CKD/Renovascular Hypertension Flashcards
Chronic Kidney Disease
general
15% of all Americans have CKD
Abnormal kidney function > 3 months
Usually asymptomatic until near end stage
Primary cause is DM, HTN, ASCVD
Progressive decline in kidney function
CKD is independent risk factor for CAD
Proteinuric CKD is ominous- worse prognosis
Most patient stage 3 CKD die from ASCVD before ESRD
Abnormal kidney function: GFR < 60mL/min or proteinuria, albuminuria
CKD
Abnormal renal studies
> 3 months
Elevated BUN
Elevated Creatinine
Albumin in urine
Elevated UACR
Cystatin C
RBC or WBC casts; broad waxy casts seen in ESRD
Trending labs is very important, especially stage I and II
CKD
RF
Diabetes mellitus
Hypertension
Chronic NSAID use
Glomerulonephritis
Polycystic kidney disease
Systemic Lupus Erythematous
Hx Kidney transplant
Chronic Kidney Disease
Causes
Diabetes mellitus, hypertension, glomerulonephritis, polycystic kidney disease, SLE, nephrotoxins, multiple myeloma, HIV, chronic pyelonephritis, renal artery stenosis, nephrolithiasis, prostate disease, neurogenic bladder
* hx of previous AKI ( esp within 1 year) increases risk of another AKI event/ CKD)
CKD
Symptoms
Fatigue, malaise, anorexia, nausea, vomiting, metallic taste, hiccups, DOE, irritability, muscle cramps, restless legs, weakness, pruritis, easy bruising, altered mentation
- Stages I-IV asymptomatic!
CKD
Physical exam
Weight loss, edema, muscle wasting, pallor, ecchymosis, bruit
Arterial narrowing and AV nicking seen in early HTN while flame hemorrhages seen later; papilledema occurs when there is increased intracranial pressure
CKD
Labs
BMP: electrolytes, bun, creatinine; Calculation of GFR (Cockcroft gault formula vs MDRD)
Urinalysis: proteinuria, albuminuria; spot UACR
Urine microscopy: waxy casts
CBC: anemia
Other: PTH, vitamin D, Ca, phosphate, lipids, Hgb, Mg
CKD
imaging/dx
Ultrasound: reduced renal cortical thickness < 6mm’ small, echogenic kidney BIL
Biopsy: only when suspect glomerular or tubulointerstitial disease; risk is important to consider; risk increases if kidney < 9 cm
CKD
Tx and goals
ACE-I and ARBS
BP control < 130/80 ( ACC/AHA/ADA) < 120/80 (KDIGO)
HgA1c < 7.0, LDL < 100 mg/dL, HDL > 50 mg/dL, Triglycerides < 150 mg/dL; Hgb 11-12 g/dL
Statins if > 50 yoa (non-hemodialysis patients) MIT
SGLT-2 (GFR > 20)
GLP-1 (additional cardiovascular risk reduction; DKD)
Non-MRA (if DKD) : Finerenone (Kerendia)
Avoid nephrotoxic drugs
Restricted protein, Na ( < 1.5 g) K diet- poss Ca and Vit D supplement
Dc tobacco, weight control
Vaccinations: Pneumococcal, HBV, influenza, COVID-19
Hemodialysis
Kidney transplant
CKD
green is for DM II
CKD pearls
In patients with CKD pay attention to Rx!!! Do NOT want to cause an AKI and renal function is very dynamic
Antibiotics:
Augmentin : avoid 875mg with CrCl< 30; use 250-500 mg
Amoxicillin: 250-500 mg po q 12 if CrCl< 30
Doxycycline: requires no dose adjustment
Azithromycin: requires no dose adjustment
Clindamycin: requires no dose adjustment
Clarithromycin: reduce dose by 50% if CrCl<30
Ciprofloxacin: reduce 500 mg q 24 hours CrCl < 30
Levaquin: reduce dose to q 48 hours CrCl < 50
Bactrim: reduce usually dose 50% CrCl <30
Nitrofurantoin: contraindicated GFR < 60?
Metronidazole: adjust CrCl< 10
Cephalexin
Tamiflu
Gout
Allopurinol: reduce 50 mg daily CrCl < 60
Colchicine: avoid GFR , 30
Indomethacin: avoid GFR < 60
*drug of choice for gout flare if CKD GFR < 30 is prednisone ( no dose adjustment)
Pain Control
Meloxicam: reduce CrCl < 20
Ibuprofen: avoid GFR < 60
Naproxen: avoid GFR < 30
Percocet: reduce dose q 12 if GFR < 30
Tylenol with codeine: no adjustment
CKD
Refer to nephro when
GFR < 30 mL /min
UACR > 300mg/g
Urine
Protein/creatinine ratio > 500 mg/g
CKD
Annual screenings
Diabetes Mellitus
Hypertension
Coronary artery disease
Age >
Obesity
Family hx CKD
Polycystic kidney disease
Systemic lupus erythematous
CKD
SCREENING TESTS
Screening for CKD includes measurement of serum creatinine, estimation of GFR using a serum creatinine-based equation, measurement of the urine albumin/creatinine ratio, and urinalysis.
Urinalysis has a high sensitivity for heavy proteinuria (greater than 300 mg per 24 hours, as estimated from the spot urine protein/creatinine ratio) but may not detect clinically significant lower levels (30 to 300 mg).
Because albumin is the predominantly filtered glomerular protein, initial proteinuria evaluation using the spot urine albumin/creatinine ratio obtained from an early morning sample is recommended
Timed 24-hour urine collections are no longer recommended as an initial diagnostic tool because of the potential for inadequate collection, inconvenience to patients, and the lack of diagnostic advantage over the urine albumin/creatinine ratio.- AAFP.org
not sure if this matters
CKD stage 1 - IV
Tx and goals
Yearly BMP, UACR, Lipids
BP < 120/80 ( ace/arb); NA < 1.5 g daily
Statin: moderate intensity pts > 50 yoa GFR < 60ml/min
Low dose asa if low bleeding risk?
Current vaccinations
Remember risk for ASCVD!!!
CKD stage III and IV
Monitoring
Yearly BMP, UACR, Lipids, PTH, calcium, Vitamin D, CBC, phosphorus
Complications of stage IV/V CKD
Anemia: decreased erythropoietin production
Check iron levels first! If therapeutic, consider erythropoietin
* use the lowest dose of erythropoietin possible as increases ASCVD risk
The goal is to maintain Hgb > 11 g/D
low iron may start on oral with Ferrous sulfate or give IV
Hyperkalemia
Dietary counseling; avoidance ACE-I/ARB; Spironolactone
K binding agents: sodium polystyrene sulfonate ( kayexalate), sodium zirconium cyclosilicate (Lokelma), patiromer ( Veltassa)
Acidemia
Consistent serum bicarbonate < 20 mEq/dl
Oral bicarbonate solution/tablets- weight based
caution with oral bicarbonate replacement as cause increase fluid retention leading to HTN and edema
Secondary hyperparathyroid
Develops in response to low Ca++
Calcitriol, paricalcitol, deoxercalciferol
Goal PTH 150-300pg/mL
Elevated phosphorus
Dietary modification
renal osteodystrophy: low Ca+ high Phosphate+ elevated PTH: pathological fractures
Oral phosphate binders with meals: calcium carbonate or calcium acetate if calcium is not elevated; sevelamer (Renagel) if elevated Calcium and phosphate levels
Phosphate goal < 5.5
Hypocalcemia
Decreased calcitriol horomone thus decreased reabsorption of ca in nephrons and gi tract
Leads to bone break down and osteoporosis-
Oral calcium carbonate or calcium acetate 550 mg -1 g TID with meals
Low vitamin D
Oral replacement tx
Ergocalciferol if vitamin D < 30ng/mL
Complications of stage IV/V CKD
Renal Osteodystrophy
Osteitis fibrosa cystica
Osteomalacia
Presentation: pathologic fractures, chondrocalcinosis, bone and proximal muscle pain
CKD- Renal Osteodystrophy
Labs and imaging
Diagnosis:
Labs: elevated PTH, hypoCa, elevated phosphate
Xray: periosteal erosions, bony cysts ( thin trabeculum and cortex), punctate trabecular bone resorption in skill ( “salt and pepper” skull)
CKD- Renal Osteodystrophy
Tx
Phosphate binders (calcium carbonate, calcium acetate, sevelamer) goal Phosphate < 5.5
Supplement Vit D ( calcitriol ) and calcium
Cinacalcet (decreased PTH)
CKD
Vascular Calcifications
CKD patients have increase in arterial calcifications which reduces vascular compliance contributing to left ventricular hypertrophy
Increases CVD risk
*Sevelamer- use if elevated CA and Phosphate
Chronic Kidney Disease “no no’s”
NSAIDS, COX-2
Proton pump inhibitors ( in CKD 4 or later)
Magnesium-containing antacids (tums, Rolaids, Gaviscon, Alka-seltzer)
IV contrast dye
Rx: aminoglycoside, vancomycin, trimethoprim/sulfamethoxazole
Digoxin
Over the counter: magnesium citrate!!!
when GFR < 30 caution will most medications- (metformin, sulfonylureas, ace/arb, HCTZ, DOAC, fenofibrates, lovenox)
Want to prevent AKI on CKD
