CKD Lecture 1 (INC) Flashcards
What defines CKD?
GFR is <60 for 3+ months w/ or w/out kidney dmg
OR
Presence of markers of kidney dmg for 3+ months despite GFR
structural problems, abnormality in blood/urine, imaging issues etc
For CKD, what happens with kidney function after treatment, and how does this differ it from AKI?
CKD will result in decline in function even if underlying issue is removed d/t chronic nephron overwork.
AKI typically results in normal kidney function after addressing underlying issue
Explain the 5 steps that make up the pathophys of CKD
- Hyperfilitration, meaning that BUN and creatinine are normal
- Hypertrophy of remaining nephrons
- RAAS system tries to maintain homeostasis
- Glomerular architecture becomes distorted (especially in glomeluruls) d/t hypertrophy hindering filtering abilities
- Inflammation and fibroblast puts in scar tissue, destroying the function in the kidney
What is the renal rebound?
- Lifestyle/meds lead to improvement in BUN creatinine, GFR (improved DM, hydration, control other disease)
- Recovery does not reflect restoration of renal tissue, just means that the nephrons that are left have a lower workload.
Prevalence of CKD
15%,
9 out of 10 adults are unaware they have CKD!
70% of ESRD (stage 5) CKD is caused by these two chronic diseases
DM
HTN/vascular disease
How does CKD lead to CVD?
Proteinuric CKD - ↑ risk of CV mortality
Many CKD pts die from CVD before progressing to ESRD!
What are the risk factors for CKD?
Old
sub-Sarahan African ancestry
Explain cardiorenal syndrome
Deterioration of one organ results in deterioration of the other.
The underlying conditions of acute kidney stuff causes problems with CV, but as you get to chronic, the kidneys start affecting the CV directly
Because they require the same things to be healthy
In the past, what is the staging of kidneys solely reliant on?
GFR
What is the new recommendation of staging CKD
GFR and albuminuria
What are the GFR stages of CKD?
- > = 90
- 60-89
- 45-59
3a. 30-44 - 15-29
- <15
What are the 3 albuminuria?
A1: <30
A2: 30-300
A3: 300+
Where do most patients fall for CKD?
G1 A1 with underlying condition causing kidney issues
A patient with a GFR of 38 mL/min and urine albumin of 100 mg/g =
Stage 3b, A2
A patient with a GFR of 96 mL/min and urine albumin of 38 mg/g
Stage 1, A2
A patient with a GFR of 10 mL/min and urine albumin of 350 mg/g =
Stage 5, A3
A patient with a GFR of 110 mL/min and urine albumin of 12 mg/g =
Normal as long as there is nothing else going on
What are the s/s of early-mid CKD, and what about when it progresses
Start asymptomatic
Eventually slow onset of non-specific s/s
MC is HTN d/t activating RAAS system
Later stages = volume overload d/t RAAS system retaining fluid
Late CKD = waste build up - leads to uremia
If a patient is at CKD stage 5 and does not do dialysis, what can happen to their skin?
Uremic frost d/t urea excreted in swear
Why do patients become anemic with CKD?
No erythropoietin
What happens to BUN and creatinine and GFR in CKD?
BUN and creatinine increase
GFR decreases
What do you see in UA for CKD and why?
Proteinuria sometimes
Broad waxy cast d/t dilated nephrons
What is the pH status of CKD and why?
metabolic acidosis d/t not being able to excrete H+
What are the s/s of stage 1 and 2?
sometimes HTN but usually asymptomatic
What are the s/s of stage 3 and 4?
More likely to have s/s
organ systems are affected
anemia, fatigue
abnormal electrolytes
What are the s/s of stage 5?
marked disturbance in ADL, well being, nutrition, water and electrolyte homeostasis
Uremic syndrome
What are the 3 abnormal renal imaging interpretations that are indicative of CKD despite normal GFR?
Polycystic kidneys
Small kidneys ( < 9-10 cm)
Asymmetric kidneys (vascular disease)
What does the primary treatment of CKD depend on?
Slowing progression
Finding underlying disease
Control BP (ACEs and ARBs, not used in AKI because you want kidneys to have as much blood as possible)
Control proteinuria (ACE/ARBs, diet)
Avoid kidney stones
DM control BG with SGLT-2 inhibitors
Adjust med doses based on renal function
What are the order of abnormalities based on progression of CKD
HTN
PTH
Anemia
Phosphorus
Acidosis, hyperkalemia
Uremic syndrome
What do most CKD patients die by?
CV disease
primarily from HTN
What is the goal BP of patients with HTN and CKD?
<130-80 or 140-90
How do you manage HTN with CKD?
diet, exercise, wt loss, low sodium diet <2300
What do ACE and ARBs d/t creatinine and potassium
Tend to increase both
Why do you use diuretics for CKD?
Nearly always needed because the kidneys try to have body retain as much fluid as possible
What diuretic do you start with first for CKD and when is this changed?
Thiazides - early CKD
Loop - more effective in later CKD (GFR < 30)
anti-HTN rx - CCBs, BBs are sometimes indicated
What is the most common problem with cholesterol if you have CKD? How do you treat?
Hypertriglyceridemia
Typically use a statin, can use PSK9 inhibitors as adjunct therapy
How does CKD lead to HF?
HTN, volume overload, anemia, atherosclerosis, leading to LVH
How do you treat HF with CKD
ACE/ARBs
monitor for hyperkalemia
How do you treat A-fib with CKD?
1-4 stage = treat normal
stage 5 = higher bleeding risk with anticoagultion
What can lead to pericarditis and what should they be put on?
Uremic patients
Put on hemodialysis
What is the typical pattern of mineral metabolism disorders in CKD?
Hyperphosphetmia
hypo
Hypocalcemia (secondary hyperparthyroidism d/t low calcium)
sometimes you just see hyperparathyroidism w/out low calcium d/t PTH kicking in
What is osteitis fibrosa cystica
bones get eaten by osteoclast (high bone turnorver), leading to bone pain and muscle weakness
Adynamic bone disease
low bone turnover
Suppression of PTH or low endobonegenous PTH
Osteomalacia
- lack of bone mineralization
In the past → aluminum toxicity
Currently → due to hypovitaminosis D, bisphosphonates
What is a brown tumor?
Osteitis fibrosa cystica
Areas of bone have more calcium pulling out
What does osteomalacia look like on CT?
Look over exposed, but it is just d/t low calcium
If you have mineral metabolism problems, what should control first
Control phosphorus
less meats, dark colas, baked goods, frozen dinners
If this does not work, you go to oral phosphorus binders
What are the oral phosphate binders?
Calcium carbonate/acetate (with each meal)
Non-calcium-based (sevelamer or lanthanum)
Aluminum hydroxide (but can lead to osteomalacia, only for really sick patients)
Iron-based agents
After getting phosphorus under control, what should you control next?
Manage hyperparathyroidism
What meds do you use for hyperparathyroidism and what do you measure?
Vitamin D3 (calcitro, animal-derivedl)
Cinacalcet to
If a patient has iron deficiency, what do you do?
Oral iron or IV iron if needed
What is the goal Hb if you have EPO?
10-11
Watch for HTN
How does CKD lead to hypocoaguability?
Normally controlling anemia helps platelets, we don’t treat this typically
Why can severe proteinuria lead to hypercoagubility?
Losing protein C and S
When does hyperkalemia typically manifest?
Stage 4-5
How do you manage chronic hyperkalemia?
List of low and high potassium foods
Loop diuretics can decrease potassium
How can CKD lead to metabolic acidosis?
Not enough tubules to get rid of acid
What type of food should you not eat with metabolic acidosis? What if this does not work by itself?
Less meat, eggs
Can give sodium bicarbonate, but can lead to swelling
How to treat uremic encephalopathy?
Dialysis
How do you treat uremic neuropathy?
dialysis
control of neuropathic pain with (TCAs and anticonvulsants)
present the same as DM neuropathy
Dietary restrictions in CKD
Decrease protein
Decrease sodium (if decreased too far, they get volume depleted and BP goes down)
What meds should we not use in CKD?
Magnesium or phosphorus containing laxiditives
NSAIDs
IV contrast
Nephrotoxic agents
Renally excreted drugs
When do you consider dialysis?
Considered at 10
Normally based on uremic symptoms
fluid overload unresponsive
can’t be controlled essentially
What are the two types of dyalsis?
Hemodyalsis
Periodyalsis (through peritenum)
After transplanting kidney, what do you need to do?
Need to put on immunosuppressive regimen
Need to be along with a specialistic
What do you use to filter blood for hemodialysis?
Dialysate that is based on the patient’s electrolyte
How do you allow vascular access for hemodyalsis?
Arteriovenous fistula (preferred)
Lasts longest
Requires 6-8 wks for maturation after surgical construction
Prosthetic graft
Shorter duration, but only needs 2 wks to mature
Higher risk of infection, thrombosis, aneurysm than fistulas
Indwelling vascular catheter
Very high risk of infection
Temporary only
What is the MC dyalsis?
Hemodyalsis
What is peritonitis?
MC complication of dialysis d/t infection of peritoneum of staph
leads to abdominal pain, cloudy urine, treatment based on AB therapy
