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CKD - Part I - Exam 1 Flashcards

1
Q

Define CKD. Give all three version. What is CKD a result of?

A

-The presence of markers of kidney damage for 3+ months, could be structural or functional abnormalities that lead to decreased GFR, abnormalities of blood, urine, imaging or biopsy results

  • hx of renal transplant
  • The presence of GFR <60 mL/min/1.73 m2 for 3+ months with or without other signs of kidney damage

CKD is the result of nephron overwork injury

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2
Q

T/F: GFR will always be abnormal if there are kidney imaging/biopsy abnormalities.

A

FALSE!! GFR can be normal if other signs
of abnormal kidney are present!

Decline in function usually
persists even if cause is removed

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3
Q

What is the pathophys behind CKD? What is the cause behind these changes?

A

number of functional nephrons decrease which leads to hyperfiltration and hypertrophy of the remaining nephrons, hypertrophy hinders filtering abilities and inflammation and fibrosis ensure

RAAS

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4
Q

What is happening in “Renal Rebound?”

A

nephrons replaced by scar tissue cannot be regenerated. BUN, creatinine and GFR might improve due to removal of whatever was harming the kidneys but does NOT reflect the restoration of renal tissue just that the disease burden was removed from the still-functioning nephrons

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5
Q

What are the top 2 causes of late-stage CKD?

A

DM and HTN/vascular dz

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6
Q

CKD is an independent risk factor for ______. ______ increases risk of CV mortality

A

CVD

Proteinuric CKD

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7
Q

What are the 6 risk factors for CKD?

A

older age
sub-Sarahan African ancestry
Previous episode of AKI
+ family hx of renal disease
Smoking
Lead exposure

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8
Q

_____ and _____ are extremely closes related and have significant influence on each other.

A

heart and kidneys called cardiorenal or renocardiac syndrome based on whatever system was affected first, comes first in the name of the syndrome

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9
Q

The newer staging recommendations for CKD are based on ______ and _______. Higher levels of ______ = higher mortality risk

A

GFR and albuminuria

albuminuria= higher risk of mortality and more advanced CKD regardless of GFR

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10
Q

**What are the stages of CKD? What is important to note about stages 1 and 2?

A

stages 1 and 2 MUST have anatomy related changes with NORMAL GFR. Such as albuminuria/polycystic kidney

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11
Q

What are the albuminuria staging? When should you order this test specifically?

A

should be ordered annually for DM pts

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12
Q

**What is the prognosis of CKD by GFR and albuminuria categories chart. Know this chart!!

A
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13
Q

How will an early/mild CKD pt present? **What is the MC PE finding in CKD overall? In later stages of CKD, ____ and _____ will be present.

A

asymptomatic

**HTN

volume overload and s/s of uremia (nausea, vomiting, fatigue, anorexia, weight loss, dysgeusia (bad taste in the mouth), chest pain, palpitations, dyspnea, muscle cramps, restless legs, pruritus, easy bleeding, or mental status changes)

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14
Q

When would you see uremic frost? What is it? How common is it?

A

late CKD not on dialysis, crystallized urea excreted in sweat

RARE

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15
Q

What are some common urinalysis findings in CKD?

A

Broad, waxy casts (dilated nephrons)
Proteinuria often present; glucosuria may be present

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16
Q

Name some common findings if renal imaging is abnormal. What is Cr/GFR doing?

A

Polycystic kidneys
Small kidneys ( < 9-10 cm )
Asymmetric kidneys (vascular disease)

Cr/GFR can be normal even in the presence of abnormal kidney imaging

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17
Q

What are the treatment goals for CKD?

A

slow progression!!

reduce intraglomerular HTN

reduce proteinuria

avoid further injury

control blood glucose

adjust med doses

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18
Q

What are ways to reduce proteinuria in CKD?

A

ACE/ARB
SGLT-2
Mineralocorticoids - nonsteroidal preferred
Finerenone (Kerendia)
Diet changes - plant-based protein, low sodium

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19
Q

What do you need to be monitoring when putting a pt on ACE/ARB for proteinuria?

A

that K stays normal becuase ACE/ARB reduces K excretion leading to increased levels in the body leading to hyperkalemia

also need to monitor BP that it does not drop too low

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20
Q

What mineralcorticoid is preferred to reduce proteinuria in CKD?

A

Finerenone (Kerendia)

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21
Q

**What medication specifically mentioned in class needs to be adjusted when GFR falls below 30? What is the pt at risk for?

A

Metformin - if GFR falls too low (<30)

lactic acidosis

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22
Q

80% of CKD pts die before needing dialysis, primarily due to ______. What are some common complications?

A

CV disease

Hypertension (HTN)
Coronary Artery Disease (CAD) / Hyperlipidemia
Heart Failure (HF)
Atrial Fibrillation
Pericarditis

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23
Q

_____ is the MC complication of CKD. What makes it worse? What is the goal?

A

HTN

hyperreninemia

Goal - < 130/80 (or 140/90) mmHg

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24
Q

What does salt intake need to be below?

A

2300 mg/day

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25
**You start a pt on ACE/ARB for HTN related to CKD, what do you need to monitor? When is it indicated to stop med?
**Check serum Cr and K+ in 7-14 d - starting or ￪ dose (usually after 1 week) Hyperkalemia or >30% Cr increase - reduce or stop
26
______ are nearly always needed in HTN due to CKD. Which ones are preferred for early CKD? Late CKD?
diuretics Thiazides - early CKD Loop - more effective in later CKD (GFR < 30)
27
Overdieresis due to diuretics can lead to ______
AKI
28
What lipid in particular is a primary finding in CKD? _____ is especially found in ESRD. _____ are recommended for most pts.
hypertriglyceridemia Accelerated atherosclerosis statins
29
_____ increased rhabdomyolysis risk when paired with statins in CKD pts
Fibrates do not use fibrates and statins together in CKD pts!!
30
What does increased cardiac workload in CKD lead to? CKD pts are at a higher risk for _______ compared to non-CKD pts. Why?
Leads to LVH and diastolic dysfunction Digoxin toxicity Due to electrolyte disturbances common in CKD
31
_______ or _____ medications can help with progression of HF
ACE/ARB, SGLT2
32
Disproportionately high rates of _______ in late-stage and end-stage CKD. These pts have a _______ risk with anticoagulation.
atrial fibrillation higher bleeding risk
33
______ heart complication may develop in uremic patients. What are two s/s?
Pericarditits retrosternal chest pain, friction rub
34
What is cardiac tamponade? What CKD condition is it commonly associated with?
a medical emergency that occurs when fluid builds up in the sac around the heart, compressing it and preventing the heart ventricles from expanding full pericarditis due to CKD
35
What are 3 things you will find in uremic pericardial effusion. What do you need to avoid and why? ______ may develop
pulsus paradoxus, enlarged cardiac silhouette, low voltage QRS Effusions are generally hemorrhagic - avoid anticoagulants cardiac tamponade
36
What is the tx for pericarditis?
hospitalization and initiation of hemodialysis
37
What are some mineral metabolism complications due to CKD?
Abnormal calcium, phosphorus, PTH, active vitamin D high: phosphatemia and PTH low: Vit D and calcium
38
Why is the phosphate high in CKD? Why is Vit D and calcium low?
high phosphate due to decreased excretion by the kidney low vit D due to decreased production by the kidney, calcium is low because of decreased calcium gut absorption due to low vit D
39
What is secondary hyperparathyroidism?
Secondary hyperparathyroidism is when your parathyroid glands release too much PTH due to kidney problems, causing weak bones and calcium buildup in your body
40
_____ is the MC form of renal osteodystrophy. What is it due to? What will they look like on Xray?
Osteitis fibrosa cystica Due to hyperparathyroidism → osteoclast stimulation increases rates of bone turnover "brown tumors"
41
What is adynamic bone disease due to?
low bone turnover due to suppression of PTH or low endogenous PTH
42
What is osteomalacia? What will it look like on xray?
lack of bone MINERALIZATION In the past → aluminum toxicity Currently → due to hypovitaminosis D, bisphosphonates softening of bones
43
What is the first step in treating the mineral metabolism dysfunction associated with CKD?
control hyperphosphatemia Phosphorus ≥ 4.5 mg/dL or ≥ 5.5 mg/dL in ESRD restrict dietary phosphorus: Meats (especially processed) Colas Baked goods/mixes Fast food Frozen premade foods
44
After pt restricts dietary phosphorus intake the phosphorus remains high, what do you do next? What is the MOA? Is it safe to use with calcium-based phosphate binder?
Sevelamer or Lanthanum Block absorption of phosphorus in GI tract; dosed TID with meals YES! Safe to combine with calcium-based phosphate binder
45
What is the MOA for calcium carbonate or calcium acetate? When are they used? What is the SE?
Block absorption of phosphorus in GI tract; dosed TID with meals in hyperphosphorus May cause increased vascular calcification, hypercalcemia
46
_______ are highly effective binder but limited due to SEs of osteomalacia and neuro complications. Name 2 scenarios in which they are used
Aluminum hydroxide May use if severe hyperphosphatemia (>7 mg/dL) or short periods (< 3 weeks)
47
______ and ________ are iron based agents that work as adjunct in hyperphosphorus tx, only have limited evidence
ferric citrate and sucroferric oxyhydroxide
48
What is the second step in managing mineral metabolism dysfunction in CKD?
manage PTH by giving Vit D that will increase calcium which will turn off the PTH negative feedback loop that will eventually decreased PTH increase Vit D, increase Cal = decrease in PTH
49
What effect does vit D have on calcium and phosphorus?
vit D will increase calcium and phosphorus so need to monitor
50
______ is given to decrease PTH levels if cannot give Vit D due to increased phosphorus or calcium. What is the MOA? May cause _______
Cinacalcet (Sensipar) Targets calcium-sensing receptors of parathyroid gland may cause hypocalcemia
51
Are goal PTH levels higher or lower in late CKD? Why?
goal PTH levels are higher to avoid adynamic bone disease
52
Why is anemia commonly seen in CKD? What stage does it often becomes a problem? What kind of anemia is common?
EPO is made/secreted by the kidneys becomes significant during stage 3 CKD iron deficiency anemia
53
**_________ blocks GI iron absorption and mobilization of iron from body stores. This will be (elevated/reduced) in CKD pts
hepcidin elevated in CKD patients aka the body has plenty of iron but it is not being ultilized due to high level of hepcidin
54
What do you need to check before given EPO to a CKD pt?
Adequate iron stores necessary before erythropoiesis - stimulating rx
55
In CKD ferritin < _____ OR iron saturation < _____ is iron deficiency. do not give iron supplementation if ferritin > _______
Ferritin < 100-200 ng/mL OR iron saturation < 20% = iron deficiency ferritin >500-800 ng/mL
56
What is the function of ferritin?
Ferritin, an iron storage protein, is the primary iron storage mechanism and is critical to iron homeostasis. Ferritin makes iron available for critical cellular processes while protecting lipids, DNA, and proteins from the potentially toxic effects of iron.
57
What is the preferred tx for iron deficiency anemia in CKD? _______ is FDA-approved for CKD anemia
oral therapy: Ferrous sulfate, ferrous gluconate, or ferrous fumarate Auryxia (ferric citrate)
58
What is the goal Hb in CKD? What does a higher hg increase your risk of? Give two medications that are used to increase Hg.
Goal Hb of 10-11 g/dL Higher Hb goal → increased risk of CV events epoetin (recombinant erythropoetin) - given 1-2x/week darbepoetin - given every 2-4 weeks
59
CKD pt's blood is _______ mainly due to ______. What are some PE findings? What is the tx?
Hypocoagulability platelet dysfunction Prolonged bleeding time, petechiae, purpura desmopressin (mainly used before sx) or dialysis -> will improve bleeding time
60
a CKD pt's blood will be ______ if severe proteinuria is present
hypercoagulable
61
________ usually manifests in stage 4-5 of CKD due to triamterene, spironolactone, NSAIDs, ACE, ARB or BBs. Name some additional causes. What is the tx?
Hyperkalemia high potassium diet, DM pts, hemolysis, rhabdomyolysis Reduce or stop medications that affect K+ metabolism Loop diuretics (if not volume-depleted)
62
What is metabolic acidosis in CKD due to ?
Loss of ability to excrete acid in the urine Primarily due to loss of renal mass
63
What bone disease is associated with CKD induced metabolic acidosis? Why?
Contributes to renal osteodystrophy Calcium pulled from bones to help buffer acidosis
64
What is the tx for CKD induced metabolic acidosis?
Maintain serum bicarbonate at > 21 mEq/L Oral sodium bicarbonate - given BID
65
What is a neurologic complication of CKD? What GFR is normally associated with it? What is the tx? What are some s/s?
Uremic Encephalopathy: Due to aggregation of uremic toxins Usually not seen till GFR < 5-10 mL/min/1.73m2 dialysis difficulty concentrating, lethargy, confusion seizure, coma, AMS, weakness
66
______ is distal, symmetrical, mixed peripheral neuropathy due to CKD. What are some s/s? Which comes first, sensory or motor?
Uremic Neuropathy Initial - loss of position and vibration sense in toes, decreased DTRs Sensory - paresthesias, burning, pain, RLS Motor - may lead to muscle atrophy, myoclonus, eventual paralysis Sensory precedes motor
67
How do you dx uremic neuropathy? What is the tx?
electrophysiologic studies dialysis, TCAs, anticonvulsants
68
which uremic neuropathy specifically will improve with tx of anemia and iron deficiency?
restless leg syndrome
69
What effect does CKD have on insulin? What is the pt at risk for?
decreased renal clearance of insulin (make need to adjust dose of oral meds and insulin) increased risk of hypoglycemia
70
When do you need to d/c metformin in CKD? Due to increased risk of _______. At what GFR should you NOT start this medication?
discontinue after serum Cr > 1.4-1.5 or GFR < 30 Increased risk of lactic acidosis DO NOT START metformin if GFR is below 45
71
If a CKD pt becomes pregnant, what is the outcome? What increases chances of healthy pregnancy?
if serum Cr >1.4, CKD may progress faster Fetal mortality almost 50% in female ESRD pts Surviving infants are often premature kidney transplant
72
What are the dietary restrictions in CKD?
restrict: -protein -sodium -water if volume overloaded -potassium if GFR is below 10-20 OR hyperkalemia -phosphorus
73
At what GFR are phosphate binders usually needed?
If GFR <20-30 mL/min - phosphate binders usually needed
74
What magnesium containing drugs do CKD pts need to avoid? What pain medication needs to be avoided?
laxatives, antacids, morphine
75
What are the 2 different types of dialysis? What GFR level is dialysis indicated?
hemodialysis and peritoneal When GFR reaches 5-10 mL/min/1.73m2
76
What are some clinical indications for dialysis?
uremic symptoms: pericarditis, encephalopathy, neuropathy Persistent metabolic disturbances refractory to medical therapy: Hyperkalemia, hyponatremia, metabolic acidosis, hyperphosphatemia, hypercalcemia or hypocalcemia fluid overload that does not respond to diuretics
77
What are some factors that determine renal transplant match? What is required post transplant?
ABO blood groups and major histocompatibility Age and race of recipient, age of donor Comorbidities (hyperlipidemia, HTN, CMV) Length of time spent on dialysis immunosuppressive regimens and following with a transplant nephrologist
78
What is hemodialysis? What is the cleansing solution called?
a constant flow of blood along one side of a semipermeable membrane diffusion and convection → removal of unwanted substances in blood and replacement of needed substances Dialysate
79
What are the different types of vascular access for hemodialysis? Which one is preferred?
Arteriovenous fistula** preferred -lasts longer but required 6-8 to mature after surgical construction Prosthetic graft - only needs 2 weeks to mature - higher risk of infection Indwelling vascular catheter - VERY high risk of infection and temporary only
80
_____ is the MC form of dialysis for ESRD
hemodialysis
81
How does peritoneal dialysis work? ______ as a dialyzer.
Dialysate put in peritoneal cavity via indwelling catheter Water and solutes move across capillary bed in peritoneum between blood and dialysate Dialysate is periodically drained and new dialysate instilled peritoneal membrane
82
What are some benefits and risks of peritoneal dialysis?
benefits: - Increased patient autonomy - continuous so less volume and electrolyte shifts - less diet restrictions because compounds are better cleared -transportation is not an issue because it can be done at home risks: - removes large amount of albumin - must have mental capacity to understand and complete exchanges - must NOT have intra-abdominal scarring/adhesions - risk of peritonitis**** MC complication
83
What are the different types of peritoneal dialysis?
Continuous Ambulatory Peritoneal Dialysis (CAPD) - patient manually exchanges dialysate 4-6x/day Continuous Cyclic Peritoneal Dialysis (CCPD) - cycler machine automatically exchanges dialysate at night
84
______ is the MC complication of peritoneal dialysis. How do you dx? What is the MC organism? What is the tx?
Peritonitis peritoneal fluid >100 WBC/mcL (with >50% PMNs)- may culture fluid staph aureus- MC. Strep is also common tx: abx
85
What is the life expectancy for a pt with ESRD and on dialysis? What is the MC cause of death? What are some poor prognostic indicators?
Estimated life expectancy - 3-5 years cardiac disease (>50%) DM advanced ag hypoalbuminemia low socioeconomic status inadequate dialysis high fibroblast growth factor
86

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