CKD Flashcards
How is chronic kidney disease defined?
markers of kidney damage for at least 3 months OR GFR <60 mL/min/1.73 m2 for 3+ months
What sort of markers of kidney damage may be present?
abnormalities in composition of blood or urine, or abnormalities in imaging tests
Spectrum of disorders associated with abnormal kidney function and/or progressive decline in GFR
chronic kidney disease
What happens if you remove the underlying cause in chronic kidney disease? Why?
decline in function persists, nephron overwork injury
What pathophysiology leads to CKD?
reduction in number of functional nephrons –> hyperfiltration and hypertrophy of remaining nephrons due to RAAS –> glomerular architecture distorted hindering filtering –> inflammation and fibrosis
In some circumstances, markers can improve such as BUN, creatinine, and GFR after CKD called the “renal rebound”. What are these circumstances (5)?
recovery from AKI on CKD
removal of toxic substances
diet changes
improved hydration
control of other disease state
Nephrons can’t regenerate once they are replaced with scar tissue. So, why can the renal rebound occur?
removal of disease burden on still-functioning nephrons
What is the cause of the majority of cases of late-stage CKD (70%)?
HTN/vascular disease or CVD
CKD is an independent risk factor for _____. What type of CKD increases risk of CV mortality?
CV disease, proteinuric CKD
What are the demographic risk factors for CKD?
Demographics: older age, sub-saharan african ancestry
Comorbid conditions:
GU: structural urinary tract abnormalities, proteinuria, abnormal urinary sediment
Metabolic conditions: diabetes mellitus, low HDL, obesity, metabolic syndrome
Other conditions: HTN, autoimmune disease, cardiorenal syndrome
What historical factors predispose a patient to chronic kidney disease?
Historical factors: previous episode of AKI, + family history of renal disease, smoking, lead exposure
What comorbid conditions can predispose a patient to chronic kidney disease?
GU: structural urinary tract abnormalities, proteinuria, abnormal urinary sediment
Metabolic conditions: diabetes mellitus, low HDL, obesity, metabolic syndrome
Other conditions: HTN, autoimmune disease, cardiorenal syndrome
What is cardiorenal syndrome?
Deterioration of one organ (heart or kidney) results in deterioration of the other
Staged based on cardiac or renal causing acute or chronic
How is chronic kidney disease staged?
formerly KDOQI guidelines based on GFR
Now based on GFR and albuminuria
If a patient has a high level of albuminuria, what does that lead to?
Higher mortality risk, higher CKD progression, higher risk of ESRD regardless of GFR
What does CKD stage 1, 2, and 3a/b mean?
GFR >90 with markers of kidney damage
GFR 60-89 with mildly decreased GFR
3a: GFR 45-59
3b: GFR 30-44
1: Early CKD with kidney damage but normal GFR
2: kidney damage with mildly decreased GFR
3a: mildly to moderately decreased GFR
3b: moderately to severely decreased GFR
What are stages 4 and 5 of CKD?
GFR 15-29
GFR <15
4: severely decreased GFR
5: kidney failure/ESRD, may add D if treated with dialysis
What are the albuminuria stages?
A1, A2, and A3
A1: <30
A2: 30-300
A3: >300
only take into account if have decreased GFR
A1: normal to mildly increased
A2: moderately increased
A3: severely increased
What GFR stage is a patient with a GFR of 38 mL/min and urine albumin of 100 mg/g
3b
What stage is a patient with a GFR of 96 mL/min and urine albumin of 38 mg/g?
G1 A2
What stage is a patient with a GFR of 10 mL/min and urine albumin of 350 mg/g
G5 A3
What stage is a patient with a GFR of 110 mL/min and urine albumin of 12 mg/g
normal
What are symptoms of early-mid CKD?
Asymptomatic
What are the eventual symptoms of CKD?
slow onset of nonspecific s/s
what is the most common PE finding of CKD overall?
HTN that worsens as disease progresses and volume overload in later stages
What are the signs and symptoms of late CKD?
GFR 10 mL/min/1.73 m2
S/S of uremia
If a patient has s/s of uremia, what does that warrant?
admission and dialysis consult
dialysis generally improves uremic syndrome
Scalp symptom related to uremia
Uremic frost
What are common serum lab findings in CKD?
Vary based on underlying cause and stage of disease
Low
Heme: RBC, H&H (normocytic normochromic anemia)
Lytes/acid base: calcium, sodium, pH (metabolic acidosis)
Renal: GFR
Others: vitamin D, HDL
High
Lytes/acid-base: potassium
renal: BUN, serum Cr
others: phosphate, PTH, triglycerides, uric acid
What will be seen on a urinalysis of a patient with CKD?
broad, waxy casts (dilated nephrons)
Proteinuria often present; glucosuria may be present
What are signs/symptoms of stage 1 and 2 of CKD?
usually no symptoms
May see s/s of underlying disease
Edema, HTN
What are s/s of stage 3/4 of CKD?
All organ systems effects
MC: anemia, fatigue, anorexia
Abnormal calcium, phosphorus, vitamin D, PTH
Abnormal Na, K, water, and acid-base balance
What are s/s of stage 5/ESRD of CKD?
marked disturbance in ADL, well being, nutrition, water and electrolyte homeostasis
Uremic syndrome
_____ can indicate CKD even if there is normal Cr/GFR
abnormal renal imaging
What indicates CKD on imaging?
polycystic kidneys
small kidneys
asymmetric kidneys
What are the treatment goals of CKD?
slow progression
control underlying process
reduce intraglomerular HTN
reduce proteinuria
avoid further injury
if diabetic-control blood glucose (A1C <7%)
adjust medication doses as needed
what can you use to reduce intraglomerular HTN and proteinuria?
Intraglomerular HTN: ACE/ARB
reduce proteinuria: ACE/ARB, dietary protein restriction
What can we control that can cause further injury in CKD?
obstruction, nephrotoxins, flare of underlying disease
If a patient is diabetic and has CKD, waht medication would we consider?
SGLT-2 inhibitors
80% of CKD pts die before needing dialysis, primarily due to ____
CV disease
What are the most common CV complications of CKD?
- Hypertension
- Coronary artery disease
- Heart failure
- Atrial fibrillation
- Pericarditis
What is the MC complication of CKD?
HTN
What is the goal BP for someone with CKD?
<130/80 mmHg
What nonpharmacologic treatment can be used to treat HTN with CKD?
- diet
- exercise
- weight loss
- treatment of OSA
- low sodium diet (2300 mg/day)
Which BP medications should be used for HTN with early CKD and what will you monitor?
- ACE inhibitors: Check serum Cr and K in 7-14 days when starting or increasing dose. Reduce or stop if hyperkalemia or >30% increase in Cr occurs
- Diuretics almost always needed: thiazides
What BP medications should be used for HTN with late CKD and what will you monitor?
- ACE inhibitors or ARBs: check serum Cr and K+ in 7-14 days when starting or increasing dose. If hyperkalemia or >30% Cr increase reduce or stop
- Loop diuretics
If too much diuretics are given with CKD leading to low vascular volume/overdiuresis, what can occur?
AKI
In addition to ACE/ARB, diuretics, what BP meds can be used in CKD?
CCBs, BBs
What are common CAD/hyperlipidemia findings in CKD?
- Hypertriglyceridemia
- Normal total cholesterol
- Low HDL and increased lipoprotein
What related to CAD/hyperlipidemia occurs with CKD, particularly with ESRD?
Accelerated atherosclerosis
What is treatment for CAD/hyperlipidemia associated with CKD?
- Agressive CAD risk factor modification through:
- Lifestyle changes
- Statins (recommended for most patients with CKD)
- PSK9 inhibitors and ezetimibe can be used as adjunct to statin
What medication used for cardiovascular risk increases rhabdomyolysis in CKD when paired with statins and is not known to reduce mortality risk?
Fibrates
Why can heart failure occure due to CKD?
increased cardiac workload due to HTN, volume overload, anemia, and atherosclerosis
Leads to LVH and diastolic dysfunction, systolic dysfunction can also develop
What medication for heart failure has a higher risk of toxicity in CKD patients than non-CKD due to electrolyte disturbances
Digoxin
How is HF treated in CKD?
Diuretics, ACE/ARB, fluid and salt restriction
Diuretics for early CKD: thiazides
Diuretics for late CKD: loop
Monitor for hyperkalemia with ACE/ARB
When are CKD patients at a disproportionately high risk for atrial fibrillation?
Late and end stage CKD
How are stage 1-4 CKD patients treated for a fib? Stage 5/ESRD?
same as general population
stage 5/ESRD: higher bleeding risk with anticoagulation
What population of patients are you worried about pericarditis in related to CKD?
Uremic patients
What are s/s of pericarditis?
- retrosternal chest pain
- friction rub
- Uremic pericardial effusion: pulsus paradoxus, enlarged cardiac silhouette, low voltage QRS
- Cardiac tamponade may develop
Effusions are generally hemorrhagic and anticoagulants should be avoided
How is pericarditis in CKD managed?
hospitalization and initiation of hemodialysis
How is cardiorenal syndrome treated?
euvolemia and control of underlying disease
what are mineral metabolism complications of CKD?
- hyperphosphatemia: decreased excretion
- hypovitaminosis D: decreased production
- Hypocalcemia: phosphorus complexes with C –> soft tissue deposits, decreased gut absorption due to decreased vit D
- secondary hyperparathyroidism due to low calcium
what bone disease can occur as a complication of CKD?
- Renal osteodystrophy
What is the most common form of renal osteodystrophy?
osteitis fibrosis cystica
what is osteitis fibrosa cystica?
- hyperparathyroidism causes osteoclast stimulation to increase
- high rates of bone turnover
- leads to bone pain, proximal muscle weakness
- Brown tumors on x-ray
What are types of renal osteodystrophy?
- osteitis fibrosa cystica
- adynamic bone disease
- osteomalacia
what causes adynamic bone disease?
- low bone turnover
- suppression of PTH or low endogenous PTH
What causes osteomalacia in kidney disease?
- lack of bone mineralization due to hypovitaminosis D, bisphosphonates
How is renal osteodystrophy diagnosed? Why is it a problem?
- diagnosed by bone biopsy
- increases risk of fracture
what is the treatment of mineral metabolism issues in CKD?
- Control hyperphosphatemia, phosphorus >4.5 mg/dL or >5.5 mg/dL in ESRD
- Manage PTH
How would you control hyperphosphatemia initially?
- Dietary phosphorus restriction of meats, colas, baked goods/mixes, fast food, frozen premade foods
after attempting to control hyperphosphatemia with diet, what would you do?
Oral phosphorus binders
what are oral phosphorus binders that can be used for hyperphosphatemia treatment?
- calcium carbonate or calcium acetate
- non-calcium-based: sevelamer or lanthanum first line therapy
- aluminum hydroxide
- iron-based agents: ferric citrate, sucroferric oxyhydroxide
what is the mechanism of action and drawbacks of calcium carbonate or calcium acetate?
- MOA: blocks absorption of phosphorus in GI tract; dosed TID with meals
- may increase vascular calcification, hypercalcemia
what is the mechanism of action of sevelamer or lanthanum?
Block absorption of phosphorus in GI tract; dosed TID with meals
Safe to combine with a calcium-based phosphate binder
why is aluminum hydroxide not used as much for treatment of hyperphosphatemia?
- SE of osteomalacia, neurologic complications
- Only used if severe hyperphosphatemia (>7 mg/dL) or short periods (<3 weeks)
this medication for hyperphosphatemia has limited evidence
iron-based agents: ferric citrate, sucroferric oxyhydroxide
how is high pth managed in CKD?
- vitamin D3 (calcitriol)
- Cinacalcet (sensipar)
what is the mechanism of action of vitamin D3?
increases serum calcium and phosphorus
which patients can be given calcitriol? What do you need to monitor?
secondary hyperparathyroidism in stages 3-5 CKD
measure vitamin D before using, routine labs for monitoring
what is the mechanism of action of cinacalcet?
- Targets calcium-sensing receptors of parathyroid gland
when would cinacalcet be a good option for treatment of PTH levels in CKD? what do you need to monitor?
if increased phosphorus or Ca prohibit use of calcitriol
labs, may cause hypocalcemia
When treating late CKD, goal PTH levels are ____
higher to prevent adynamic bone disease
what are hematologic complications of CKD?
- anemia
- coagulopathy
why does anemia occur in CKD?
not making EPO
iron deficiency
how would you treat anemia in CKD?
- R/O other causes of anemia before treatment with EPO stimulating agent
- treat iron deficiency before EPO stimulating treatment
why do patients with CKD often have iron deficiency?
Hepcidin is elevated and blocks GI iron absorption and mobilization from storage
What is considered iron deficiency in CKD?
- Ferritin <100-200 ng/mL
- Iron saturation <20%
how would you treat iron deficiency in a pre-ESRD CKD patient?
- Oral ferrous sulfate, ferrous gluconate, or ferrous fumarate
- Auryxia (ferric citrate)
- If oral iron isn’t tolerate or has poor response –> parenteral iron
- Do not give iron if ferritin >500-800 even if iron <20%
what is the Hb goal with EPO treatment of anemia in CKD?
- 10-11 g/dL
- Higher Hb goal –> increased risk of CV events, should rise at most 1 g/dL every 3-4 weeks
- No benefit to treatment if Hb >9 g/dL
What EPO treatment can be used for patients with CKD?
- Epoetin
- Darbepoetin
- Can be given IV or SQ
What side effect is seen in 20% of patients using a EPO treatment?
HTN
Why can hypocoagulopathy occur in CKD?
Platelet dysfunction
How does hypocoagulopathy present in CKD?
Prolonged bleeding time, petechiae, purpura
When would you treat hypocoagulopathy? How?
Only if symptomatic
Desmopressin
Dialysis
Conjugated estrogens, cryoprecipitate (rarely used)
In addition to hypocoagulopathy, what coagulopathy can occur?
If severe proteinuria, hypercoagulability
What acid base dysfunctions can occur due to CKD?
hyperkalemia
metabolic acidosis
when does hyperkalemia usually present?
stages 4-5
earlier in high potassium diet, DM, hemolysis, rhabdomyolysis, medications
which medications decrease K secretion? Which block K uptake by cells?
triamterene, spironolactone, NSAIDs, ACE, ARB
BBs
how do you treat chronic hyperkalemia due to CKD?
dietary K restriction
reduce or stop medications that affect K metabolism
loop diuretics (if not volume-depleted)
why can metabolic acidosis be a complication of CKD?
- Loss of ability to excrete acid
- Primarily due to loss of renal mass
- Distal tubules unable to help excrete
What can metabolic acidosis contribute to?
Renal osteodystrophy
calcium pulled from bones to help buffer acidosis
how is metabolic acidosis treated?
maintain serum bicarb at >21 mEq/L
Oral sodium bicarbonate given BID and titrated to maintain normal level
What are neurologic complications of CKD?
uremic encephalopathy
uremic neuropathy
What causes uremic encephalopathy in CKD?
aggregation of uremic toxins
not seen until GFR <5-10 mL/min/1.72 m2
What are signs and symptoms of uremic encephalopathy?
- Early- difficulty concentrating
- Later- lethargy, confusion, seizure, coma
- Exam- altered mental status, asterixis, weakness
what is treatment of uremic encephalopathy?
dialysis
what is uremic neuropathy?
- distal, symmetrical, mixed peripheral neuropathy
- indication to start dialysis
what are s/s of uremic neuropathy?
- initial- loss of position and vibration sense in toes, decreased DTRs
- Sensory- paresthesias, burning, pain, RLS
- Motor- muscle atrophy, myoclonus, eventual paralysis
how is uremic neuropathy diagnosed?
electrophysiologic studies
how is uremic neuropathy treated?
- dialysis
- symptomatic treatments for neuropathic pain (TCAs, anticonvulsants)
- RLS- may improve with treatment of anemia, iron deficiency
what are endocrine complications of CKD?
- hypoglycemia
- decreased libido and ED
- faster CKD progression in pregnancy
why can CKD increase risk of hypoglycemia?
- Decreases renal clearance of insulin
May need dose adjustment of oral medication, exogenous insulin
When should metformin be discontinued in CKD? Why?
- After serum Cr >1.4-1.5 or GFR <30
- Increased risk of lactic acidosis
How does CKD impact men?
decreased testosterone –> decreased libido and ED
How does CKD impact men?
- often anovulatory
- if serum Cr >1.4 CKD may progress faster in pregnancy
- Fetal mortality almost 50% in ESRD patients
- Surviving infants are often premature
transplant = best odds for healthy pregnancy
what are diet changes for CKD?
- Protein restriction may slow CKD progression (avoid if cachectic or low albumin)
- sodium restriction to 2 g/d
- water restriction to 2 L/d
- K restriction to <2 g/d (if GFR <10-20 mL/min or Hyperkalemia)
- Phosphorus restriction and binders if GFR <20-30 mL/min
> 3-4 g sodium –> hypertension, fluid overload
<1 g/day sodium –> hypotension, volume depletion
What are medication changes in CKD?
- Renally excreted drugs: adjust dose based on pts GFR and clinical presentation
- Magnesium-containing drugs: avoid use (laxatives, antacids, etc)
- Phosphorus-containing drugs: avoid use
- Nephrotoxic drugs (NSAIDs, contrast, etc): avoid use
- Morphine: avoid
Morphine metabolites can accumulate in late CKD
What are indications for dialysis in CKD?
- GFR 10 mL/min/1.73 m2
- Uremic symptoms
- Persistent metabolic disturbances refractory to medical therapy
- Fluid overload unresponsive to diuretics
can be hemodialysis, peritoneal dialysis, or transplant
when should CKD patients be followed by a nephrologist?
- no later than late stage 3 or if rapidly progressing
what is the ideal method of renal replacement therapy?
- renal transplantation
what factors determine match with renal transplantation?
- ABO blood groups and major histocompatibility
- Age and race of recipient, age of donor
- Comorbidities
- Length of time on dialysis
What must be used after transplantation?
immunosuppressive regimens
transplant nephrologist usually also follow patient to manage
what is hemodialysis?
- flow of blood on one side of membrane
- dialysate on other side
- diffusion and convection to remove unwanted substances in blood
how can vascular access be done to perform hemodialysis?
- AV fistula
- Prosthetic graft
- Indwelling vascular catheter
what is the longest lasting vascular access for hemodialysis? shortest? Which has the highest risk of infection?
- Longest: AV fistula
- Shortest: prosthetic but higher risk of infection, thrombosis, aneurysm
- High risk of infection: indwelling vascular catheter
How often do patients need to do hemodialysis?
3x/week for 3-5 hrs at hemodialysis center
3-6x/week for shorter sessions at home
what is the MC dialysis modality in the US?
hemodialysis
what is peritoneal dialysis?
- peritoneal membrane is dialyzer
- dialysate put into peritoneal cavity
- water and solutes move into dialysate
- dialysate periodically drained
what are types of peritoneal dialysis?
- continuous ambulatory peritoneal dialysis: manually exchanges 4-6x/day
- continuous cyclic peritoneal dialysis: cycler automatically exchanges at night
what are the benefits of peritoneal dialysis?
- increased patient autonomy
- continuous
- poorly dialyzed compounds are better cleared
- may be better for pts with limited transport
- allows pt to stay in home
what are risks of peritoneal dialysis?
- removed large amounts of albumin
- requires mental/physical ability to understand and complete exchanges
- access may not be possible in patients with significant intra-abdominal adhesions or scarring
- risk of peritonitis
what is the most common complication of peritoneal dialysis and how does it present?
peritonitis
* N/V/D/C
* abdominal pain
* fever
* cloudy dialysate
how is peritonitis diangosed?
peritoneal fluid >100 WBC/mcl
may culture
what are the most common organism in peritonitis due to peritoneal dialysis?
MCC: staph aureus
gram negative rods, streptococcus
how is peritonitis due to peritoneal dialysis treated?
antibiotic therapy
ESRD and dialysis prognosis
- higher mortality than transplant
- estimated life expectancy 3-5 years
- MCC death: cardiac disease
what are poor prognostic indicators for ESRD with dialysis?
- DM
- advanced age
- hypoalbuminemia
- low socioeconomic status
- inadequate dialysis
- high fibroblast growth factor
