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Mod 4 > CKD > Flashcards

CKD Flashcards

1
Q

CKD

A

broad range of disease severity and significant heterogeneity in risk of profession to end-stage renal disease, morbidity, mortality

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2
Q

CKD definded

A

based on 3 or more months of either kidney damage (albuminuria, kidney biopsy finding, imaging abmn) or GFR ,60

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3
Q

CKD- epidemiology

A

low GFR increases risk of systemic complications-CV disease, HTN, mineral/bone disorders, anemia- mortality and progression to end stage renal disease.

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4
Q

Dominant Risk factors for CKD

A

DM and HTN

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5
Q

Testing, risk stratification, treatment plan

A

differ based on eGFR and UACR

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6
Q

Detection of CKD- Recommendation

A

Test for CKD among high risk populations with DM and HTN

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7
Q

early detection

A

allows for complication management before symptoms occur and slows loss of kidney function over time

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8
Q

Detection by PCP

A

likely to avoid NSAIDs, use ACE/ARB when indicated and receive proper nephro care

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9
Q

Estimated Glomerular Filtration rate

A

most accurate assessment of kidney function, inaccurate in setting of AKI

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10
Q

Urine studies- Elevated albuminuria or protenunuria

A

Albuminuria- critical to evaluate prognosis
Albumin-CR- Ratio- more sensitive and specific marker of CKD than spot urine protein/creatinine ratio

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11
Q

CKD progression and complications- treatment aims to

A

delay progressive loss of kidney function, prevent/manage complications

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12
Q

Interventions fo Delay CKD Progression

A

manage HTN, Statin Use, Control DM, Correct Metabolic acidosis

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13
Q

Manage HTN

A

BP target is <130/80, sodium controlled diet, <2000mg of NA per day

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14
Q

Use of RAAS bloackers (ACE/ARB) for albuminuria and HTN

A

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

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15
Q

Statin Control

A

statin based therapies reduce vascular even in CKD

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16
Q

Control DM-

A

target A1c 7%, Higher target with limited life expectancy, reduces progression of albuminuria and loss of kidney function over time

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17
Q

CKD Anemia

A

measure hgb annually, start in G3a CKD- erythropoietin production decrease with low GFR

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18
Q

CKD+ mineral/bone disorder

A

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

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19
Q

Correct Metabolic acidosis

A

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

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20
Q

Patient safety in CKD

A

Meds and metabolites are excreted by kidneys- dose adjustments on eGFR need to occur to reduce complications

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21
Q

D/c or briefly hold

A

RAAS blockers, NSAIDs, diuretics, metformin- r/t lactic acidosis- A patient safety approach to CKD considers the level of eGFR in prescription practice

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22
Q

NSAIDs

A

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

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23
Q

Metformin:

A

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

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24
Q

iodinated Contrast

A

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

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25
Q

CKD & CV disease

A

all patients with CKD are at increase risk for CV disease

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26
Q

Framingham Risk Factors for CV

A

Low eGFR and albuminuria

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27
Q

CKD risk factors for CV-

A

anemia, mineral/bone disorder, vascular clacification

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28
Q

Anti-platelet agents in CKD

A

advise to take low-dose aspirin for secondary prevention of CV disease- unless bleeding risk

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29
Q

referral to nephrologists

A

PCP are central to referring to specialists- associated with improved outcomes

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30
Q

Timely referral

A

improves preparation for kidney replacement therapy, lower use of hemodialysis/emergent dialysis, and increase use of kidney transplants/selfcare dialysis

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31
Q

Severe Albuminuria + DM

A

Don’t need referral- can be managed by PCP

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32
Q

Stage G4-G5 CKD + limited life expectancy + adv dementia

A

Manage conservatively

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33
Q

common complications for PCPs

A

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

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34
Q

Elderly+ lab evidence of stage G3a CKD

A

Monitor closely for AKI after major surgeries.

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35
Q

When to referr

A

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

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36
Q

early recognition of CKD

A

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

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37
Q

Improved CKD diagnosis

A

increased urinary albumin testing, Increased appropriate use of ACE/ARBs, Avoids NSAIDs with lower eGFR,

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38
Q

Modifiable Risk Factors

A

DM, HTN, NSAID use, hx of AKI

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39
Q

Non-Modifiable

A

fHx of kidney dx, >60 year old, ethnicity- AA, hispanic, Asian/Pacific islander, American Indian

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40
Q

eGFR-

A

Provides insight regarding overall kidney function

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41
Q

ACR- Albumin-Creatinine ratio

A

provides insight regarding extent of kidney damage

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42
Q

Albuminuria categories- A1

A

normal to mildly increased-
<30 mg/g <3 mg/mmol

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43
Q

Albuminuria categories- A2

A

moderately increased
30-200 mg/g, 3-29 mg/mmol

44
Q

Albuminuria categories- A3

A

Severely Increased
>300 mg/g >30 mg/mmol

45
Q

eGFR Categories- G1

A

Normal or high
<90

46
Q

eGFR Categories - G2

A

mildly decreased
60-89

47
Q

eGFR Categories G3a

A

mildly to moderately decreased
45-59

48
Q

eGFR Categories G3b

A

moderately to severely decreased
30-44

49
Q

eGFR Categories G4

A

severely decreased
15-29

50
Q

eGFR Categories G5

A

Kidney failure
<15

51
Q

Diagnostic Criteria

A

eGFR <60, ACR >30, Markers of kidney damage- 1+ glomerular hematuria, kidney biopsy abnm, polycystic kidney dx on imaging

52
Q

CKD-EPI creatinine equation

A

Most accurate and least biased method to estimate eGFR

53
Q

Urine Albumin creatinine ratio

A

calculated by dividing albumin concentration/creatinine concentration
Assist in adjusting levels of varying urine concentrations- more accurate than albumin alone

54
Q

Spot UACR

A

qualifies proteinuria, 3 levels exist, normal/mild/moderate/severe

55
Q

Patient safety- Electroyletes

A

HyperK, magnesemia, phosphatemia, Hypoglycemia

56
Q

AKI RISK

A

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

57
Q

indications for Referal

A

eGFR <30, persistent albuminuria, atypical progression of CKD, AKI, urinary red cell cast, RBC >20, refractory HTN, abnm K persistent, nephrolithiasis, hereditary kidney disease,

58
Q

Which vitamin D is perferred form to achieve normal serum levels

A

Vit D3,

59
Q

Which stage does the complications normally start?

A

Stage 3

60
Q

What can a PCP do for CKD?

A

recognizing and test at-risk patients, educate, manage blood pressure and DM

61
Q

How to address othe risks?

A

Vaccinations, malnutrition, depression, refer to dietitian for nutritional guidance,

62
Q

Stage 1- 90-100 function

A

no symptoms, other health issues, DM, HTN, obesity

63
Q

Stage 2- 60-89

A

no symptoms, protein leaking in urine <200mg

64
Q

Stage 3 30-59

A

edema, fatigue, back pain, foamy-darker urine, microalbumin >200, food restrictions, sodium/phosphorous

65
Q

Stage 4 15-29%

A

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

66
Q

Stage 5 <15%

A

Stage 4 symptoms, fatigue, easy bruising, thirst, cramps, skin color changes, making little to no urine, kidney dialysis/ transplant

67
Q

Anemia + CKD+ ESA

A

Not required until Stage 4-5

68
Q

Anemia Treatment

A

Iron supplements needed for ESA to be effective,

69
Q

Initiate Iron therapy

A

if TSAT is <30 and ferritin <500- IV for dialysis and oral for non

70
Q

Individualized ESA therapy

A

start at Hb <10, and maintain Hb <11.5, Ensure good iron stores

71
Q

Avoid transfusion in who?

A

transplant patients- if needed use leukocyte filter to reduce HLA sensitization

72
Q

Testing in Stage 3

A

Calcium+ phos Q6-12 months, PTH- Once, 25-D- once/annually

73
Q

Testing in stage 4

A

Calcium + Phos Q3-6 months, PTH- Q6-12M, Vit D- Based on treatment levels

74
Q

Testing in stage 5

A

Calcium + Phos Q 1-3m, PTH- Q3-6M, Vit D- based on treatment levels

75
Q

Vit D treatment

A

D3- 2000 IU by mouth is cheaper and better absorbed than 50000- IM monthly,

76
Q

Diet-

A

Limit phosphorus, emphasis on decreasing packaged products, refer to renal RD

77
Q

Fracture risks

A

Dexa scan wont predict fx risk in CKD 3-5, PTH goals and use of Calcutriol

78
Q

Lipid management- >50 and CKD 1-2

A

Statin alone

79
Q

Lipid Management- >50 and CKD 3a- 5

A

use statin alone or statin/zetia combo

80
Q

Lipid Management- adults <50 + CKD+ hx of CAF, MI, DM, Stroke

A

use statin alone

81
Q

Lipid Management- Dialysis and transplant pt

A

cont but do not start a statin after dialysis initiation

82
Q

Lipid management- all transplant patients

A

statin generally recommended

83
Q

Risk factors of infection

A

Advanced age, high burden of coexisting illness, HYPOalbuminemia, Immunosuprrive therapy, Nephrotic syndrome, uremia, anemia and malnutrition, high prevalence of functional disabilities.

84
Q

mental health conseling

A

depression is associated with chronic dx, patient with eGFR < 60 requires constant assessment of impairment of function and well-being

85
Q

Vaccinations

A

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

86
Q

malnutrtion

A

common with protein energy wasting
Beings at stage 3-4,
Prevent- assess nutritional status, individualize prevention/tx patient education, promote patient adherence

87
Q

Common meds requiring reduction of dose

A

Allopurinol, gabapentin, reglan, narcotics, BB, Digoxin, Statins, antimicrobials, lovenox, methotrexate, colchicine

88
Q

Hyperkalemia

A

1st line- stop diet K intake, stop NSAIDs, Cox 2 inhibitors, stop K sparing diuretics, avoid salt substitutes
New binding agent- Patiromer

89
Q

Conditions that increase risk for CKD

A

DM, HTN, CV, >60 y/o, ethic/racial minority, obesity, fam hx, AKI history

90
Q

eGF < 60 Safety risk

A

drug dose consider, reduce risk of AKI volume depletion, contrast induced AKI,

91
Q

eGFR 45-60 Safety risk

A

avoid prolong NSAIDs, cont metformin

92
Q

eGFR 30-45 safety risk

A

avoid prolong NSAIDs, use metformin with close monitoring at 50% dose

93
Q

eGFR <30 safety risk

A

avoid NSAIDs, AVOID bisphophonates, avoid metformin, Avid PICC lines, Monitor PT INR, closely given increased risk of warfarin anticoagulation bleeding

94
Q

CKD progression and Complications- HTN

A

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

95
Q

CKD progression and Complications- DM

A

Target A1C- 7%

96
Q

CKD progression and Complications– testing

A

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,

97
Q

CKD progression and Complications– testing

A

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,

97
Q

CKD progression and Complications– testing

A

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,

98
Q

CKD progression and Complications– testing

A

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,

99
Q

CKD- Prevalence

A

10% of Americans- most are asymptomatic untill end stage

100
Q

70% of cases of late stage are due to what

A

DM or HTN/Vascular disease

101
Q

APOL-1 Gene

A

increase risk of CKD in African Decent

102
Q

Most Stg 3

A

die from CVD prior to progression to ESRD

103
Q

Patho

A

Destruction of nephrons- compensatory hypertrophy and supernormal GFR of remaining nephrons- ACE/ARB can help with hyperfiltration

104
Q

Clinical signs

A

Early stg- saymptomatic- accumulation of metabolic waste products-uremic syndrome- any signs of uremia=hospital admit

105
Q

Reversible causes of kidney injury

A

Infection, obstruction, extracellular fluid volume, HypoK, Hypercalemia, hyperuricemia, nephrotoxic agents, severe/urgent HTN, heart failure

106
Q

CKD- Dx imaging

A

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

Mod 4 (4 decks)

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