CKD

Question 1

Signs of left atrial enlargement on ECG

Answer 1

“Notched p” in Lead II

Biphasic p in V1

Question 2

What are the three factors that tell you how a patient with CKD likely to be doing?

Answer 2

1. GFR
2. Degree of proteinuria
3. Age

Question 3

How do we think about diagnosing CKD?

Answer 3

• Evidence of kidney damage or dysfunction spanning at least 2 visits across at least 3 months, including:
  
  • GFR < 60
  • Proteinuria > 30 mg/g creatinine
  • Abnormal sediment, imaging study, or pathological biopsy

Question 4

Key electrolytes to monitor in CKD

Answer 4

• Potassium
• Calcium
• Phosphate

Question 5

Signs and symptoms of CKD

Answer 5

• Usually don’t start to appear until CKD stage 4 and are ultimately due to buildup of urea and other nitrogenous waste (uremia)
• Symptoms:
  
  • Fatigue, anorexia, nausea, cramping, sleep disturbance, amenorrhea, sexual dysfunction, frequent hiccups, itching
• Signs:
  
  • Decreased mental acuity, peripheral neuropathy, seizures, asterixis, pericarditis

Question 6

Sevelemer

Answer 6

Phosphate binder that does not contain calcium

Useful for reducing phosphate levels in individuals with CKD who have normal serum calcium, but low free calcium due to hyperphosphatemia

Question 7

Calciphylaxis

Answer 7

A serious, uncommon disease in which calcium phosphate accumulates in small blood vessels of the fat and skin tissues. Calciphylaxis causes blood clots, painful skin ulcers and may cause serious infections that can lead to death.

You can determine risk for calciphylaxis by using the calcium-phosphate product. When it is over 50, we start to be worried about kidney function. When it is over 75, then we are worried that the patient may be approaching calciphylaxis.

Question 8

Aluminum hydroxide in CKD

Answer 8

Quick-fix to drop phosphate levels in the short-term

Not a chronic solution for patients with CKD. Actually, patients with CKD can’t clear the aluminum very well, so it is actually contraindicated in these patients anyway.

Question 9

If someone with diabetes relies on orange juice to raise their blood sugar, but is then diagnosed with stage 4 CKD, you should advise them. . .

Answer 9

. . . to switch to a less potassium-rich substitute like apple juice.

Question 10

What condition do you miss by using albumin-to-creatinine ratio over protein-to-creatinine ratio

Answer 10

Multiple myeloma

Question 11

Screening for CKD

Answer 11

Patients older than 55 years and those with hypertension and diabetes should be screened for CKD by estimating GFR from serum creatinine measurement and urinalysis.

Screening for proteinuria in patients with diabetes can be done by using the urine albumin- or protein-to-creatinine ratio. Maintaining strict glycemic control to prevent CKD in patients with diabetes is essential.

Question 12

Diabetic vs hypertensive retinopathy

Answer 12

Question 13

Which diuretic to use in CKD to mitigate cardiovascular risk factors

Answer 13

By this point, basically all patients are already on an ACE-I or an ARB

The choice of diuretic depends on the level of GFR: A thiazide-type diuretic should be used in patients with an estimated GFR ≥30 mL/min/ 1.73 m2 and a loop diuretic, such as furosemide, when GFR is <30 mL/min/1.73 m2

Question 14

Who gets ACE-Is and ARBs for CKD?

Answer 14

Those w/ significant proteinuria

Check up in one month to check how K+ and GFR have tolerated the change.

Question 15

Main metabolic complications of CKD

Answer 15

The main metabolic complications of concern are hyperphosphatemia and vitamin D deficiency, which lead to secondary hyperparathyroidism, hyperkalemia, and metabolic acidosis.

Question 16

Kayexalate

Answer 16

Aka Sodium polystyrene sulfonate resin

Soaks up potassium in the gut. Used in advaned CKD with hyperkalemia.

However, it has a risk of bowel necrosis, and so it must be used judiciously and wisely.

Question 17

Monitoring CKD progress

Answer 17

Annual assessment of blood pressure; estimation of GFR; and measurement of hemoglobin, serum potassium, calcium, phosphorous, parathyroid hormone, and albumin levels

Question 18

When is it time to start dialysis?

Answer 18

Common indications to initiate dialysis are:

1. Volume overload unresponsive to diuretics,
2. Pericarditis,
3. Uremic encephalopathy,
4. Major bleeding secondary to uremic platelets (uremia inhibits platelet function),
5. Hypertension that does not respond to treatment

Question 19

Pseudohyperkalemia

Answer 19

May be identified by the lab indicating that the specimen was hemolyzed or by identifying a very high white blood cell count or platelet count, or by repeat fist clenching or tourniquet use during phlebotomy.

Question 20

Types of renal tubule acidosis and treatments

Answer 20

Question 21

VERY rough CKD staging based on GFR

Answer 21

Recall that to stage properly, you really need to know about proteinuria. This is a good estimate.

Question 22

What is going on in this patient?

Answer 22

Uremic frost

When a patient is highly azotemic, yellow-white urea crystals will form on the skin

As such, this is an indication of advanced uremia. Usually only occurs in patients with ESRD.

Question 23

Hyperkalemia on ECG

Answer 23

Early: Peaked T waves

Late: Progresses to “sine wave” pattern

Question 24

Hyper- and hypo-calcemia on ECG

Answer 24

They effect the length of the ST segment inversely

The more calcium, the shorter it gets

Question 25

If you want to add a diuretic for a patient with CKD on an ACE-I or ARB, what family of diuretics should you probably go with?

Answer 25

Loop diuretics

Thiazides aren’t as effective in patients with lower GFR.