyperK
5) Anemia of chronic disease (low EPO production)
6) Abnormal hemostasis caused by impaired platelet aggregation
7) Hypocalcemia, hyperphosphatemia (low PO4 excretion’ imapired vit D producting leading to renal osteaodystrophy)

Question 4

Tx for CKD

Answer 4

1) ACEIs/ARBs and HTN control have been shown to reduce the progression of CKD
2) Desmopressin in cases of abnormal bleeding
3) EPO analogs for anemia of chronic disease
4) Fluid restriction; low Na/K/PO4 intake
5) Oral phosphate binders and calcitrol (1,25-OH Vit D) for renal osteodystrophy
6) Renal replacement therapy includes hemodialysis, peritoneal dialysis, and renal transplant

Question 5

Site of action for carbonic anhydrase inhibitors

Answer 5

Prox convoluted tubules

Question 6

Site of action for osmotic agents like mannitol or urea

Answer 6

Entire tubule

Question 7

Site of action for loop diuretics

Answer 7

Ascending loop of Henle

Question 8

Site of action for thiazides

Answer 8

Distal convoluted tubules

Question 9

Site for K sparing diuretics

Answer 9

Cortical collecting tubule

Question 10

Side effects of acetazolamide

Answer 10

Hyperchloremic metabolic acidosis

Sulfa allergy

Question 11

Side effects of Mannitol, urea

Answer 11

Pulmonary edema due to CHF and anuria

Question 12

Side effects of loops

Answer 12

1) Water loss
2) Metabolic alkalosis
3) Low K
4) Low Ca
5) Ototoxic
6) Sulfa allergy (not ethacrynic acid tho)
7) Hyperuricemia

Question 13

Thiazide side effects

Answer 13

1) Water loss
2) Metabolic alkalosis
3) Low Na
4) Low K
5) High glucose
6) High Ca
7) High uric acid
8) sulfa allergy
9) pancreatitis

Question 14

Side effects of K sparing agents

Answer 14

1) Metabolic acidosis
2) High K
3) Antiandrogenic effects - gynecomastia