Chronic Kidney Disease (Hein) Flashcards

1
Q

Markers of Kidney Damage (one or more present for > 3 months)

A
  • Albuminuria (albumin excretion rate > or equal to 30mg/g of creatinine)
  • Electrolyte & other abnormalities due to tubular disorders (in particular hyperphosphatemia & hyperkalemia)
  • Abnormalities detected by histology
  • Structural abnormalities detected by imaging
  • History of kidney transplantation
  • Decreased GFR (<80 mL/min; usually a secondary thing used for staging)
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2
Q

Risk factors that make a patient susceptible to CKD

A
  • Diabetes
  • HTN
  • Older age (>55)
  • Family history of CKD
  • Racial/Ethnic minority
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3
Q

Progression factors for CKD

A
  • Higher level of proteinuria
  • Higher BP
  • Poor glycemic control
  • smoking
  • hyperlipidemia
  • Drugs
  • Obesity
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4
Q

Complications in CKD

A
  • CVD
  • Anemia
  • Altered bone & mineral metabolism (hypo-Ca & Hyper-P)
  • hyperparathyroidism
  • Volume overload (lots of edema b/c they’re not producing much urine)
  • electrolyte disorders
  • cardiovascular complications
  • acidosis
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5
Q

Pathophysiology of CKD

A
  1. Loss of nephron mass (primarily this)
  2. Glomerular capillary HTN (controlling/reducing Ang II is a mainstay of tx)
  3. Proteinuria (marker + toxin)
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6
Q

If the patient is showing s/sx of decreased renal fxn and just had an infection what do you think is causing it?

A

Post-strepglomerulonephritis

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7
Q

If the patient is showing sx with urination what do you think is causing it?

A

UTI

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8
Q

If patient is showing s/sx of decreased renal fxn and has a skin rash/arthritis what do you think is causing it?

A

Lupus

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9
Q

If patient is showing s/sx of decreased renal fxn and has CHF or cirrhosis what do you think is causing it?

A

Prerenal issue (under perfused state)

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10
Q

If patient is showing s/sx of decreased renal fxn and has long standing uncontrolled diabetes or HTN what do you think is causing it?

A

CKD

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11
Q

if patient is showing s/sx of decreased renal fxn and they’re young/have a family history of this, what do you think is causing it?

A

Polycystic Kidney Disease

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12
Q

Management Principles for CKD

A
  • Delay progression
  • Treat underlying conditions (aggressive BP/diabetes control)
  • Consider protein restriction
  • prevent CV morbidity & mortality
  • Vaccinations (flu, pneumococcal)
  • Treat complications from CKD
  • Prepare for dialysis or transplantation
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13
Q

Progression is defined as:

A

a drop in GFR more than 5mL/min/year

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14
Q

Interventions that delay progression of CKD

A
  • ACEI/ARBs
  • BP Control
  • Blood Glucose Control
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15
Q

When to use ACEI/ARBs

A
  • in all diabetic CKD patients with urinary albumin excretion > or equal to 30mg/g
  • in all CKD patients with urinary albumin excretion > 300mg/g
    (all patients with stages 3,4,and 5 CKD should be on an ACEI/ARB)
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16
Q

After putting someone on an ACEI/ARB how much of a decrease in their GFR is a sign that something else might be going on?

A

If there is a 30% or more drop in GFR then it is a warning sight that something else might be going on

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17
Q

Patiromer (Veltassa)

A
  • Place in therapy: May be considered in patients w/ persistent or recurring hyperkalemia while receiving or considering treatment with a RAAS inhibitor
  • Not for emergency treatment of hyperkalemia
  • Black box warning: binding to other oral medications (administer other oral meds at least 6 hours before or 6 hours after patiromer)
  • Adverse Effects: constipation and hypomagnesemia
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18
Q

If GFR drops by 0-15% after initiating an ACEI/ARB what do you do?

A

Nothing. Continue monitoring GFR at regular intervals as suggested in the guideline. No need to evaluate cause.

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19
Q

If GFR drops by 15-30% after initiating an ACEI/ARB what do you do?

A
  • Continue current dose.
  • Monitor GFR after 10-14 days. If repeat GFR remains w/in 15-30% of baseline, resume monitoring schedule per guidelines.
  • No need to evaluate cause.
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20
Q

If GFR drops by 30-50% after initiating an ACEI/ARB what do you do?

A
  • Reduce the dose
  • Monitor GFR every 5-7 days until GFR is w/in 30% of baseline
  • Evaluate the cause for the decreased GFR
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21
Q

If GFR drops by >50% after initiating an ACEI/ARB what do you do?

A
  • Discontinue until we can figure out what caused the drop (possibly indefinitely if it was the cause)
  • Monitor GFR every 5-7 days until GFR is w/in 15% of baseline
  • Evaluate the cause for the decreased GFR
22
Q

ONTARGET

A
  • ramipril vs. telmisartan vs. combo
  • No real benefit in decreasing CV events
  • did decrease proteinuria
  • Not a kidney disease study so maybe not the best place to pull info from
  • the combo showed a more pronounced decrease in GFR and higher prevalence of hyperkalemia
23
Q

When do we use a thiazide diuretic in CKD?

A

Thiazides are good add ons to help control blood pressure if the patient has a CrCl > 30ml/min. If CrCl is <30ml/min then thiazides don’t work so we won’t start one and if they’re already on one we’ll stop it.

24
Q

When do we use a loop diuretic in CKD?

A

Loops are good in a patient who has edema or for BP control in a patient with a CrCl < 30ml/min. Loops will stay effective all they way til dialysis.

25
Q

When do we use a K+ sparing diuretic in CKD?

A

TRICK QUESTION! You don’t because the risk of hyperkalemia is too high

26
Q

What disease state do we risk the hyperkalemia and give patients ACEI/ARBs and K+ sparing diuretics?

A

CHF with reduced ejection fraction

27
Q

What to monitor when giving loop diuretics to a patient with CKD?

A

Monitor for hypokalemia, hypomagnesemia, and hypocalcemia

28
Q

What to monitor when giving thiazide diuretics to a patient with CKD?

A

Monitor for hypokalemia and hypercalcemia

29
Q

What Constitutes Uremia?

A
  • Renal Failure
  • Muscle Weakness
  • Anorexia
  • Pericarditis
  • Pruritis
  • Dyspnea
  • Mental Status changes (lethargy, confusion)
  • Dysgeugia (taste disturbance-metallic)
  • Neuropathy
  • Nausea & Vomiting
  • Pulmonary Edema
30
Q

Nutritional Considerations in CKD

A
  • Eat low in K+ and low in phos foods
  • limit salt intake (2g/day)
  • Limit protein intake (0.8g/kg/day if GFR <30ml/min for just normal CKD patients)
  • Eat low in sugar, carb, and calorie
  • Goal of normal BMI (18.5-24.9 kg/meters squared)
31
Q

What are the major monitoring parameters in HTN and CKD?

A
  • level of proteinuria

- blood pressure

32
Q

According to NKF what is the blood pressure goal of someone with CKD +/- DM + UAE < 30mg/g?

A

<140/ <90

33
Q

According to NKF what is the blood pressure goal of someone with CKD +/- DM + UAE > 30mg/g?

A

< 130/ < 80

34
Q

According to JNC8 what is the blood pressure goal of someone with CKD + HTN?

A

< 140/ <90

35
Q

According to JNC8 what is the blood pressure goal of someone with CKD + HTN +/- DM?

A

< 140/ <90

36
Q

What is the preferred sulfonylurea to use in CKD for diabetes?

A

Glipizide is the only sulfonylurea without an active metabolite so it is preferred in kidney disease

37
Q

What is the side effect of giving metformin for diabetes in a patient with CKD?

A

The drug and metabolites accumulate and cause lactic acidosis

38
Q

Definition of Diabetic Nephropathy

A
  • longstanding history of diabetes (it occurs 5-10 yrs down the road)
  • Persistent (2 occasions separated by 3 months) finding of protein (albumin) in the urine (> 30mg/g)
  • 1 out of every 2 diabetes develop CKD
39
Q

Preprandial blood sugar goal for diabetic nephropathy patients:

A

80-140 mg/dL

40
Q

Postprandial blood sugar goal for diabetic nephropathy treatment:

A

<180mg/dL

41
Q

Recommended restricted protein intake for patients with diabetes and CKD Stages 1-4 is:

A

0.6g/kg/day

42
Q

UKPDS

A
  • UK Prospective Diabetes Study
  • 20 yr old trial that still stands as our most powerful trial to show what BP control can do for a patient w/ CKD and diabetes
  • wasn’t good at tight BP control but a BP difference of 10/5 is clinically significant
  • SUPER DUPER BIG DECREASE IN STROKE
43
Q

Biggest cause of death in dialysis patients:

A

cardiovascular cause

44
Q

CKD-related (nontraditional) CVD risk factors

A
  • Type (diagnosis) of CKD
  • Decreased GFR
  • Proteinuria
  • RAAS activity
  • Extracellular fluid volume overload
  • Abnormal Ca and Phos metabolism (cardiac calcifications)
  • Dyslipidemia (CKD patients have on a higher scale than normal HF patients)
  • Anemia (LVH)
  • Malnutrition
  • Inflammation
  • Infection
  • Thrombogenic factors
  • Oxidative stress
  • Elevated Homocysteine
  • Uremic Toxins
45
Q

SHARP Trial

A
  • Benefit of statins in CKD patients (average GFR ~30ml/min)
  • No history of CAD, low percentage of diabetes
  • Combination of ezetimibe/simvastatin did reduce major atherosclerotic events (risk reduction of 17% and risk reduction against placbo of 4%, but it was not statistically significant)
  • Combo did not slow progression of CKD
  • Patients on dialysis did not have statistical benefit
  • No difference in mortality
46
Q

Number Needed to Treat

A
  • the number you have to treat to see the benefit in 1 patient
  • 1/absolute risk reduction
47
Q

Common Symptoms of PKD

A
  • High BP
  • Family history of kidney problems
  • heart problems or strokes
  • kidney stones
  • frequent UTIs
  • Constant or intermittent pain in the back, side, or stomach areas (enlarged kidneys)
  • Hematuria
48
Q

Complications of PKD

A
  • Loss of kidney function
  • Brain aneurysms (cysts on brain vessels)
  • Headaches
  • frequent urinary infections
  • Chronic flank or back pain
  • Enlarged heart, damaged heart valves
  • Kidney stones
  • diverticulitis of the colon
  • liver cysts (80%)
49
Q

Treatment of PKD

A
  • manage pain
  • treat infections
  • treat HTN (ACEI); goal= <130/ <80
  • Prepare for ESRD (dialysis and/or transplant)
50
Q

Tolvaptan and PKD

A
  • vasopressin receptor antagonist

- has some data that shows it may slow the increase in renal volume and the decline in renal function