CKD + CKD Progression Flashcards
1
Q
CKD Definition
A
- Abnormalities in kidney structure or function present for 3 months or more, WITH IMPLICATIONS FOR HEALTH
- OR eGFR < 60 mL/min/1.73 m^2 via the MDRD or CKD-EPI equation
2
Q
Kidney Structural Abnormalities
A
- Albuminuria >= 30 mg/day
- Presence of hematuria or red cell casts in urine
- Electrolyte and other abnormalities due to tubular disorders
- Abnormalities detected by histology (biopsy)
- Abnormalities detected by imaging
- History of kidney transplant
3
Q
Steps for Delaying CKD Progression
A
- Reduce proteinuria
- Control BP
- Glycemic Control (patients with DM)
- Other interventions
4
Q
Albuminuria/Proteinuria Assessment
A
- Albumin is a subtype of protein
- 24-Hr Urine Creatinine to calculate Albumin excretion rate (AER) and protein excretion rate (PER)
5
Q
Ratios with Creatinine
A
- Single urine sample collected from patient
- Albumin: Creatinine ratio (ACR)
- Protein:Creatinine Ratio (PCR)
6
Q
Urine Dipstick
A
- Single urine sample collected from patient
- Protein reagent strip
- Results considered qualitative
- Follow-up with quantitative measure (ACR, AER, PCR, PER)
7
Q
A1 Albumin/Protein Levels
A
- ACR/AER: <30
- PCR/PER: <150
- Normal to mild
8
Q
A2 Albumin/Protein Levels
A
- ACR/AER: 30-300
- PCR/PER: 150-500
- Moderate
9
Q
A3 Albumin/Protein Levels
A
- ACR/AER: >300
- PCR/PER: >500
- Severe
10
Q
BP Control - Lifestyle Modification
A
- Achieve/maintain health body weight: BMI 20-25
- Lowering sodium intake unless C/I: <2g per day
- Exercise program compatible with CV health and tolerance: at least 30 minutes 5x/week
- Limit alcohol intake: Women =<1 drink/day, Men =<2 drinks/day
11
Q
NON-DM + CKD BP Targets
A
- A1: <140/90
- A2/A3: <130/80
12
Q
NON-DM + CKD BP Agents
A
- A1: Any agent except loop diuretics
- A2/A3: ACE-I/ARBs
13
Q
DM + CKD BP Targets
A
- A1: <140/90
- A2/A3: <130/80
14
Q
DM + CKD BP Agents
A
- A1: Any agent except loop diuretics
- A2/A3: ACE-I/ARBs
15
Q
BP Agents + Decreasing Proteinuria/Albuminuria
A
- 1st line: ACE-I or ARBs (DON’T COMBINE)
- Alternative agent: NDP CCB
16
Q
BP + CKD Goals of Therapy
A
- Decrease amount of protein/albumin in urine
- Prevent progression from A2 to A3
- Slow GFR loss
17
Q
Monitoring ACEI/ARB
A
- Monitor K+ and SCr within 1-2 weeks of starting or increasing dose
- Discontinue if SCr increased more than 50% or eGFR decreases more than 50% from baseline
- Optimizing BP is also beneficial for proteinuria
18
Q
Serum K+ and ACEI/ARBs
A
- If K+ 5-5.5 mEq/L, decrease ACEI/ARB by 50% and recheck
- If K+ is >5.5 mEq/L, discontinue the ACEI/ARB and recheck
19
Q
eGFR + ACEI/ARB
A
- If eGFR decreases by 30-50%, decrease ACEI/ARB by 50%, repeat process until eGFR is within 30% of baseline
- If eGFR has decreased by more than 50%, discontinue the ACEI/ARB and recheck
20
Q
CKD + BP 1st Principles
A
- Considered high risk for CV disease
- Most will require 2+ antihypertensive agents to achieve target blood pressure
- With exception of ARB or ACEI in CKD patients with albuminuria, no strong evidence to support preferential use of any particular antihypertensive agent
- Consider half-life of drug and dose adjustment according to CKD stage
21
Q
Thiazide Diuretics
A
- Hydrochlorothiazide: CrCl < 30 mL/min, decreased diuretic efficacy (BP may be preserved)
- Chlorthalidone: Longer half life than HCTZ, may contribute to better BP control, may be effective at lowering renal function more than HCTZ
- Metolazone: effective at CrCl < 30 mL/min
- Often used in combination with loop diuretics for additive diuresis (dual nephron blockage)
22
Q
Loop Diuretics
A
- Considered when fluid overload also present
- Can be used in all stages of CKD (decreased diuresis with lower eGFR)
- Typically larger doses required with decreased renal function
23
Q
Calcium Channel Blockers
A
- NDP: antiproteinuric activity
- Amlodipine: AE of edema is a concern
24
Q
Beta-Blockers
A
- Masks signs and symptoms of hypoglycemia
- Atenolol and bisoprolol renally eliminated: initiate at smaller doses
25
Q
Aldosterone Antagonists
A
- Shown to decrease urine albumin excretion when added to ACEI or ARB
- USE WITH CAUTION
26
Q
Potassium Sparing Diuretics
A
-Usually avoided due to hyperkalemia risk
27
Q
Direct Renin Inhibitors
A
-Limited data in CKD
28
Q
HTN + Proteinuria in CKD
A
- HTN associated with a faster rate of CKD decline
- Proteinuria associated with faster rate of GFR decline
- Proteinuria and decreased GFR can worsen BP
- Agents used to decrease proteinuria are also BP agents
- BP lowering itself may decrease protein excretion
29
Q
Glycemic Control
A
- Diabetic Nephropathy (CKD + DM) - microvascular complication of DM
- Intensive DM management with goal of achieving near normoglycemia (A1c =<7%) has been shown to delay onset/progression of urinary albumin excretion and slow GFR loss
30
Q
DM + CKD First Line
A
- Metformine
- Effective and safe, inexpensive, and may reduce risk off CV events and death
- C/I if eGFR < 30 mL/min/1.73 m^2
- If already on therapy and eGFR is 30-45 mL/min/1.73 m^2 then consider cutting the dose in half
- Initiating Metformin when eGFR is 30-45 is not recommended
- Calculate eGFR at least annually
- Patients have increased risk of hypoglycemia with these disease combinations
31
Q
DM + CKD 2nd Line Options
A
- SGLT2i
2. GLP-1RA
32
Q
GLP-1RA
A
- Dulaglutide (Trulicity), Liraglutide (Victoza), Semaglutide (Ozempic)
- Demonstrated direct renal benefits (appear to possibly slow CKD progression)
- Reduced risk of CVD events
- No renal dose adjustments needed
33
Q
SGLT2i
A
- Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)
- Independent of glycemia benefits, demonstrated direct renal benefits
- Decreases intraglomerular pressure, decreases albuminuria, slows GFR loss
- Reduced risk of CVD events
- C/I in patients with eGFR < 30 mL/min/1.72 m^2, EXCEPT with Invokana, if they are already on the medication, and patient has A3 albuminuria, then may continue with therapy
- C/I with dialysis
34
Q
Blood Glucose Optimization Summary
A
- Tight glycemic control - delays onset/progression of diabetic nephropathy
- Metformin is 1st line, but be cautious with eGFR
- Preferred second lines are GLP-1RA and SGLT2i due to direct renal benefits and reduced CVD events
- Consider how oral agents are eliminated
- Insulin is appropriate at all levels of CKD
- Patients with CKD and DM are at an increased risk of hypoglycemia, so ensure they are aware of the signs/symptoms and how to treat this
- Encourage self blood glucose monitoring when appropriate
