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Clin Med 3 > CKD - Exam 2 > Flashcards

CKD - Exam 2 Flashcards

1
Q

what are the 2 most important contributors to CKD?

A

DM and HTN

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2
Q

how fast is kidney fxn lost in acute kidney disease

A

rapid loss of kidney fxn (hours to days)

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3
Q

is acute kidney disease reversible?

A

yes, acute kidney disease is reversible

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4
Q

what is acute kidney disease caused by?

A

dehydration, blood loss, medication, IV contrast, obstruction (I.e. enlarged prostate -> no urine output -> AKI)

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5
Q

how fast is kidney fxn lost in chronic kidney disease?

A

Progressive loss of renal function that persists for more than 3 months

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6
Q

is chronic kidney disease reversible?

A

no, CKD is irreversible

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7
Q

what is CKD caused by?

A

long term diseases

-DM and HTN

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8
Q

what is the fxn of the kidney?

A
  • Regulation of water, minerals and acid-base status
  • Removal of metabolic waste products from the blood and excretes them in urine (kidneys excrete urea-> nitrogenous waste)
  • Removal of foreign chemicals from blood and excretes them in urine

-Secretion of hormones
(EPO, renin, Vit D)

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9
Q

what is the mnemonic for kidney fxn?

A

A WET BED

Acid base, water balance, electrolytes, toxin excretion, BP, EPO, Vit D

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10
Q

where does filtration occur in the kidney

A

at the glomerulus

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11
Q

what is the individual unit of the kidney?

A

nephron

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12
Q

what is the ultimate measure of kidney fxn?

A

GFR

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13
Q

where does reabsorption occur in the kidney?

A

in proximal/distal tubule and loop of henle

ALL DONE PASSIVELY

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14
Q

what is the secretion fxn of the kidney?

A

actively pumping K, H, and urea back into tubule to be excreted

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15
Q

in kidney failure, what happens to the secretion fxn? leads to what?

A

build up of K, H, and urea in the body

leads to metabolic acidosis and encephalopathy

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16
Q

where does excretion occur in the kidney?

A

collecting duct

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17
Q

what is the GFR for CKD?

A

GFR < 60 mL/min for more than 3 months

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18
Q

what is there a persistence of in CKD?

A

proteinuria, hematuria, or abnormal urinary sediment (casts)

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19
Q

CKD definition?

A
  • GFR <60 mL/min for more than 3 months
  • Persistence of proteinuria, hematuria, or abnormal urinary sediment
  • Progressive nephrosclerosis (irreversible reduction in nephron number)
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20
Q

CKD results in the inability to maintain what?

A

A WET BED:

Acid-base balance (ex: Chronic hyperkalemia)

Fluid and electrolyte balance (ex: Edema)

Excretion of nitrogenous wastes (ex: Uremic encephalopathy)

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21
Q

what is the basic pathophysiology of CKD?

A

nephron damage -> hyperfiltration -> hypertrophy of remaining nephrons b/c want to maintain GFR -> glomerular capillary HTN -> pressure stretches capillary and causes glomerular injury -> RAAS and angio 2 activated -> pore size altered by angio 2 -> increases protein leak across glomerular basement membrane -> excessive protein filtration -> microalbuminuria/proteinuria

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22
Q

what contributes to progressive kidney damage?

A

excess protein in the urine (albuminuria/proteinuria) - clog up tubules -> inflammation -> scarring

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23
Q

what are the pro-inflammatory mediators for CKD?

A

angio 2 and aldosterone

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24
Q

how do angio 2 and aldosterone affect the kidney?

A

they are directly inflammatory to the kidney -> cause even more damage

cause glomerulosclerosis and tubulointerstitial fibrosis which promotes CKD

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25
Q

what does GFR measure?

A

how well the kidneys are removing wastes and excess fluid from the blood

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26
Q

how is GFR calculated?

A

from the serum creatinine using

-age, weight, gender, body size

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27
Q

what is Creatinine?

A

muscle breakdown product that goes thru the kidney untouched

surrogate marker to assess filtration rate

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28
Q

what is a surrogate marker to assess filtration rate?

A

Cr

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29
Q

GFR will go up with?

A

age and weight

-use ideal body weight (muscle)

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30
Q

normal GFR?

A

90 or above

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31
Q

GFR < 60 means?

A

sign that kidneys not working properly

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32
Q

GFR <15 means?

A

indicates treatment plan for kidney failure (dialysis or transplant) is needed

ESRD

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33
Q

when do pts with CKD start to develop sx’s?

A

not until stage 3 or 4

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34
Q

CKD sx’s

A

anemia (not producing as much EPO)

fatigue/weakness

decreased appetite with progressive malnutrition

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35
Q

stage 5 CKD sx’s

A
  • N/V
  • Decreased mental sharpness/encephalopathy
  • Muscle twitches and cramps
  • Swelling of feet and ankles
  • Puritis
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36
Q

clinical manifestations of advanced stages of CKD?

A

Uremic syndrome

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37
Q

what is uremic syndrome?

A

symptomatic manifestations associated with azotemia

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38
Q

what is azotemia?

A

the accumulation of urea and other nitrogenous compounds and toxins caused by the decline in renal fxn

increase in Cr and BUN but NO SX’S

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39
Q

do you have sx’s in azotemia? what increases in azotemia?

A

NO!!! but have increase in Cr and BUN

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40
Q

difference b/w azotemia and uremic syndrome?

A

azotemia has no sx’s associated with increase in Cr and BUN

Uremic syndrome has sx’s

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41
Q

high end of normal for BUN?

A

20

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42
Q

if pts have super high BUN what can you smell? what about their skin?

A

the pee -> uremic factor

have uremic frost -. sweat out urea -> water evaporates -> dry leathery skin

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43
Q

pts with uremic syndrome are usually on what?

A

dialysis or almost on it

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44
Q

what are the complications of progressive CKD?

A

Anemia (b/c of less EPO), Metabolic acidosis

Derangements in Vit D, Ca2+ and Ph metabolism -> weak bones -> FRACTURE risk

Volume overload (not just edema, can also look like CHF)

Hyperkalemia (arrhythmias- can be one of the most common causes of MI)

Uremia

CV complications (HTN, atherosclerosis, valvular stenosis, CHF)

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45
Q

what must you consider when approaching a pt with new renal dysfunction?

A

pre-renal, renal, and post-renal etiologies

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46
Q

what will GFR and Cr be in CKD?

A

Cr will be UP and GFR will be DOWN

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47
Q

what labs do you run for pt with new renal dysfunction?

A

serum Cr, urine dipstick, microscopy, and spot protein

urinalysis

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48
Q

what imaging do you start with for pt with new renal dysfunction?

A

renal U/S

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49
Q

what do you do after renal U/S?

A

Ct without contrast

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50
Q

when do a urinalysis for pt with renal dysfunction, what are you looking for?

A

casts in the urine

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51
Q

what must you consider for pt with new renal dysfunction?

A

multiple myeloma - especially if have new renal insufficiency and new anemia, blood in urine, but no RBCs

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52
Q

how do you check for MM in pt with new renal dysfunction?

A

serum protein electrophoresis, urine protein electrophoresis

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53
Q

abnormal labs in CKD

A

elevated BUN, elevated Cr, hyperkalemia, hyperphosphatemia, hypocalcemia, proteinuria, RBC/cast in urine, WBC/cast in urine

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54
Q

what do normal levels of Cr depend on?

A

age, race, body/muscle size

55
Q

what are early signs of kidney dysfunction in men and women for Cr?

A

Cr > 1.2 in women

Cr > 1.4 in men

56
Q

as kidney fxn decreases, Cr ____

A

increases (Cr not getting filtered at the same rate b/c of kidney dysfunction)

57
Q

what is the measure of BUN?

A

measure of nitrogen in your blood that comes from the waste product urea

58
Q

when is urea made?

A

when protein is broken down in your body

59
Q

normal BUN?

A

7-20

60
Q

as kidney function decreases, BUN ___

A

increases (urea isn’t being filtered out)

61
Q

what does a 24hr urine test compare? what does it show?

A

urine Cr to the blood Cr

shows how much blood the kidneys are filtering out each minute

62
Q

what does a urinalysis test for?

A

tests for protein (albumin) in the urine

63
Q

in nephrotic syndrome, what urine sediment is seen?

A

heavy proteinuria

64
Q

in glomerulonephritis, what urine sediment is seen?

A

RBC casts

65
Q

in acute tubular necrosis, what urine sediment is seen?

A

pigmented granular casts

66
Q

in interstitial nephritis, what urine sediment is seen?

A

WBC casts

67
Q

in dehydration, what urine sediment is seen?

A

hyaline casts

68
Q

when does microalbuminuria occur?

A

when the kidney leaks small amounts of albumin into the urine (have a leaky glomerulus)

69
Q

what is the preferred test for microalbuminuria?

A

24hr urine collection

-positive for microalbuminuria = albumin 30-300mg/24hrs

70
Q

when do you see macroalbuminuria in CKD?

A

more advanced disease

71
Q

test for macroalbuminuria?

A

spot sample -> > 300mg/L

24hr urine collection -> > 300mg/day

72
Q

what is hematuria?

A

> 3 RBCs per high power field on at least 2 occasions

73
Q

conditions that hematuria?

A

not only in CKD

-urologic malignancy, UTI, interstitial nephritis, AAA

74
Q

as protein goes up in the urine, what does this portray?

A

worsening kidney function (should not have protein in the urine)

75
Q

> 150-160 mg/24 hrs of protein in urine is what?

A

abnormal

76
Q

what level of proteinuria signifies underlying kidney abnormality?

A

> 1-2 g/24hr

-usually glomerular problem

77
Q

what level of proteinuria signifies nephrotic syndrome?

A

> 3.5 g/24hr

78
Q

what is a normal spot urine?

A

< 0.2

79
Q

spot urine is equivalent to what?

A

24hr urine for urine protein/urine Cr ratio

80
Q

normal values spot urine in men and women

A

men < 1.1

women < 1.6

81
Q

how does anemia occur in CKD?

A

secondary to decreased production of EPO by the kidney

82
Q

what should be provided to pts with CKD and Hgb < 10mg/dL

A

EPO stimulating agents (Procrit)

83
Q

goal of Hgb with EPO stimulating agents?

A

goal is 11-12 mg/dL

-higher goals are associated with increased mortality

84
Q

how does metabolic acidosis occur in CKD?

A

Secondary to decreased bicarb reabsorption and generation by the kidneys

-can’t secrete H+ and reabsorb bicarb

85
Q

how do you treat metabolic acidosis in CKD? when do you treat?

A

Treat with bicarb supplementation when bicarb <18 mg/dL (target is 22 mg/dL)

86
Q

why do you get vitamin d deficiency with CKD?

A

b/c kidney is responsible for activating vitamin D, but with CKD it can’t

87
Q

what vitamin D do you measure?

A

25-OH vitamin D (storage form)

88
Q

normal vitamin D level?

A

> 30mg/mL

89
Q

why do you get bone disease in CKD?

A

Secondary to abnormalities in the complex interaction between Vit D, phosphorous, Ca and PTH

90
Q

bone disease in CKD results in what? what do they lead to?

A

Results in either:
-Excessive bone resorption (osteilitis fibrosa cystica)

-State of bone quiescence (adynamic bone disease)

Both lead to increased risk of fractures

91
Q

what is difficult to control in CKD stage 4 (GFR 15-29 ml/min)?

A

HTN (requires large doses of loop diuretics) and edema

92
Q

how to treat hyperkalemia in CKD?

A

kayexalate

93
Q

uremia in what stage of CKD?

A

CKD stage 4 (GFR 15-29 ml/min)

94
Q

if have CKD stage 4 or 5, who must you be referred to?

A

nephrologist

95
Q

if in CKD stage 5 (GFR < 15 ml/min), what do you need?

A

renal transplant or discussions regarding end of life

96
Q

once on dialysis, what is the mortality rate within 5 years?

A

> 50%

97
Q

CKD is a significant risk factor for what?

A

for CV disease (most die from complications of CV disease)

98
Q

most common causes of ESRD?

A

*Diabetic glomerular disease

HTN nephropathy

  • Primary glomerulopathy with HTN
  • Vascular and ischemic renal disease
99
Q

what is the leading cause of ESRD?

A

DM

100
Q

what reduces progression of kidney disease when have DM?

A

intensive insulin therapy to maintain HbA1c < 7%

101
Q

what should pts BP be if DM and have CKD?

A

<130/80

-lowering the BP delays the onset of microalbuminuria by decreasing glomerular HTN

102
Q

first sign of diabetic nephropathy? important to do what test?

A

microalbuminuria

-doing spot urine checks is really important

103
Q

most common comorbidity of diabetic nephropathy?

A

HTN

104
Q

tx for diabetic nephropathy?

A
  • ACE/ARBs (renal protective properties)
  • Diuretic (addition of a second agent to aid in BP control)
  • Also need tight glycemic control, weight loss, diet, exercise
105
Q

what is the 2nd leading cause of ESRD?

A

HTN - accelerates CKD

106
Q

controlling BP, slows down what?

A

the decline in GFR

107
Q

inhibiting RAAS is effective in what?

A

lowering BP and reducing microalbuminuria

108
Q

goal of therapy for HTN in terms of CKD?

A

halt progression to hypertensive nephropathy

109
Q

hypertensive nephropathy develops in what pts?

A

pts with protein uric and HTN

110
Q

BP goals in a pt with CKD and HTN?

A

<140/90

111
Q

guidelines for tx of hypertensive nephropathy, advise caution with use of what?

A

use of ACE/ARB in the presence of renal impairment

Expect worsening Cr up to 30% or reduction of GFR 20% from baseline
-if values stabilized after initial rise, then safe to continue use

-If values continue to rise, then D/C ACE/ARBs and consult nephrologist

112
Q

when should you D/C ACE/ARBs and consult nephrologist when treating hypertensive nephropathy?

A

if Cr levels continue to rise and GFR continues to decline

113
Q

at what level of K do you stop K-sparing drugs and what other drugs do you reduce dose of?

A

hyperkalemia >6

reduce loop diuretic dosage (they lower the flow)

114
Q

when treating hypertensive nephropathy what must you check before starting meds and after starting meds?

A

Cr, K, and GFR (and any time there is a dose change)

115
Q

if pt has CHF, what meds MUST they be on?

A

ACE and ARBs

116
Q

how do you ACEs and ARBs help with CHF?

A
  • Reduce the glomerular permeability barrier to proteins
  • Limit proteinuria and filtered protein-dependent inflammatory signals
  • Decrease glomerular intra capillary pressure
117
Q

CKD is a risk factor for what?

A

CV disease

118
Q

what is independently associated with an increase in CV mortality?

A

reduced GFR and proteinuria

119
Q

elevated BP leads to what?

A

to damage of blood vessels within kidney and throughout body -> Increase CKD

120
Q

what is the primary prevention for CKD?

A

weight loss, exercise, BP control, glucose control

121
Q

treat underlying ___ for CKD

A

Treat underlying disorder

122
Q

tx for CKD (stage 5)

A

dialysis - hemodialysis and peritoneal dialysis

renal transplant

123
Q

dialysis is considered what?

A

a holding measure until renal transplant can be done

or a supportive measure in those with AKI where transplant is unlikely/unnecessary

124
Q

methods for hemodialysis

A

AV fistula/graft

need a flow rate b/w an artery and a vein

125
Q

what is bad about synthetic grafts for hemodialysis?

A

clot more and get infected more

126
Q

dialysis catheter/port is used in who?

A

people who need dialysis acutely -> NOT chronically

127
Q

peritoneal dialysis is less efficient than ____

A

hemodialysis

128
Q

when does someone need a kidney transplant? GFR?

A

ESRD regardless of primary cause (GFR < 15 ml/min)

can also do preemptive transplant before dialysis is needed in those with CKD

129
Q

majority of renal transplant recipients are on what at time of transplant?

A

dialysis

130
Q

where is the new kidney put into the body?

A

into lower abdomen

131
Q

do you still need dialysis if got kidney transplant?

A

NO!!!

132
Q

what is a kidney pancreas transplant?

A

Operation to place both a kidney and pancreas at same time into someone with kidney failure secondary to Type 1 Diabetes -> Cures them of DM

133
Q

who is NOT a candidate for kidney pancreas transplant?

A

type 2 DM b/c already have working pancreas just can’t use insulin properly

134
Q

when do you refer a pt to a nephrologist?

A
  • GFR <30 ml/min í CKD stages 4 and 5
  • Rapidly progressing CKD
  • Poorly controlled HTN despite 4 agents
  • Rare or genetic causes of CKD (polycystic kidney disease)
  • Suspected renal artery stenosis

Clin Med 3 (21 decks)

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