Chronic Kidney Disease Part 1 Flashcards
Hallmark of DM nephropathy
persistent albuminuria > 300 mg/24 hours
DM nephropathy diagnosed clinically if the following are fulfilled
dm retinopathy + absence of clinical or laboratory evidence of other kidney or renal tract disease
urinary albumin excretion of > 30 mg/24 hours and less than 300 mg/24 hours in 2 of 3 samples
microalbuminuria
first pathologic sign in dm nephropathy type 1 dm and proteinuria
glomerular basement membrane thickening
arteriolar hyalinosis usually seen within
3 to 5 years
exudative lesions in type 1 DM nephropathy pathology
arteriolar hyalinosis, bowmans capsular drops, hyaline caps
45-59 ml/min GFR
stage 3a
GFR 30-44
stage 3b
GFR 15-29
stage 4
GFR less than 15
stage 5
BP target in CKD with proteinuria
less than 130/80
BP target if no proteinuria
less than 140/80
education on RRT and hepatitis B vaccination
Stage 4
AVF creation
stage 5
Goal for Acei or ARB treatment
urine protein level < 0.5 g/day
target for weight loss in obese patients
5%
dietary salt restriction
<5 g (90 meqs sodium per day)
protein requirement for normal adults or those with uncomplicated CKD
0.8 g protein/kg/day
CKD patients with complications
0.6 g protein/kg/day or 0.3 g/kg + ketoacids or a mixture of aminoacid
Protein recommendation CKD patients with loss of muscle mass
0.8 g protein/kg/day
CKD with proteinuria
< 0.8 g protein/kg/day + 1 g protein/g proteinuria
at least 3 episodes of itch in a 2 week period that causes difficulty for the patient or as itch that occurs over a 6 month period in a regular pattern
pruritus
associated with hyperparathyroidism or elevated Ca x Phos
calciphylaxis
main regulator of systemic iron hoemostasis
hepcidin
increase in PTH secretion immediate effects
increase in 1a hydroxylase activity, bone turnover, ca reabsoprtion
decrease in renal po4 reabsorption
more than 3 rbc/hpf in atleast 2 of 3 freshly voioded midstream clean catch urine
asymptomatic hematuria
most common cause of hematuria in young women
UTI
most common cause of hematuria in older patients
malignancy
gross hematuria more pronounced on initiation
urethral source
gross hematuria more pronounced on termination
bladder neck/prostatic urethra
preferred initial imaging modality
computed tomography
next best initial imaging test
renal ultrasonography
imaging to localize and control source of bleeding
cystoscopy
diagnostic when there is any suspicion of upper tract disease
retrograde pyelography
glomerular hematuria + active urine sediment + wbcs/casts
nephritic syndrome
hallmark of nephritic syndrome
glomerular hematuria
definitive finding in nephritic syndrome
rbc casts
principal underlying abnormality in nephrotic syndrome
increased permeability of the glomerular capillaries
most common underlying systemic disease causing nephrotic syndrome
Diabetes Mellitus
1+ urine dipstick protein is equivalent
30-100 mg/dL
most common urine lipid
esterified cholesterol
birefingent birght cross like appearance in polarizing microscope
lipiduria
type of RTA associated in obstructive uropathy
type 4
test of choice to diagnose obstructive uropathy
renal ultrasonography
stage 1 hypertension
140-159/90-99
benzene ring-shaped cysteine crustals
cystinuria
coffin lid crystals
struvite
imaging procedure of choice for stones
noncontrast helical CT scan
radioopaque stones
calcium, cysteine
radiolucent stones
uric acid, indinavir or triamterene stones
size of stones that will pass spontaneously
4 mm
most important vascular complication in patients with CKD
CAD
strongest indicator of possible renal underpefusion
overt hypotension
normal blood glucose in OGTT
less than 140 mg/dL
impaired glucose tolerance or preDM
OGTT 140-199 mg/dL
primary cause of insulin resistance in uremia
impaired tissue sensitivity
independent risk factors for cardiovascular complication in patients with ESKD
insulin resistance and hyperinsulinemia
uremic dyslipidemia
increased triglycerides, ldl and vldl, decreased hdl cholesterol
metformin should be used with caution when eGFR is
less than 60 ml/min
when to discontinue metformin
less than 30 ml/min
insulin sensitizer, causes lactic acidosis in CKD
metformin
T3 levels in CKD
low due to low conversion of T4
strong inhibitors of protein binding of T4
urea, creatinine, indoles, phenols ,heparin
Increase in GH secretion
fasting, insulin induced hypoglycemia, increase of protein
glucose load in growth hormone secretion
decrease GH secretion
reason for reduced linear bone growth in CKD
reduced effectiveness of GF and IGF-1
primary mediator of effects of GH
IGF-1
GH deficiency in GFR and renal plasma flow
decrease GFR and plasma flow
reason for GH resistance
decreased GH receptors and post GH receptor defects, decreased IGF-1 synthesis
stimulates protein synthesis, decreases urea generation and improves nitrogen balance
recombinant human GH
adverse reaction to GH treatment
benign intracranial hypertension, hyperglycemia, fluid retention
most abundant steroid hormone
DHEA
antifibrotic and antiapoptotic effects in kidney
estrogen
responsible for decreased libido, erectile dysfunction, oliospermia and infertility, osteopenia in adults with ESKD
hypogonadism, low testoteron and hyperprolactinemia
development of lipid enriched plaques in the intimal layer of the artery
atherosclerosis
phenomenon of noncalcified nonatheromatous stiffening of smaller muscular arteries
arteriolosclerosis
characterized by medial thickening and heavy calcification without the presence of atheroma
monckerberg’s medial calcific sclerosis
LV remodeling occurs as early as
stage 2
indirect risk factors of CVD/CKD
DM, obesity
partially treated uremia and side effects of dialysis
residual syndrome
most abundant solute excreted by kidney
urea
uremic toxin that impairs platelet function
guanidosuccinic acid
aromatic waste compound normally excreted in the largest quantity
hippurate
uremic solute associated with cardiovascular death in patients undergoing hd
p-cresol sulfate
Fractional excretion of calcium remains unchanged until gfr
<25 ml/min
As GFR decrease Na and Phosphate is maintained by
Decreased reabsorption
absence of cellular (osteoblast and osteoclast) activity, osteoid formation and endosteal fibrosis
low turn over (adynamic bone disease)
bone biopsies that features secondary hpt and mineralization defect, extensive osteoclastic and osteoblastic activity and increased endosteal peritrabecular fibrosis with more osteoid
mixed uremic osteodystrophy
rate of skeletal remodeling: bone resoprtion + formation
turn over
how well bone collagen calcified during the formation phase of skeletal remodeling
mineralization
amount of bone per unit volume of tissue
volume
Dxa to assess fracture risk is recommended/not recommended in
stage 1-3/stage 3b-5
LV remodeling occurs
Stage 2-3 CKD
primary disease of cardiac muscle assoc with ckd causing systolic dysfunction; interstitial myocardial fibrosis
Uremic cardiomyopathy
when is statins recommended in ckd
Stage 3-5 in older than 50 years or less than 50 yo with additional risk factors
screening of anemia starts at stage
G3
tx of aluminum toxicity
deionized water or chelation with desferrioxamine
most effective tx of posttransplantation erythrocytosis
Raas blocker
gold standard in assesing iron stores
Bone marrow iron
if hit is established, what should be considered
Direct thrombin inhibitors or factor Xa
Other tx for uremic bleeding
Ddvap
cryoprecipitate
estrogen
primary prevention of stroke
aspirin
