Chronic Kidney Dz Flashcards
Chronic Kidney Disease (CKD)- End Stage Renal Disease (ESRD)
Patients remain asymptomatic until their disease has significantly progressed, true or false?
True
Common causes of late-stage chronic kidney disease
most are due to DM and HTN
Some are unknown or due to other causes
CKD
Definition
-GFR less than 60 mL/min for greater than or equal to 3 months with or without kidney damage
OR
-Kidney damage for greater than or equal to 3 months with or without decreased GFR
CKD
disease progression
- CKD is rarely reversible and leads to a progressive decline in renal function
- reduction in renal mass leads to hypertrophy if the remaining nephrons
- this places a burden on the remaining nephrons and leads to progressive glomerular sclerosis and interstitial fibrosis
CKD
Risk factors
- DM
- HTN
- older age
- FHx
- drug toxicity
- urinary obstruction
- african american
- american indian
- asian
- pacific islander
How many nephrons does each kidney contain?
What are the consequences of destruction of the nephrons?
At what GFR % decrease do blood urea and Cr start to show a measurable increase?
Plasma Cr value will approximately double with a ____% reduction in GFR
How many nephrons does each kidney contain?
-1 million
What are the consequences of destruction of the nephrons?
-hyperfiltration and compensatory hypertrophy
At what GFR % decrease do blood urea and Cr start to show a measurable increase?
-Only after GFR has decreased by 50%
Plasma Cr value will approximately double with a _50__% reduction in GFR
What five steps are taken during the initial assessment of CKD?
- Confirm primary renal dx
- Establish chronicity
- Identify reversible factors
- Detect co-morbid factors
- Establish a baseline database
What are the five stages of CKD?
At which stages do symptoms appear?
Stage 1: Kidney damage with normal or increased GFR (greater than 90 mL/min)
Stage 2: Mild reduction in GFR (60-89 mL/min)
Stage 3: Moderate reduction in GFR (30-59 mL/min)
Stage 4: Severe reduction of GFR (15-29 mL/min)
Stage 5: Kidney failure (GFR less than 15 mL/min or dialysis)
*sx typically appear in stages 4 and 5, 1-3 are frequently asymptomatic
How do you measure renal function?
Serum Creatinine
- it will increase as renal function worsens
- alone, SCr is not an accurate measurement of GFR
The national kidney foundation advises that what two testes be used together to improve prognostic accuracy?
GFR and Albuminuria
**Microalbuminuria is a key parameter for measuring nephron injury and repair (its an early sign of kidney disease)
What is Azotemia?
What are the types?
What can Azotemia lead to?
What is Azotemia?
-condition characterized by high levels of nitrogen-containing compounds in the blood
What are the types?
- Prerenal azotemia
- Primary renal azotemia
- Postrenal azotemia
What can Azotemia lead to?
-If not treated, can lead to Uremia
What is Uremia?
When do sx occur?
What is Uremia?
-condition resulting from advanced stages of kidney failure in which urea and other nitrogen containing wastes are found in the blood
When do sx occur?
-sx may not occur until 90% of the nephrons are destroyed
Uremia
sx
signs
labs
sx: fatigue, weakness, easy bruising, breath “fishy odor”, metallic taste in mouth, epistaxis, dyspnea, pulm edema, pericarditis, anorexia/n/v, ED, amenorrhea, restless legs, numbness, cramps, irritability
signs: Sallow (unhealthy) appearing, pallor, ecchymosis, excoriations, edema, yellow, urinous breath, pale conjunctiva, rales, pleural effusion, HTN, cardiomegaly, friction rub, stupor, asterixis ( tremor of the hand when the wrist is extended), peripheral neuropathy
labs:
- BUN/Cr: elevated
- CBC: anemia
- CMP: hyperphosphatemia, hyperkalemia, hypocalcemia
- Serum albumin levels: low (spilling into urine)
- lipid profile: risk of CVD
- Urinalysis: broad waxy cast cells
- also look for evidence of renal bone disease by serum phosphate, Vit D, alkaline phosphatase, intact PTH levels
Uremia
imaging
complications
Imaging:
- renal ultrasound (small echogenic kidney bilaterally
- CT
- MRI/MRA
- Retrograde pyelogram
- renal bx (indicated when real impairment is present and the dx is unclear after extensive work-up
Complications
- Hyperkalemia (especially when GFR drops below 10 mL/min, kidneys have a decreased ability to secrete potassium)
- metabolic acidosis (damaged kidneys are unable to excrete the 1 mEq/kg/day of acid generated by metabolism of dietary proteins, this limits the production of ammonia and limits buffering of H+ in the urine…excess H+ are buffered by large calcium carbonate and calcium phosphate stores in the bone…this contributes to renal osteodystrophy of CKD)
(more) Complications of CKD
CV
Hematologic
Neurologic
CV
-HTN, pericarditis, CHF, pulmonary edema, Heart disease (LVH and Ischemic heart disease)
Hematologic
- Anemia (normochromic, normocytic), due to decreased EPO production
- Coagulopathy (d/t platelet dysfunction, abnormal adhesiveness and aggregation)
Neurologic
- uremic encephalopathy
- peripheral neuropathy (stocking glove distribution)
- Sub-arachnoid hemorrhage
(more) Complications of CKD
Disorders of mineral metabolism
Skin
Disorders of mineral metabolism
- hypocalcemia
- hyperphosphatemia
Skin
- dry, yellow, brown color
- fingernails become thin and brittle
- Uremic Frost
What are disorders of calcium, phosphorus, and bone referred to in CKD?
Pathophys
Renal Osteodystrophy
- hyperphosphatemia leads to hypocalcemia
- PTH is stimulated and leads to Osteitis Fibrosa Cystica (a skeletal disorder caused by hyperparathyroidism, stimulates the activity of osteoclasts, cells that break down bone) and high level of bone turnover
Renal Osteodystrophy
causes
Complications
Causes:
- ability to excrete phosphate is lost
- decreased production of Vit D leads to decreased intestinal absorption of calcium (to balance out phosphate)
- hypoglycemia triggers PTH production and release
- secondary hyperparathyroidism leads to Ca mobilization from bone and increase renal phosphate excretion to maintain electrolyte homeostasis
Complications
- Osteomalacia
- bony pain and proximal muscle weakness
CKD management
- Appropriately screen and dx early CKD
- consult nephrologist
Delay or halt progression by:
- treat underlying condition
- BP control (ACE/ARB)
- treat hyperlipidemia
- control blood sugar
- avoid nephrotoxins (contrast dye)
- treat hypocalcemia (calcium supplements)
- loop diuretics for volume overload
- oral alkali supplements for metabolic acidosis
Why is a special diet important for patients that are on dialysis?
What is the special diet?
Because dialysis alone will not effectively remove all waste production. Also, these products can build up between dialysis tx.
Protein restriction (1 gram/kg/day)
salt and water restriction
potassium restriction
iron supplements
Who to screen for CKD
- FHx (especially in african americans)
- metabolic syndrome and smoking
- patients greater than 65 years old with associated CV risk factors and normal plasma creatinine
How to screen for CKD
- GFR (24 hour urine no longer required, eGFR (estimated) can be calculated)
- Proteinuria (urine dipstick)
- Screening for proteinuria, albuminuria, and microalbuminuria can reveal a decrease in kidney function when GFRs are normal
CKD tx Overall
- Restriction of daily protein
- fluid restriction
- daily caloric intake of 40-50 cal/kg/day
- control HTN, DM, lipids
- sodium restriction (2-4 g/day)
- potassium restriction
- calcium and phosphorus control
- management of metabolic acidosis and anemia
- vascular access for dialysis
- transplantation
Dialysis
Indications
how often?
Indications
- hyperkalemia
- severe metabolic acidosis
- pericarditis
how often?
-3x/week, takes 3-5 hours
Hemodialysis
types of access
Types of access
- vascular shunt (surgically constructed)
- Prosthetic graft (common to get infection, thrombosis, aneurysm formation)
- Temporary indwelling catheters (PICC lines)
Peritoneal dialysis
what is the “dialyzer”?
benefits?
Complications
what is the “dialyzer”?
-peritoneal membrane
benefits?
-permits greater pt autonomy
-minimizes the symptomatic swings observed in
hemodialysis pts
-phosphates are better cleared
Complications
- n/v
- abd pain
- fever
- diarrhea/constipation
- infection (staph aureus)
To be considered for an Kidney transplant, patient must:
- have a condition for which transplantation is considered an effective tx
- have severe and progressive disease
- be willing to accept the risks of surgery and subsequent medical tx
- be physically and emotionally capable of undergoing surgery and subsequent medical tx
Kidney transplant requirements
- pre-transplant exam
- CXR
- complete medical and surgical hx
- EKG
- ultrasound with doppler
- blood tests
- pulmonary function test
- viral testing (hepatitis, CMV, EBV, HIV
- histocompatability testing
Who is excluded from Kidney transplant consideration?
- Age greater than 70
- high risk pts for major surgery (severe CV dz)
- high risk pts for:cancer, acute or chronic infections
- surgical impediments: calcified vessels, bladder diseases
What do all transplant patients need to be started on before surgery?
- Pre-transplant immunosuppression
- gancyclovir
- broad spectrum abx
- monitor drugs and levels
Who is exculded from donating a kidney?
- age greater then 70
- carriers of chronic infections (HIV, Hep B/C)
- carriers of chronic diseases (DM, cancer, amyloidosis, vascular pts, autoimmune
- and of course someone with just one functioning kidney
Post-transplant complications
- rejection
- infection
- CV (CAD, CHF, CVA, HTN)
- Cancer (Skin, blood, solid organs)
- Drug toxicity
- DM/cataract/hirtruism/alopecia….etc
Follow up schedule for kidney transplant pts
1st month: 3x week
1-3 months: once a week
3-6 months: once every 2 weeks
6 months-2 years: once a month
2 years and over: every 2 months
What should the kidney transplant follow up visit include?
- hematology
- general biochemistry
- urine
- drug level monitoring
- detailed clinical exam
- diagnostic imaging (when necessary)
- biopsy
- special attention to: CV dz, neoplastic dz, infection, parathyroid function
Kidney transplant rejection
clinical signs
Clinical signs
- malaise
- fever
- oliguria
- HTN
- graft tenderness
- dx hinges on serial creatinine measurements
What vaccinations should all CKD patients have?
H1N1
Hep A/B
Influenza
Pneumococcal (PPV)
