CKD - Exam 2 Flashcards
1
Q
what are the 2 most important contributors to CKD?
A
DM and HTN
2
Q
how fast is kidney fxn lost in acute kidney disease
A
rapid loss of kidney fxn (hours to days)
3
Q
is acute kidney disease reversible?
A
yes, acute kidney disease is reversible
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)
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
6
Q
is chronic kidney disease reversible?
A
no, CKD is irreversible
7
Q
what is CKD caused by?
A
long term diseases
-DM and HTN
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)
9
Q
what is the mnemonic for kidney fxn?
A
A WET BED
Acid base, water balance, electrolytes, toxin excretion, BP, EPO, Vit D
10
Q
where does filtration occur in the kidney
A
at the glomerulus
11
Q
what is the individual unit of the kidney?
A
nephron
12
Q
what is the ultimate measure of kidney fxn?
A
GFR
13
Q
where does reabsorption occur in the kidney?
A
in proximal/distal tubule and loop of henle
ALL DONE PASSIVELY
14
Q
what is the secretion fxn of the kidney?
A
actively pumping K, H, and urea back into tubule to be excreted
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
16
Q
where does excretion occur in the kidney?
A
collecting duct
17
Q
what is the GFR for CKD?
A
GFR < 60 mL/min for more than 3 months
18
Q
what is there a persistence of in CKD?
A
proteinuria, hematuria, or abnormal urinary sediment (casts)
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)
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)
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
22
Q
what contributes to progressive kidney damage?
A
excess protein in the urine (albuminuria/proteinuria) - clog up tubules -> inflammation -> scarring
23
Q
what are the pro-inflammatory mediators for CKD?
A
angio 2 and aldosterone
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
25
what does GFR measure?
how well the kidneys are removing wastes and excess fluid from the blood
26
how is GFR calculated?
from the serum creatinine using
| -age, weight, gender, body size
27
what is Creatinine?
muscle breakdown product that goes thru the kidney untouched
surrogate marker to assess filtration rate
28
what is a surrogate marker to assess filtration rate?
Cr
29
GFR will go up with?
age and weight
| -use ideal body weight (muscle)
30
normal GFR?
90 or above
31
GFR < 60 means?
sign that kidneys not working properly
32
GFR <15 means?
indicates treatment plan for kidney failure (dialysis or transplant) is needed
ESRD
33
when do pts with CKD start to develop sx's?
not until stage 3 or 4
34
CKD sx's
anemia (not producing as much EPO)
fatigue/weakness
decreased appetite with progressive malnutrition
35
stage 5 CKD sx's
- N/V
- Decreased mental sharpness/encephalopathy
- Muscle twitches and cramps
- Swelling of feet and ankles
- Puritis
36
clinical manifestations of advanced stages of CKD?
Uremic syndrome
37
what is uremic syndrome?
symptomatic manifestations associated with azotemia
38
what is azotemia?
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
39
do you have sx's in azotemia? what increases in azotemia?
NO!!! but have increase in Cr and BUN
40
difference b/w azotemia and uremic syndrome?
azotemia has no sx's associated with increase in Cr and BUN
Uremic syndrome has sx's
41
high end of normal for BUN?
20
42
if pts have super high BUN what can you smell? what about their skin?
the pee -> uremic factor
have uremic frost -. sweat out urea -> water evaporates -> dry leathery skin
43
pts with uremic syndrome are usually on what?
dialysis or almost on it
44
what are the complications of progressive CKD?
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)
45
what must you consider when approaching a pt with new renal dysfunction?
pre-renal, renal, and post-renal etiologies
46
what will GFR and Cr be in CKD?
Cr will be UP and GFR will be DOWN
47
what labs do you run for pt with new renal dysfunction?
serum Cr, urine dipstick, microscopy, and spot protein
urinalysis
48
what imaging do you start with for pt with new renal dysfunction?
renal U/S
49
what do you do after renal U/S?
Ct without contrast
50
when do a urinalysis for pt with renal dysfunction, what are you looking for?
casts in the urine
51
what must you consider for pt with new renal dysfunction?
multiple myeloma - especially if have new renal insufficiency and new anemia, blood in urine, but no RBCs
52
how do you check for MM in pt with new renal dysfunction?
serum protein electrophoresis, urine protein electrophoresis
53
abnormal labs in CKD
elevated BUN, elevated Cr, hyperkalemia, hyperphosphatemia, hypocalcemia, proteinuria, RBC/cast in urine, WBC/cast in urine
54
what do normal levels of Cr depend on?
age, race, body/muscle size
55
what are early signs of kidney dysfunction in men and women for Cr?
Cr > 1.2 in women
Cr > 1.4 in men
56
as kidney fxn decreases, Cr ____
increases (Cr not getting filtered at the same rate b/c of kidney dysfunction)
57
what is the measure of BUN?
measure of nitrogen in your blood that comes from the waste product urea
58
when is urea made?
when protein is broken down in your body
59
normal BUN?
7-20
60
as kidney function decreases, BUN ___
increases (urea isn't being filtered out)
61
what does a 24hr urine test compare? what does it show?
urine Cr to the blood Cr
shows how much blood the kidneys are filtering out each minute
62
what does a urinalysis test for?
tests for protein (albumin) in the urine
63
in nephrotic syndrome, what urine sediment is seen?
heavy proteinuria
64
in glomerulonephritis, what urine sediment is seen?
RBC casts
65
in acute tubular necrosis, what urine sediment is seen?
pigmented granular casts
66
in interstitial nephritis, what urine sediment is seen?
WBC casts
67
in dehydration, what urine sediment is seen?
hyaline casts
68
when does microalbuminuria occur?
when the kidney leaks small amounts of albumin into the urine (have a leaky glomerulus)
69
what is the preferred test for microalbuminuria?
24hr urine collection
| -positive for microalbuminuria = albumin 30-300mg/24hrs
70
when do you see macroalbuminuria in CKD?
more advanced disease
71
test for macroalbuminuria?
spot sample -> > 300mg/L
24hr urine collection -> > 300mg/day
72
what is hematuria?
>3 RBCs per high power field on at least 2 occasions
73
conditions that hematuria?
not only in CKD
-urologic malignancy, UTI, interstitial nephritis, AAA
74
as protein goes up in the urine, what does this portray?
worsening kidney function (should not have protein in the urine)
75
>150-160 mg/24 hrs of protein in urine is what?
abnormal
76
what level of proteinuria signifies underlying kidney abnormality?
>1-2 g/24hr
-usually glomerular problem
77
what level of proteinuria signifies nephrotic syndrome?
>3.5 g/24hr
78
what is a normal spot urine?
< 0.2
79
spot urine is equivalent to what?
24hr urine for urine protein/urine Cr ratio
80
normal values spot urine in men and women
men < 1.1
women < 1.6
81
how does anemia occur in CKD?
secondary to decreased production of EPO by the kidney
82
what should be provided to pts with CKD and Hgb < 10mg/dL
EPO stimulating agents (Procrit)
83
goal of Hgb with EPO stimulating agents?
goal is 11-12 mg/dL
| -higher goals are associated with increased mortality
84
how does metabolic acidosis occur in CKD?
Secondary to decreased bicarb reabsorption and generation by the kidneys
-can't secrete H+ and reabsorb bicarb
85
how do you treat metabolic acidosis in CKD? when do you treat?
Treat with bicarb supplementation when bicarb <18 mg/dL (target is 22 mg/dL)
86
why do you get vitamin d deficiency with CKD?
b/c kidney is responsible for activating vitamin D, but with CKD it can't
87
what vitamin D do you measure?
25-OH vitamin D (storage form)
88
normal vitamin D level?
>30mg/mL
89
why do you get bone disease in CKD?
Secondary to abnormalities in the complex interaction between Vit D, phosphorous, Ca and PTH
90
bone disease in CKD results in what? what do they lead to?
Results in either:
-Excessive bone resorption (osteilitis fibrosa cystica)
-State of bone quiescence (adynamic bone disease)
Both lead to increased risk of fractures
91
what is difficult to control in CKD stage 4 (GFR 15-29 ml/min)?
HTN (requires large doses of loop diuretics) and edema
92
how to treat hyperkalemia in CKD?
kayexalate
93
uremia in what stage of CKD?
CKD stage 4 (GFR 15-29 ml/min)
94
if have CKD stage 4 or 5, who must you be referred to?
nephrologist
95
if in CKD stage 5 (GFR < 15 ml/min), what do you need?
renal transplant or discussions regarding end of life
96
once on dialysis, what is the mortality rate within 5 years?
>50%
97
CKD is a significant risk factor for what?
for CV disease (most die from complications of CV disease)
98
most common causes of ESRD?
*Diabetic glomerular disease
HTN nephropathy
- Primary glomerulopathy with HTN
- Vascular and ischemic renal disease
99
what is the leading cause of ESRD?
DM
100
what reduces progression of kidney disease when have DM?
intensive insulin therapy to maintain HbA1c < 7%
101
what should pts BP be if DM and have CKD?
<130/80
| -lowering the BP delays the onset of microalbuminuria by decreasing glomerular HTN
102
first sign of diabetic nephropathy? important to do what test?
microalbuminuria
-doing spot urine checks is really important
103
most common comorbidity of diabetic nephropathy?
HTN
104
tx for diabetic nephropathy?
- 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
what is the 2nd leading cause of ESRD?
HTN - accelerates CKD
106
controlling BP, slows down what?
the decline in GFR
107
inhibiting RAAS is effective in what?
lowering BP and reducing microalbuminuria
108
goal of therapy for HTN in terms of CKD?
halt progression to hypertensive nephropathy
109
hypertensive nephropathy develops in what pts?
pts with protein uric and HTN
110
BP goals in a pt with CKD and HTN?
<140/90
111
guidelines for tx of hypertensive nephropathy, advise caution with use of what?
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
when should you D/C ACE/ARBs and consult nephrologist when treating hypertensive nephropathy?
if Cr levels continue to rise and GFR continues to decline
113
at what level of K do you stop K-sparing drugs and what other drugs do you reduce dose of?
hyperkalemia >6
reduce loop diuretic dosage (they lower the flow)
114
when treating hypertensive nephropathy what must you check before starting meds and after starting meds?
Cr, K, and GFR (and any time there is a dose change)
115
if pt has CHF, what meds MUST they be on?
ACE and ARBs
116
how do you ACEs and ARBs help with CHF?
- Reduce the glomerular permeability barrier to proteins
- Limit proteinuria and filtered protein-dependent inflammatory signals
- Decrease glomerular intra capillary pressure
117
CKD is a risk factor for what?
CV disease
118
what is independently associated with an increase in CV mortality?
reduced GFR and proteinuria
119
elevated BP leads to what?
to damage of blood vessels within kidney and throughout body -> Increase CKD
120
what is the primary prevention for CKD?
weight loss, exercise, BP control, glucose control
121
treat underlying ___ for CKD
Treat underlying disorder
122
tx for CKD (stage 5)
dialysis - hemodialysis and peritoneal dialysis
renal transplant
123
dialysis is considered what?
a holding measure until renal transplant can be done
or a supportive measure in those with AKI where transplant is unlikely/unnecessary
124
methods for hemodialysis
AV fistula/graft
need a flow rate b/w an artery and a vein
125
what is bad about synthetic grafts for hemodialysis?
clot more and get infected more
126
dialysis catheter/port is used in who?
people who need dialysis acutely -> NOT chronically
127
peritoneal dialysis is less efficient than ____
hemodialysis
128
when does someone need a kidney transplant? GFR?
ESRD regardless of primary cause (GFR < 15 ml/min)
can also do preemptive transplant before dialysis is needed in those with CKD
129
majority of renal transplant recipients are on what at time of transplant?
dialysis
130
where is the new kidney put into the body?
into lower abdomen
131
do you still need dialysis if got kidney transplant?
NO!!!
132
what is a kidney pancreas transplant?
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
who is NOT a candidate for kidney pancreas transplant?
type 2 DM b/c already have working pancreas just can't use insulin properly
134
when do you refer a pt to a nephrologist?
- 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
