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CLIN MED PA 581: GU > CKD > Flashcards

CKD Flashcards

Objectives

1
Q

normal nephron fxn diagram

A
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2
Q

non-urinary renal fxn

A
  • Erythropoietin production
  • Vitamin D activation
  • BP regulation
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3
Q

Evaluating kidney function

A
  • BUN
  • Creatinine clearance
  • Estimated GFR
  • Albumin to creatinine ratio in a spot urine sample
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4
Q

BUN

A
  • Urea is formed in liver from protein metabolism
  • 85% excreted by kidney
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5
Q

Creatinine clearance

A
  • Produced by muscle in relatively steady state, filtered by kidney, some tubular secretion, almost no reabsorption
  • ( [creatinine Urine] x Urine flow rate) / [creatinine Plasma]
    • urine flow rate (volume/time = ml/min),
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6
Q

Estimated GFR

A
  • Nl in adult male is 90-120 ml/min
  • https://www.kidney.org/professionals/kdoqi/gfr_calculator
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7
Q

Albumin to creatinine ratio in a spot urine sample

A
  • 1st method of preference to detect inc protein
  • To calculate, divide [albumin] in mg by [creatinine] in grams
  • microalbuminuria = ACR 30-300 mg/g
    • Not detectable on dipstick
    • Must check immediately in type 2 DM
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8
Q

Screening for CKD

A
  • no generally accepted screening tool for CKD or risk of complications of CKD for asymptomatic adults. DM and HTN are risk factors with strong links to CKD and screening in those population is reasonable
  • tests often suggested that are feasible in 1o care include testing the urine for protein and checking serum creatinine to estimate GFR
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9
Q

CKD definition

A
  • The Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation definition:
  • kidney damage

OR

  • ↓ GFR (<60 mL/min/1.73 m2 )*
  • for >3 months

•*Nl GFR =120 but with nl aging dec. to ~70 by age 70 yo

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10
Q

Stage 1 CKD

A
  • Kidney damage with normal or increased GFR (>90)
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11
Q

Stage 2 CKD

A
  • Mild reduction in GFR (60-89)
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12
Q

Stage 3 CKD

A
  • Moderate reduction in GFR (30-59)
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13
Q

Stage 4 CKD

A
  • severe reduction in GFR (15-29)
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14
Q

Stage 5 CKD

A
  • Kidney failure (GFR < 15) [or dialysis]

* some classifications combine Stages 5 and 6

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15
Q

Stage 6 CKD

A
  • Dialysis

* some classifications combine Stages 5 and 6

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16
Q

Consideration for nephrology consult

A
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17
Q

CKD etiologies

A
  • DM
  • HTN
  • Cystic kidney ds
  • Congenital defects
  • Unrecovered AKI (eg prerenal → permanent ischemic damage)
  • Urinary tract obstruction or dysfunction
  • Vascular ds
  • Tubulointerstitial
  • Primary Glomerular dz
  • Secondary Golmerular dz
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18
Q

Urinary tract obstruction or dysfunction CKD causes

A
  • BPH
  • kidney stones
  • Urethral stricture
  • Tumors
  • Neurogenic bladder
  • Congenital defects of kidney or bladder
  • Retroperitoneal fibrosis
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19
Q

Vascular dz CKD causes

A
  • RAS
  • vasculitides
  • atheroemboli
  • renal vein thrombosis
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20
Q

Tubulointerstitial causes of CKD

A
  • Drugs; sulfonamides, allopurinol
  • Infections: viral, bacterial, parasitic
  • Sjögren syndrome
  • Chronic hypokalemia
  • Chronic hypercalcemia
  • Sarcoidosis
  • Multiple myeloma cast nephropathy
  • Heavy metals
  • Radiation nephritis
  • Polycystic kidneys
  • Cystinosis, other inherited ds
21
Q

Primary Glomerular Dz causes

A
  • Membranous nephropathy
  • Alport synd
  • IgA nephropathy
  • Focal and segmental glomerulosclerosis (FSGS)
  • Membranoproliferative GN
22
Q

secondary glomerular dz causes

A
  • DM
  • SLE & other autoimmune ds
  • Wegener granulomatosis
  • Hepatitis B and C
  • Syphilis
  • HIV
  • Parasitic infection
  • Drugs: Heroin, Gold, Penicillamine
  • Light-chain deposition ds, Amyloidosis, MM
  • Neoplasia
  • TTP, HUS
  • Henoch-Schönlein purpura
  • Reflux nephropathy
23
Q

CKD Epidemiology

A
  • 1/10 American adults has some level of CKD
  • 9th leading cause of death in the US
  • prevalence ↑ with age
  • 4% at age 29-39 yo
  • 47% at age >70 yo
  • ESRD ~350 per 1 million population
24
Q

Uremia

A
  • encompassing the signs and symptoms of renal failure often used a synonym for chronic renal failure
  • Usually occurs when creatinine clearance is <20/ml/min (Stage 4 or 5)
25
Q

Signs and symptoms of uremia

A
  • Metabolic acidosis
    • dec. lean body mass
    • muscle weakness
    • inc. RR (Kussmaul respirations)
  • Abn salt and water balance
    • peripheral edema
    • pulmonary edema
    • HTN
  • Electrolyte imbalances
    • Arrhythmias
    • Hyperkalemia
    • Peaked T-wave
  • Pericarditis
    • Uremic pericarditis
  • Anemia
    • normochromic normocytic
    • due to dec. erythropoietin
    • fatigue
  • Encephalopathy
  • Peripheral neuropathy
  • Restless leg syndrome
  • Depression
  • Malnutrition
  • Bone disease
    • Vit D deficiency
    • dec. Ca++, inc. PO4-
    • secondary hyperparathryoidism
  • Sexual dysfunction
    • ED
    • dec. libido
    • amenorrhea
  • Platelet dysfunction
    • with NORMAL platelet count (thrombocytopathy)
      • Thrombocytopathyà renal failure causes
      • Thrombocytopeniaà renal failure does NOT cause
  • GI symptoms
    • anorexia
    • N&V
    • diarrhea
  • Skin manifestations
    • dry skin
    • pruritus
    • ecchymosis
    • uremic frost in feet picture

​

26
Q

Uremia Labs

A
  • Chemistry
    • inc. K+, Mg++, PO4-, BUN, creatinine
    • dec. HCO3- (inc. AG metabolic acidosis), Ca++
  • ABGs
    • metabolic acidosis dec. pH, dec. HCO3-
  • CBC
    • dec. Hgb, Hct; nl MCV, MCH, MCHC
  • Other labs
    • vary depending on the cause
27
Q

Delay Progression of CKD

A
28
Q

management of anemia in CKD

A
  • treat with erythropoiesis-stimulating agents (ESAs), e.g. epoetin alfa and darbepoetin alfa If Hgb <10, after Fe sat and ferritin are at acceptable levels
29
Q

management of Hyperphosphatemia in CKD

A
  • treat with dietary phosphate binders and dietary phosphate restriction
30
Q

management of hypocalcemia in CKD

A
  • treat with calcium supplements + calcitriol (vit D)
31
Q

management of Hyperparathryoidism in CKD

A
  • treat with vit D or calcimimetics
    • Cinacalcet is only FDA-approved drug of this class. It mimics Ca++ at the PTH receptor. This will inc. sensitivity of Ca++-sensing receptors on the parathyroid gland. As a result of the receptor “thinking” there is sufficient Ca++-, PTH secretion will dec.
32
Q

Management of volume overload in CKD

A
  • treat with loop diuretics (e.g. furosemide/Lasix, bumetanide/Bumex, torsemide/demadex)
33
Q

management of metabolic acidosis in CKD

A
  • treat with oral alkali supplementation
34
Q

management of Uremic manifestations in CKD

A
  • treat with long-term renal replacement therapy (hemodialysis, peritoneal dialysis, or renal transplantation)
35
Q

Dialysis

A
  • separation of substances in solution by means of their unequal diffusion through semipermeable membranes normally passing from the side of higher concentration to that of lower
36
Q

Hemodialysis

A
  • Intermittent (IHD)
  • Continuous renal replacement therapies (CRRT)
37
Q

Peritoneal dialysis (PD)

A
  • Continuous ambulatory peritoneal dialysis
  • Automated peritoneal dialysis
38
Q

Intermittent hemodialysis

A
  • Most commonly used for CKD
  • Total amount of solute transported per unit of time (clearance), depends on the MW of the molecule, membrane characteristics (dialysance), dialysate flow, and blood flow
  • Usually, 3–6 h per treatment 3x/wk
39
Q

Intermittent hemodialysis acutely used for OD Tx of…

BLISTMEDO

A
  • Barbiturates
  • Lithium
  • Isoniazid
  • Salicylates (aspirin)
  • Theophylline/caffeine (methylxanthines)
  • Methanol
  • Ethylene glycol
  • Depakote
  • Others - carbamazepine
40
Q

CRRT

A
  • Applied for 24 h per day most commonly in an ICU for AKI
  • Solute removal achieved by convection (hemofiltration), diffusion (hemodialysis), or combo(hemodiafiltration)
  • Hemodialysis most efficiently removes small MW substances such as urea, creatinine, and K
  • Middle and larger MW substances more efficiently removed by hemofiltration
41
Q

CRRT vs IHD

A
  • CRRT has theoretical advantages
    • better fluid mgmt
    • less hypotension
    • better control of middle and large MW substances
    • ??? beneficial immunomodulatory effect in sepsis
  • But these have not been demonstrated in RCTs to improve mortality or recovery of kidney function
  • CRRT is more expensive
42
Q

Peritoneal dialysis

A
  • Uses the peritoneum as a natural semi-permeable membrane for diffusive removal of solutes
  • Very effective treatment modality in CKD, and pt outcomes are at least equivalent to hemodialysis
  • Valuable in peds critical care
    • vascular access is challenging
    • peritoneal surface area is relatively larger than in adults
  • Two methods
    • Continuous Ambulatory Peritoneal Dialysis (CAPD)
    • Automated peritoneal dialysis
43
Q

Continuous Ambulatory Peritoneal Dialysis (CAPD)

A
  • Done while pt does nl activities. Pt places ~2L of fluid into abdomen by hooking a plastic bag of dialysis fluid to the tube in the belly. Raising the bag to shoulder level causes gravity to pull fluid into the belly. When empty, bag is removed and discarded.
  • When exchange is finished, the fluid (which now has wastes removed from the blood) is drained from the belly and thrown away.
  • Usually done 3-5x/day while pt is awake. Takes ~30 to 40 min. Some pts do exchanges at mealtimes and bedtime.
44
Q

Automated Peritoneal Dialysis (APD)

A
  • A machine (cycler) delivers then drains dialysis fluid. Treatment usually done at night while pt sleeps.
45
Q

Indications for dialysis

A
  • diuretic-resistant pulmonary edema
  • hyperkalemia (refractory)
  • met acidosis (refractory)
  • uremic sx (pericarditis, encephalopathy, bleeding, etc.)
  • dialyzable intoxications (eg, lithium, salicylates)
46
Q

Transplantation: recipient with ESRD gets a functioning kidney from a donor

A
  • Donation may be from a living person, usually a relative
    • Best option in terms of success
    • May create a “chain” whereby a living donor who is incompatible with a relative gives their kidney to a stranger who also has a living relative who is willing to donate but incompatible. Then that person donates to another stranger continuing the chain.

OR

  • Donation may be from a deceased person (formerly called cadaveric donation)
    • brain dead (heart still pumping) or
    • cardiac death given no chance of survival, mechanical ventilation is stopped, death is pronounced, body rushed to OR, organs removed and flushed with storage solution and anticoagulants – important to follow strict ethical guidelines!
47
Q

transplant recipients must…?

A
  • Must take life-long immunosuppressives
    • Most commonly tacrolimus, prednisolone, mycophenolate
    • Also may use cyclosporine, sirilomus, azathioprine
    • Must avoid grapefruit, pomegranate, green tea bc of interactions with these meds
48
Q

transplant complications

A
  • Rejection
    • Hyperacute within minutes
      • kidney must be removed immediately to prevent patient’s death
    • Acute 1 week - 3 months
      • 10-25% in initial 30 days but does not mean kidney is lost
      • Only 7% have failed within a year
    • Chronic ongoing over years
  • Bleeding
  • Thrombosis
49
Q

transplant : Drug-related complications

A
  • Immunosuppressive drugs
    • infection/sepsis
      • CMV, HSV, HZ
      • bacterial, esp pneumonia
      • fungal , parasitic
    • post-transplant lymphoproliferative disorder (form of lymphoma)
  • Cyclosporine
    • hirsutism
  • Tacrolimus
    • Alopecia
  • Steroids
    • UGI bleeding
    • Cushings synd
    • DM
    • osteoporosis
    • acne
    • dyslipidemia

CLIN MED PA 581: GU (7 decks)

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