CKD and Nephrotic Syndrome Flashcards
Leading cause of ESRD
Diabetes
Components that increase risk of mortality with CKD
DM, CVD, & CKD
Most likely to get CKD
Black females
CKD Definition
Decreased kidney function OR kidney damage for 3 or more months
Clinical evidence CKD
- GFR <60
2. Evidence of kidney damage
Evidence of kidney damage
- Albuminuria - Urine albumin-to-Cr ratio >30*
- Abnormal imaging test
- Abnormal urinary sediment
- History of kidney transplant
Best marker for kidney function
GFR
Poor measure of kidney function
Serum creatinine
Hallmark of progressive kidney disease
Declining GFR
Staging CKD
Based on GFR: G1. >90 G2. 60-89 G3a. 45-59 G3b. 30-44 G4. 15-29 G5. <15 (Kidney failure - Add "D" if treated by dialysis)
What is classification of CKD based on?
Cause, GFR, and albuminuria
Classifying CKD
Stage A1) ACR<30; neg to trace protein dipstick
Stage A2) ACR 30-300; trace to 1+ protein dipstick
Stage A3) ACR>300; >1+ protein dipstick
Low risk of CKD progression
A1 with G1 or G2
Mod risk of CKD progression
1) A1 with G3a
2) A2 with G1 or G2
High risk of CKD progression
1) A1 with G3b
2) A2 with G3a
3) A3 with G1 or G2
Very high risk of CKD progression
1) A2 with G3b
2) A3 with G3a and G3b
3) ALL G4 and G5 (no matter the albumin)
Progression of CKD
Destruction of nephrons»_space;
Compensatory hypertrophy of working nephrons»_space; Overwork of remaining nephrons»_space;
Progressive glomerular sclerosis and fibrosis
Causes of CKD
DM* HTN* Glomerular disease Polycystic kidney disease Chronic tubulointerstitial disorders
Screening for CKD
- First determine risk for ALL patients
- At risk patients should be screened by checking: Urine albumin-to-creatinine ratio and serum creatinine to estimate GFR
Patients “at risk” for CKD
>60 YO DM HTN CVD FHx of kidney disease Ethnic minority Cancer Systemic infection (HIV or Hep C) Recurrent UTIs Nephrolithiasis Nephrotoxic drug exposure Autoimmune disorders History of AKI
Clinical Presentation of CKD
Depends on underlying cause and stage. Asymptomatic early and may not have symptoms until kidney failure is advanced!
Uremic syndrome
Accumulation of metabolic waste products typically seen with GFR <15
S/Sx of uremic syndrome
Fatigue, malaise, pericarditis, encephalopathy
Renal U/S findings for CKD
Small kidneys, bilaterally (<9-10cm)
Leading cause of death in CKD patients
Cardiovascular disease
Complications of CKD
CVD* HTN Dyslipidemia Anemia Mineral/Bone disorders Fluid and electrolyte abnormalities Uremia Malnutrition
CKD-MBD labs
Hyperphosphatemia, hypocalcemia, decreased Vitamin D - Secondary hyperparathyroidism*
When is CKD-MBD clinically detectable
Stage 3 CKD
Important to managing CKD
Treat the underlying cause!
- Glycemic control (if DM)
- BP control (ACE or ARBs)
- Weight management
- Control CV factors (ie. lipids, smoking cessation)
Slowing progression of proteinuric CKD
ACE or ARB
Caution of ACE and ARB
Acute reduction in GFR - Caution in AKI
Contraindication for ACE and ARB in CKD
Bilateral renal artery stenosis
Target BP in CKD patients
W/out proteinuria - <140/90
W/ proteinuria - <130/80
When to refer CKD
GFR <30 Determine cause of CKD Mange complications Preparation/initiation of dialysis Transplant eval
When to refer based on GFR and albumin classifications
- Always if ACR >300 (A3)
- Always if GFR <30 (G4 and G5)
- For all other patients, MONITOR (unless in low risk of progression - ACR <30 and GFR >60 (A1 with G1 or G2))
What is renal replacement therapy (RRT)
Dialysis (hemo or peritoneal) or Kidney transplant
RRT is used for
Patients with kidney failure/ESRD
Indications for dialysis
Uremic symptoms
Fluid overload refractory to diuresis
Refractory hyperkalemia, acidosis, hyperphosphatemia
When to start preparing for dialysis
GFR <30
Acute complications of hemodialysis
HYPOTENSION (25-55% of treatments) Cramps N/V HA CP Back pain Pruritus Fever/chills
Fluid used to “clean” the blood in dialysis
Dialysate
Complications of peritoneal dialysis
PERITONITIS
Exit site infection
Poor dialysate drainage
Treatment of choice for ESRD
Kidney transplant
Chronic Tubulointerstitial Disease
Interstitial scarring, fibrosis, and tubular atrophy –> progressive decrease in GFR (CKD)
Underlying etiologies of chronic tubulointerstitial disease
Obstructive neuropathy Reflux nephropathy Analgesic nephropathy Heavy metals (lead) Lithium
General findings of chronic tubulointerstitial disease
Polyuria (can’t concentrate urine secondary to damage)
Hyperkalemia (tubules become aldosterone resistant)
Urinalysis is nonspecific (proteinuria <2g/d, broad waxy casts)
Obstructive uropathy definition
Prolonged obstruction of the urinary tract leads to:
1. Decreased GFR
2. Decreased renal blood flow
3. Impaired tubular function
Eventually leads to irreversible renal injury
Causes of obstruction
Prostatic disease Ureteral calculus in a single kidney Bilateral ureteral calculi Carcinoma of cervix, colon, or bladder Retroperitoneal tumors or fibrosis
Labs/Diagnostics for obstruction
UA, U/S
UA findings with obstruction
Often BENIGN - may show hematuria, pyuria, or bacteriuria
U/S findings with obstruction
Possible mass, hydroureter, hydronephrosis
Cause of reflux nephropathy
Vesicoureteral reflux (VUR) or other urologic anomalies in early childhood. Leads to inflammation and fibrosis of kidney.
Reflux nephropathy in kids
History of recurrent UTIs
Reflux nephropathy in adults
Present with HTN
Imaging for reflux nephropathy
U/S, VCUG
U/S findings in reflux nephropathy
Renal scarring and hydronephrosis
VCUG findings in reflux nephropathy
Often have VUR
What is analgesic nephropathy
CKD caused by LONG-TERM consumption of analgesics (ie. acetaminophen, NSAIDS)
Labs/diagnostics for analgesic nephropathy
UA, CT scan
UA findings for analgesic nephropathy
Hematuria, mild proteinuria, sterile pyuria (WBC w/out bacteria)
CT findings for analgesic nephropathy
Papillary microcalcifications/necrosis
Treating chronic tubulointerstitial disease
Treat underlying cause and refer to nephrology or urology
What is nephrotic syndrome
Noninflammatory damage to the glomerular capillary wall
Nephrotic spectrum vs syndrome
Spectrum - Diseases that present primarily with proteinuria and a bland urine sediment (no cells or casts)
Syndrome - Distinct clinical and laboratory features of renal disease
Clinical and lab features of nephrotic syndrome
Proteinuria (>3.5 g/d)
Hypoalbuminemia
Edema
Hyperlipidemia
Nephrotic vs Nephritic (pathogenesis)
Nephrotic: Non-inflammatory
Nephritic: Inflammatory
Nephrotic vs Nephritic (hematuria)
Nephrotic: +/-
Nephritic: ++
Nephrotic vs Nephritic (proteinuria)
Nephrotic: >3.5 g/day
Nephritic: <3.0 g/day
Nephrotic vs Nephritic (urine)
Nephrotic: “Foamy”/oval fat bodies*
Nephritic: Colar-colored urine; RBC casts
Nephrotic vs Nephritic (edema)
Nephrotic: ++++
Nephritic: ++
Cola-colored urine
Nephritic
Foamy urine
Nephrotic
Oval fat bodies
Nephrotic
RBC casts
Nephritic
Nephrotic syndrome primary etiologies
Minimal change disease (MCD) Membranous nephropathy (MN) Focal Segmental Glomerulosclerosis (FSGS)
Nephrotic syndrome secondary etiologies
Diabetic nephropathy
Amyloidosis
S/Sx of nephrotic syndrome
Edema Ascites "Foamy urine" Malaise Anorexia Dyspnea Weight gain Orthostatic hypotension (hypovolemia)
Anasarca
Massive, generalized edema
Complications of nephrotic syndrome
HYPERCOAGULABILITY* INFECTION* Protein malnutrition Vitamin D deficiency and hypocalcemia Anemia
Work-up for nephrotic syndrome
UA (ACR, proteinuria, lipiduria) Urine microscopy (few cells/casts, OVAL FAT BODIES) Serology U/S Biopsy if indicated
Management of nephrotic syndrome
ACE/ARBs Statins Loops Sodium/fluid restriction Anticoagulants (when indicated) Immunosuppressants (corticosteroids, cytotoxic agents) Nephrology referral
Most common cause of nephrotic syndrome in children
Minimal change disease (MCD)
Causes of MCD
Most are IDIOPATHIC Secondary MCD following: -URI* (esp in children) -Hypersensitivity reactions (NSAIDs & bee stings) -Medications (lithium) -Malignancies (hodgkins)
MCD presentation
Sudden onset (days to week or two) of EDEMA
MCD histopathology
No changes on light microscopy
Primarily effects the PODOCYTE
MCD 1st line treatment
Prednisone
MCD prognosis
Good (w/ treatment) - Very few progress to ESRD
MN epidemiology
M>F; Adults - peak around 4th and 5th decades
Primary MN causes
Most are IDIOPATHIC
Thought to be immune-mediated against podocytes
Secondary MN causes
Hep B Autoimmune diseases Thyroiditis Malignancy Drugs
Nephrotic syndrome with higher risk for hypercoagulable state
MN
MN Presentation
Presents with features of nephrotic syndrome (80%):
- GRADUAL development
- Higher risk for hypercoagulable state
Diagnosing MN
Serology, biopsy
Treating MN
Supportive
+/- immunosuppressive agents
Transplant
MN prognosis
Depends on renal function and amount of proteinuria
Adverse risk factors for MN prognosis
Male, >50 YO
Most common cause of PRIMARY glomerular diseases in adults
Focal Segmental Glomerulosclerosis (FSGS)
Presentation of FSGS
VARIES a great deal Nephrotic syndrome (>70%)
FSGS Epidemiology
Black
Male
18-45 YO (no age group exempt)
FSGS pathogenesis
Glomerular injury resulting from damage to PODOCYTES
Cause of primary FSGS
Idiopathic
Cause of secondary FSGS
Obesity Infection Inflammation Toxins Healed previous glomerular injury Reflex nephropathy
FSGS treatment
Supportive
Immunosuppressive agents (primary)
Disease-specific treatment (secondary)
Adverse risk factors for FSGS prognosis
Nephrotic-range proteinuria (>3.5 g/day)
African-American
Renal insufficiency
Most common cause of ESRD in the US
Diabetic Nephropathy
Common comorbidity in Type I DM with nephropathy
Retinopathy
Peak incidence diabetic nephropathy
DM for 10-20 years (esp if uncontrolled)
Progression of diabetic nephropathy
Hyperfiltration»Albuminuria»Declined GFR
Diabetic nephropathy treatment
Glycemic and BP control
ACE/ARBs
Statins (may add ezetimibe)
Dialysis and transplant (when indicated)
Abnormally folded/shaped proteins
Amyloid
Pathophysiology of Renal Amyloidosis
Deposition of amyloid in the GLOMERULUS
AL Amyloidosis
Monoclonal light chain
AA Amyloidosis
Chronic inflammatory disease (RA) or infection
Presentation of renal amyloidosis
Proteinuria
Decreased GFR
Nephrotic syndrome
Screening test for renal amyloidosis
Serum/urine protein electrophoresis (SPEP & UPEP)
Renal amyloidosis prognosis
VARIES depending on the nature, number, and extent of other organ involvement
Treatment for renal amyloidosis
Treat underlying cause
Refer to nephrology
