Chronic Kidney Disease. Large Group 5. -Barnes

Question 1

What is the number one cause of ESRD?

Answer 1

Diabetes (43%)

HTN (26%)

Question 2

What are the stages of CKD?

Answer 2

I=GFR >90 (w/evidence of kidney damage)

II=GFR 60-90

III=GFR 30-60 (moderate)

IV=GFR 15-29 (severe)

V=<15 =ESRD

Question 3

What are the stages of Diabetic Nephropathy?

Answer 3

1=hyperfunction and hypertrophy (increase in GFR)

2=silent (thickened BM and normal GFR)

3=incipient—> microalbuminuria (slight decrease in GFR)

4=overt Diabetic Nephropathy–> macroalbuminuria (>300) (large decrease in GFR)

5=uremia

Question 4

Will microalbuminuria be seen on a urine dipstick?

Answer 4

NO!

Only measures >300 (macroalbuminuria)

Question 5

What is UACR? What is it used to determine? Why?

Answer 5

Urine albumin: urine creatinine ratio

Microalbuminuria–> ratio >30=CKD

urine dipsticks will not detect it and 24 hour urine samples are often not accurate

Question 6

What is microalbuminuria a risk marker for? Why?

Answer 6

other small vasculature problems because the kidney small vessels are affected

HTN progression, CV disease, CKD

Question 7

What histological changes can be seen before the onset of microalbuminuria in diabetic nephropathy?

Answer 7

GBM thickening

mesangial expansion

Kimmelstiel-wilson lesion

glomerular sclerosis

Question 8

When do we want to catch Diabetic Nephropathy?

Answer 8

before the albuminuria is >300

Question 9

What are the PE findings in Diabetic Retinopathy?

Answer 9

micro aneurysms and cotton wool spots on fundoscopic exam

Question 10

What is the treatment of Diabetic Nephropathy?

Answer 10

• slow progression of CKD
• RAAS suppression/Albuminuria therapy (ACE Is and ARBS) (proteinuria <100)
• Discontinue smoking, Na+ restriction, weight loss
• protein restriction (.8g/kg/day)

Question 11

What physiological changes take place in the nephron of a Diabetic Nephropathy patient? What medication can help with this?

Answer 11

AGE damage the afferent arteriole –> decrease perfusion of the glomerulus–> macula densa senses less Na+ flow and more renin is secreted –> AgII increases–>
constricted efferent arteriole–> increased pressure –> dilated afferent arteriole –> glomerular loss of proteins

kidneys can become very large

ACE inhibitors and ARBs decrease efferent pressure to minimize this but can also decrease GFR

Question 12

What will present with a waxy cast?

Answer 12

CKD

Question 13

Why can anemia (normochromic and normocytic) develop due to CKD?

Answer 13

decreased erythropoietin released from the kidney due to decreased renal mass

inflammation can lead to decrease iron release from the liver –> iron deficiency

hyperparathyroidism

hemoglobinopathies

inadequate dialysis

can also get platelet dysfunction

Question 14

What is the treatment goal for CKD (hemodynamics)?

Answer 14

hemoglobin 10-12

TSAT >20%

ferritin >100

Question 15

What mineral bone disorders can result from CKD? Why?

Answer 15

Vitamin D deficiency (kidneys have 1 alpha hydroxyls that converts vitamin D to the active form normally)

Hypocalcemia

Hyperphosphatemia (inc retention from the kidneys and bones inc)

Hyperparathyrodism (from low active vitamin D)

increase in FGF-23 –> causes changes in phosphorous and vitamin D–> allow phosphorous to appear normal

Question 16

What are the clinical features of bone mineral disorders in CKD pts?

Answer 16

Asymptomatic 
Bone pain 
Proximal myopathy
Fractures
Vascular medial wall calcification
Soft tissue calcification
Calciphylaxis

Question 17

What is uremic fetor? When can this be seen?

Answer 17

stale urine smell coming from mouth

can be seen in uremia

Question 18

What neurologic symptoms can be seen in uremia/CKD?

Answer 18

Tremors
Encephalopathy
Seizures
Peripheral and autonomic neuropathy

Question 19

What is calciphylaxis? What causes it?

Answer 19

caused by chronic hyperphosphatemia in CKD pts

get Ca2+ in the small vessels that feed the skin–> necrosis

Question 20

What lab changes could be found in CKD?

Answer 20

Hyperkalemia 
Hypocalcemia 
Hyperphosphatemia
Metabolic acidosis
AGMA (from uremia) +NAGMA (from decreased distal perfusion)

Question 21

What will the US of a CKD kidney show?

Answer 21

long shrunken kidney

loss of cortex

Question 22

At what GFR should dialysis be initiated?

Answer 22

non-DM: <15

Question 23

What are the indications of dialysis?

Answer 23

AEIOU

 Acidosis
 Electrolyte (highK+ mostly)
 Intoxication 
 Overload (volume)
 Uremia

refractory to medical treatment

Question 24

What type of medication do renal transplant pts have to be on forever?

Answer 24

immunosuppressants

Question 25

What is the diagnostic criteria for autosomal dominant polycystic kidney disease?

Answer 25

Two renal cysts unilaterally or bilaterally before age 30 years by renal ultrasound.

Two cysts in each kidney between the ages of 30 and 59 years by renal ultrasound.

Four or more cysts in each kidney after age 60 years by renal ultrasound.

Question 26

What is the most common genetic disruption in ADPKD?

Answer 26

PKD1

it also progresses more rapidly

Question 27

What are the extra renal associations with ADPKD?

Answer 27

cysts in liver

heart valve abnormalities (mitral valve prolapse)

aneurysms

Question 28

How is the progression of ADPKD monitored?

Answer 28

kidney and cyst volume are monitored by MRI

get a decrease in GFR once the kidneys become significantly enlarged

Question 29

What is the treatment of ADPKD?

Answer 29

V2 receptor antagonists prevent ADH from binding and promoting fluid secretion –> decrease cyst size

Question 30

Which ADPKD pt should be screened for intracranial aneurysm?

Answer 30

Patients with a family history of SAH

High risk occupation such as pilots

Prior to major elective surgeries with anticipated hemodynamic instability.

Question 31

What is the treatment of asymptomatic aneurysms?

Answer 31

Under 10 mm in diameter - Observation and follow-up (at 6 months initially and then yearly)

For >10 mm - surgical clipping is indicated.