CKD Flashcards
CKD
broad range of disease severity and significant heterogeneity in risk of profession to end-stage renal disease, morbidity, mortality
CKD definded
based on 3 or more months of either kidney damage (albuminuria, kidney biopsy finding, imaging abmn) or GFR ,60
CKD- epidemiology
low GFR increases risk of systemic complications-CV disease, HTN, mineral/bone disorders, anemia- mortality and progression to end stage renal disease.
Dominant Risk factors for CKD
DM and HTN
Testing, risk stratification, treatment plan
differ based on eGFR and UACR
Detection of CKD- Recommendation
Test for CKD among high risk populations with DM and HTN
early detection
allows for complication management before symptoms occur and slows loss of kidney function over time
Detection by PCP
likely to avoid NSAIDs, use ACE/ARB when indicated and receive proper nephro care
Estimated Glomerular Filtration rate
most accurate assessment of kidney function, inaccurate in setting of AKI
Urine studies- Elevated albuminuria or protenunuria
Albuminuria- critical to evaluate prognosis
Albumin-CR- Ratio- more sensitive and specific marker of CKD than spot urine protein/creatinine ratio
CKD progression and complications- treatment aims to
delay progressive loss of kidney function, prevent/manage complications
Interventions fo Delay CKD Progression
manage HTN, Statin Use, Control DM, Correct Metabolic acidosis
Manage HTN
BP target is <130/80, sodium controlled diet, <2000mg of NA per day
Use of RAAS bloackers (ACE/ARB) for albuminuria and HTN
use in CKD with/out DM + A2/A3 levels of albuminuria, hyperkalemia ensues then look into ways to lower K, D/C RAAS blocker only of other methods to lower K fail. NEVER use ace and ARB in combo
Thiazides- stage G1-3b, loop diuretics second line with stage 4- BID
Statin Control
statin based therapies reduce vascular even in CKD
Control DM-
target A1c 7%, Higher target with limited life expectancy, reduces progression of albuminuria and loss of kidney function over time
CKD Anemia
measure hgb annually, start in G3a CKD- erythropoietin production decrease with low GFR
CKD+ mineral/bone disorder
secondary hyperparthyroidsm, hypocalcemia, hyperphosphatemia, decreased Vitd, vascular calcification- Begins in stage G3b- Measure at least once for baseline levels- Ca, phosphorus, intact parathyroid hormone, total 25-hydroxy VitD
Correct Metabolic acidosis
tx with oral alkali- achieve normal serum bicarb- slows kidney disease progression, Bicarb <22 prescribe sodium bicarb (650 TID), alternative- Sodium Citrate 30ml daily, if these fail- refer to nephro
Patient safety in CKD
Meds and metabolites are excreted by kidneys- dose adjustments on eGFR need to occur to reduce complications
D/c or briefly hold
RAAS blockers, NSAIDs, diuretics, metformin- r/t lactic acidosis- A patient safety approach to CKD considers the level of eGFR in prescription practice
NSAIDs
inhibit vasodilatory prostaglandins- esp with dehydration and HF- acute kidney injury; long term use increase rate of progression of CKD; Inquire about use of these OTC meds-educate potiental harm and SE- allergic interstitial nephritis, ^K, HTN, edema. Avoid with GFR less than 30. Limit these meds with GFR <60
EXTREME caution with CKD+ RAAS And/or diuretic therapy
Metformin:
Discontinue use with GFR <30, use with caugiton for pt with GFR <30-45, not reccomended with pt with Cr men >1.5 woman >1.4 r/t to risk of lactic acidosis
iodinated Contrast
major risk of nephropathy in CKD, prevention strategies include- Minimize dose, volume expansion with IV isotonic saline/bicarb, consider holding med that increase risk fo AKI, IV fluids 1ml/kg start 1 hour prior to procedure cont for 3-6hr post, measure kidney function 48-96h after
CKD & CV disease
all patients with CKD are at increase risk for CV disease
Framingham Risk Factors for CV
Low eGFR and albuminuria
CKD risk factors for CV-
anemia, mineral/bone disorder, vascular clacification
Anti-platelet agents in CKD
advise to take low-dose aspirin for secondary prevention of CV disease- unless bleeding risk
referral to nephrologists
PCP are central to referring to specialists- associated with improved outcomes
Timely referral
improves preparation for kidney replacement therapy, lower use of hemodialysis/emergent dialysis, and increase use of kidney transplants/selfcare dialysis
Severe Albuminuria + DM
Don’t need referral- can be managed by PCP
Stage G4-G5 CKD + limited life expectancy + adv dementia
Manage conservatively
common complications for PCPs
pt age over 65 with eGFR 45-60 but NO albuminuria or urinalysis Abmn- manage conservatively, avoid use of RAAS blockers, limit NSAIDs and IV contrast procedures
Elderly+ lab evidence of stage G3a CKD
Monitor closely for AKI after major surgeries.
When to referr
GFR <30, >25% drop in GFR, progression of CKD with sustain decline in eGFR of more than 5 per year, consistent finding of significant albuminuria, persistent and unexplained hematuria, secondary hyperparathyroidism, persistent anion gap acidosis, non-iron deficiency anemia, CKD and HTN in refractory, persistent abn in K, recurrent Nephrolithisais, hereditary kidney disease, or unkwn cause
early recognition of CKD
Enhances Kidney Protective Care by improving modifiable RF, Improves prediction of CV, events beyond RF, encourages timely nephro referral, limits patient safety risks with CKD
Improved CKD diagnosis
increased urinary albumin testing, Increased appropriate use of ACE/ARBs, Avoids NSAIDs with lower eGFR,
Modifiable Risk Factors
DM, HTN, NSAID use, hx of AKI
Non-Modifiable
fHx of kidney dx, >60 year old, ethnicity- AA, hispanic, Asian/Pacific islander, American Indian
eGFR-
Provides insight regarding overall kidney function
ACR- Albumin-Creatinine ratio
provides insight regarding extent of kidney damage
Albuminuria categories- A1
normal to mildly increased-
<30 mg/g <3 mg/mmol
Albuminuria categories- A2
moderately increased
30-200 mg/g, 3-29 mg/mmol
Albuminuria categories- A3
Severely Increased
>300 mg/g >30 mg/mmol
eGFR Categories- G1
Normal or high
<90
eGFR Categories - G2
mildly decreased
60-89
eGFR Categories G3a
mildly to moderately decreased
45-59
eGFR Categories G3b
moderately to severely decreased
30-44
eGFR Categories G4
severely decreased
15-29
eGFR Categories G5
Kidney failure
<15
Diagnostic Criteria
eGFR <60, ACR >30, Markers of kidney damage- 1+ glomerular hematuria, kidney biopsy abnm, polycystic kidney dx on imaging
CKD-EPI creatinine equation
Most accurate and least biased method to estimate eGFR
Urine Albumin creatinine ratio
calculated by dividing albumin concentration/creatinine concentration
Assist in adjusting levels of varying urine concentrations- more accurate than albumin alone
Spot UACR
qualifies proteinuria, 3 levels exist, normal/mild/moderate/severe
Patient safety- Electroyletes
HyperK, magnesemia, phosphatemia, Hypoglycemia
AKI RISK
Avoid NSAIDs, Dual RAAS blockade, Med >30% clearance in kidney- requires dose adjustment, No bisphophonares of eGFR <30, avoid gadolinium-based contrast fo egFR <30
indications for Referal
eGFR <30, persistent albuminuria, atypical progression of CKD, AKI, urinary red cell cast, RBC >20, refractory HTN, abnm K persistent, nephrolithiasis, hereditary kidney disease,
Which vitamin D is perferred form to achieve normal serum levels
Vit D3,
Which stage does the complications normally start?
Stage 3
What can a PCP do for CKD?
recognizing and test at-risk patients, educate, manage blood pressure and DM
How to address othe risks?
Vaccinations, malnutrition, depression, refer to dietitian for nutritional guidance,
Stage 1- 90-100 function
no symptoms, other health issues, DM, HTN, obesity
Stage 2- 60-89
no symptoms, protein leaking in urine <200mg
Stage 3 30-59
edema, fatigue, back pain, foamy-darker urine, microalbumin >200, food restrictions, sodium/phosphorous
Stage 4 15-29%
Stage 3 symptoms + n/v, difficulty concentration, tingling in toes/fingers, loss of appetite, sleep issues, kidney dialysis, renal dietitian required, most food restrictions, less K
Stage 5 <15%
Stage 4 symptoms, fatigue, easy bruising, thirst, cramps, skin color changes, making little to no urine, kidney dialysis/ transplant
Anemia + CKD+ ESA
Not required until Stage 4-5
Anemia Treatment
Iron supplements needed for ESA to be effective,
Initiate Iron therapy
if TSAT is <30 and ferritin <500- IV for dialysis and oral for non
Individualized ESA therapy
start at Hb <10, and maintain Hb <11.5, Ensure good iron stores
Avoid transfusion in who?
transplant patients- if needed use leukocyte filter to reduce HLA sensitization
Testing in Stage 3
Calcium+ phos Q6-12 months, PTH- Once, 25-D- once/annually
Testing in stage 4
Calcium + Phos Q3-6 months, PTH- Q6-12M, Vit D- Based on treatment levels
Testing in stage 5
Calcium + Phos Q 1-3m, PTH- Q3-6M, Vit D- based on treatment levels
Vit D treatment
D3- 2000 IU by mouth is cheaper and better absorbed than 50000- IM monthly,
Diet-
Limit phosphorus, emphasis on decreasing packaged products, refer to renal RD
Fracture risks
Dexa scan wont predict fx risk in CKD 3-5, PTH goals and use of Calcutriol
Lipid management- >50 and CKD 1-2
Statin alone
Lipid Management- >50 and CKD 3a- 5
use statin alone or statin/zetia combo
Lipid Management- adults <50 + CKD+ hx of CAF, MI, DM, Stroke
use statin alone
Lipid Management- Dialysis and transplant pt
cont but do not start a statin after dialysis initiation
Lipid management- all transplant patients
statin generally recommended
Risk factors of infection
Advanced age, high burden of coexisting illness, HYPOalbuminemia, Immunosuprrive therapy, Nephrotic syndrome, uremia, anemia and malnutrition, high prevalence of functional disabilities.
mental health conseling
depression is associated with chronic dx, patient with eGFR < 60 requires constant assessment of impairment of function and well-being
Vaccinations
Annual Flu recommended
Polyvalent when eGFR < 30, both vaccines
COIVD- mRNA booster,
HepB immunization when GFR < 30- confirm with response sero testing
Use of live vaccine- most consider Pt, immune system status first
malnutrtion
common with protein energy wasting
Beings at stage 3-4,
Prevent- assess nutritional status, individualize prevention/tx patient education, promote patient adherence
Common meds requiring reduction of dose
Allopurinol, gabapentin, reglan, narcotics, BB, Digoxin, Statins, antimicrobials, lovenox, methotrexate, colchicine
Hyperkalemia
1st line- stop diet K intake, stop NSAIDs, Cox 2 inhibitors, stop K sparing diuretics, avoid salt substitutes
New binding agent- Patiromer
Conditions that increase risk for CKD
DM, HTN, CV, >60 y/o, ethic/racial minority, obesity, fam hx, AKI history
eGF < 60 Safety risk
drug dose consider, reduce risk of AKI volume depletion, contrast induced AKI,
eGFR 45-60 Safety risk
avoid prolong NSAIDs, cont metformin
eGFR 30-45 safety risk
avoid prolong NSAIDs, use metformin with close monitoring at 50% dose
eGFR <30 safety risk
avoid NSAIDs, AVOID bisphophonates, avoid metformin, Avid PICC lines, Monitor PT INR, closely given increased risk of warfarin anticoagulation bleeding
CKD progression and Complications- HTN
Blood pressure goals, <140/90, Consider BP goal <130/80 only if ACR >300, ACE/ACR for HTN of ACR >30, avoid ACE/ARB use together, diuretic is normally required, Dietary sodium <2000mg/day
CKD progression and Complications- DM
Target A1C- 7%
CKD progression and Complications– testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10
Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily
CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
CKD progression and Complications– testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10
Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily
CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
CKD progression and Complications– testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10
Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily
CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
CKD progression and Complications– testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10
Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily
CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
CKD- Prevalence
10% of Americans- most are asymptomatic untill end stage
70% of cases of late stage are due to what
DM or HTN/Vascular disease
APOL-1 Gene
increase risk of CKD in African Decent
Most Stg 3
die from CVD prior to progression to ESRD
Patho
Destruction of nephrons- compensatory hypertrophy and supernormal GFR of remaining nephrons- ACE/ARB can help with hyperfiltration
Clinical signs
Early stg- saymptomatic- accumulation of metabolic waste products-uremic syndrome- any signs of uremia=hospital admit
Reversible causes of kidney injury
Infection, obstruction, extracellular fluid volume, HypoK, Hypercalemia, hyperuricemia, nephrotoxic agents, severe/urgent HTN, heart failure
CKD- Dx imaging
US- small echogenic kidneys b/l-chronic parenchymal scarring of advanced CKD, Large kidneys- adult polycystic kidney disease, DM neuropathy, HOV, plasma cell myeloma, amyoidosis, obstructive ureopathy
