CKD, nephrotic Flashcards
What are the two leading causes of kidney disease
- HTN
- Diabetes
who is at risk for CKD
- diabetes
- HTN
- cardiovascular disease
when is someone in kidney failure
- GFR < 15
- signs and symptoms of uremia
Define chronic kidney disease
- kidney damage or decreased kidney function for 3 or more months
- GFR < 60 mL/min
- Evidence of kidney damage
- albuminuria: urine albumin-creatinine ratio > or = 30 mg/g
- abnormal imaging tests
- abnormal urinary sediment
what is the best marker of kidney function
GFR
classify CKD into stages based on declining GFR
- Stage 1: GFR > 90 with persistent albuminuria
- Stage 2: GFR 60-89 with persistent albuminuria
- Stage 3: GFR 30-59
- Stage 4: GFR 15-29
- Stage 5: GFR < 15 or dialysis
Normal to mildly increased albuminuria Stage 1 will have what ACR (urine albumin to creatinine ratio) and protein dipstick
- ACR < 30
- protein dipstick: neg to trace
Moderately increased albuminuria Stage 2 will have what ACR (urine albumin to creatinine ratio) and protein dipstick
- ACR: 30-300
- Protein dipstick: trace to 1+
severely increased albuminuria Stage 3 will have what ACR (urine albumin to creatinine ratio) and protein dipstick
- ACR: > 300
- protein dipstick: >1+
progressive nephron and GFR loss leads to abnormalities in production and metabolism of what hormones
- erythropoietin
- calcitriol (active form of vit D)
patients who are at risk for developing CKD should be screened for
- urine albumin-to-creatinine ratio
- serum creatinine to estimate GFR (eGFR)
What is uremic syndrome? What are some critical symptoms
- profound disease in GFR < 5-10
- build up of metabolic waste products
- critical symptoms
- pericarditis
- sz
- encephalopathy
what kidney size on renal US implies CKD
< 10 cm
- kidney normally 10-12 cm
How can ARB/ACE-I be helpful in patients with kidney disease
- renoprotective
- helpful in slowing progressive of CKD
- decrease albuminuria
How can ARB/ACE-I be harmful in patients with kidney disease
- exacerbation of renal failure
- hyperkalemia
- contraindicated in bilateral renal artery stenosis
Patients who have proteinuric CKD should be treated more aggressively. What is the target BP in patients with proteinuria and those without proteinuria.
- CKD, no proteinuria: < or = 140/90
- CKD, + proteinuria: < or = 130/80
How can CKD lead to mineral and bone disorder (CKD-MBD)
- CKD -> hypocalcemic, hyperphosphatemia and low vit D ->
- secondary hyperparathyroidism
- renal osteodystrophy
- abnormalities in bone turnover
list some complications of CKD
- cardiovascular disease
- HTN
- anemia
- mineral and bone disorders
- hyperkalemia
- metabolic acidosis
- uremia
- fluid and salt retention
What are the two types of renal replacement therapy
- for patients with kidney failure (ESRD)
- dialysis
- hemodialysis
- peritoneal dialysis
- kidney transplant
At what GFR is dialysis considered
GFR < 30
When is chronic dialysis indicated
- Uremia (pericarditis, encephalopathy)
- Fluid overload unresponsive to diuretics
- HTN- med resistant
- Refractory acidosis, hyperkalemia, and hyperphosphatemia
- Progressive deterioration in nutritional status
Describe the process of hemodialysis
- requires a constant flow of blood along one side of a semipermeable membrane with a cleansing solution, or a dialysate, along the other
- removal of unwanted substances from blood while adding back needed components
Complications of hemodialysis
- hypotension
- dialysis disequilibrium syndrome
- HA, N/V, lethargy
- arrhythmias
- clotting/bleeding
In peritoneal dialysis, what is the dialyzer
the peritoneal membrane
explain the process of peritoneal dialysis
- dialysate is instilled into peritoneal cavity via indwelling catheter
- peritoneal membrane acts as partially permeable membrane
- diffusion and osmosis drive waste products and excess fluid through peritoneum into dialysate until reaches equilibrium
- dialysate is drained
- *3-4 x/day
complications of peritoneal dialysis
- peritonitis
- exit site infection
- poor dialysate drainage
what is the treatment of choice for ESRD
kidney transplant
When do you refer a patient with CKD to a nephrologist
- GFR < 30
- refer to
- manage complications
- EPO therapy
- bone and mineral metabolism abnormalities
- resistant HTN
- prep for dialysis
- transplant eval
- manage complications
Name some interventions to delay progression of CKD
- ACE-I, ARB
- BP control
- glycemic control
- protein resistriction
What characteristics are associated with chronic tubulointerstitial disorders
- interstitial chronic inflammation
- intersititial fibrosis
- tubular atrophy
What characteristics are essential to diagnosis of chronic tubulointerstitial disorders
- kidney size small and contracted
- decreased urinary concentrating ability
- hypercholermic metabolic acidosis
- reduced GFR
What are the most common causes of chronic tubulointerstitial disorders
- obstructive uropathy
- reflux nephropathy
What causes obstructive uropathy
- prolonged obstruction of urinary tract
- obstruction -> decrease in renal blood flow, GFR and impaired tubular function
- stones
- bladder outlet obstruction
- carcinoma of cervix, colon, or bladder
what imaging modality would you get to assess for obstructive uropathy
- US
- detect mass lesions
- hydroureter
- hydronephrosis
What are common causes of reflex nephropathy
- vesicoureteral reflux (VUR): urologic abnormality in childhood
- hx of recurrent UTI -> scarring is associated with intrarenal reflux
- typically goes unnoticed until early adulthood
Ingestion of what medications can cause analgesic nephropathy? What is the minumum dose they have to take
- Aspirin and NSAIDs
- ingestions of at least 1g/day for 3 years
clinical presentation
- hematuria
- mild proteinuria
- polyuria ( inability to concentrate urine due to tubular damage)
- anemia
analgesic nephropathy
What are three common general findings of all chronic tubulointerstitial disorders
- polyuria
- inability to concentrate urine secondary to tubular damage
- hyperkalemia
- decreased GFR
- distal tubules become resistant to aldosterone
- UA is nonspecific
- proteinuria ( < 2 g/d), broad waxy casts
Define Nephrotic syndrome
- Noninflammatory damage to glomerular capillary wall (podocyte and glomerular basement membrane)
Nephrotic syndrome is characterized by what 5 things
- Heavy Proteinuria: > 3.5 g/d
- Hypoalbuminemia
- Edema
- Hyperlipidemia
- Lipiduria
What are the three primary disease that cause Nephrotic syndrome
- Minimal change disease
- Membranous Nephropathy
- Focal Segmental Glomerulosclerosis
What are the two secondary diseases that cause Nephrotic syndrome
- diabetic nephropathy
- amyloidosis
What are complications Nephrotic syndrome
- Hypercoagulability -> thrombosis
- Vit D deficiency and hypocalcemia
- infection
- malnutrition
- anemia
what would you characteristically see in urine microscopy in a patient with Nephrotic syndrome
- oval fat body: represents lipiduria
What is initial diagnostic imaging modality for Nephrotic syndrome
renal US
What is the most common cause of proteinuric renal disease in children
Minimal change disease
cause of Minimal change disease
idiopathic (80-90%)
what is Minimal change disease
- injury to glomerular epithelial foot processes (podocyte)
tx of Minimal change disease
-
Predinose
- often treated empirically without biopsy
- progression to ESRD is rare
Causes of Membranous Nephropathy
- idiopathic
- secondary
- autoimmune, infection, malignancy
- seen in all ethnic and racial groups and in both sexes
What histopathology is seen with Membranous Nephropathy
- diffuse thickening of the GBM in the absence of significant hypercellularity/glomerular inflammation
tx of Membranous Nephropathy and Focal Segmental Glomerulosclerosis
- supportive
- +/- immunosuppresive medication
What is Focal Segmental Glomerulosclerosis
- renal pattern of injury resulting from damage to podocytes
- Glomerulosclerosis = hardening -> scarring
Focal Segmental Glomerulosclerosis normally affects what patient population
- african american
- M >F
how is Focal Segmental Glomerulosclerosis diagnosed
- diagnosis is established definitively with biopsy
- segmental solidification of glomerular tuft
- injury to podocyte -> collapse of glomerular capillaries -> scarring
Diabetic Nephropathy presents with what clinical syndrome
- persistent albuminuria
- progressive CKD
- +/- retinopathy
peak incidence of Diabetic Nephropathy
persons who have had diabetes for 10-20 years
how does diabetes lead to Diabetic Nephropathy
- long standing hyperglycemia -> development of albuminuria
tx of Diabetic Nephropathy
- strict glycemic control
- BP control
- ACE-I/ARB
- dialysis and transplant when indicated
What is Amyloidosis
- extracellular deposition of an abnormally folded protein (amyloid)
how does amyloidosis lead to nephrotic syndrome
glomeruli are filled with amorphous deposits -> proteinuria and decreased GFR
how is amyloidosis diagnosed
- serum and urine protein electrophoresis
