Chronic Kidney Disease (Hein) Flashcards
Markers of Kidney Damage (one or more present for > 3 months)
- 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)
Risk factors that make a patient susceptible to CKD
- Diabetes
- HTN
- Older age (>55)
- Family history of CKD
- Racial/Ethnic minority
Progression factors for CKD
- Higher level of proteinuria
- Higher BP
- Poor glycemic control
- smoking
- hyperlipidemia
- Drugs
- Obesity
Complications in CKD
- 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
Pathophysiology of CKD
- Loss of nephron mass (primarily this)
- Glomerular capillary HTN (controlling/reducing Ang II is a mainstay of tx)
- Proteinuria (marker + toxin)
If the patient is showing s/sx of decreased renal fxn and just had an infection what do you think is causing it?
Post-strepglomerulonephritis
If the patient is showing sx with urination what do you think is causing it?
UTI
If patient is showing s/sx of decreased renal fxn and has a skin rash/arthritis what do you think is causing it?
Lupus
If patient is showing s/sx of decreased renal fxn and has CHF or cirrhosis what do you think is causing it?
Prerenal issue (under perfused state)
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?
CKD
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?
Polycystic Kidney Disease
Management Principles for CKD
- 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
Progression is defined as:
a drop in GFR more than 5mL/min/year
Interventions that delay progression of CKD
- ACEI/ARBs
- BP Control
- Blood Glucose Control
When to use ACEI/ARBs
- 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)
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?
If there is a 30% or more drop in GFR then it is a warning sight that something else might be going on
Patiromer (Veltassa)
- 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
If GFR drops by 0-15% after initiating an ACEI/ARB what do you do?
Nothing. Continue monitoring GFR at regular intervals as suggested in the guideline. No need to evaluate cause.
If GFR drops by 15-30% after initiating an ACEI/ARB what do you do?
- 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.
If GFR drops by 30-50% after initiating an ACEI/ARB what do you do?
- Reduce the dose
- Monitor GFR every 5-7 days until GFR is w/in 30% of baseline
- Evaluate the cause for the decreased GFR
If GFR drops by >50% after initiating an ACEI/ARB what do you do?
- 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
ONTARGET
- 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
When do we use a thiazide diuretic in CKD?
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.
When do we use a loop diuretic in CKD?
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.
