CKD wk 2 & half of wk 3

Question 1

How common is CKD?

Answer 1

Very common and rising. More common than liver disease; but not focused on that much.

Question 2

What is the best available screening test for CKD? Why is this superior to eGFR?

Answer 2

a. Urine protein or albumin: need to confirm single abnormal test in 1-2 months
b. For both SCr & eGFR: by the time they are abnormal, it’s too late

Question 3

Why does albuminuria increase the risk for cardiovascular disease?

Answer 3

a. Albuminaria correlates w/ angiographic coronary atherosclerosis
b. Baseline albuminuria predicts long term CV morbidity, mortality in patients with HTN

Question 4

How does proteinuria itself contribute to kidney damage?

Answer 4

Proteinuria will disrupt the charge gradient across the glomerular membrane. This is thought to be a main filtration barrier, so disrupting it will cause even more mal-filtration.

Question 5

What are realistic outcomes of CKD patients by stage?

Answer 5

a. Early disease (stage I): stabilization, improvement IF causes are removed
b. Moderate disease (stages II, III): stabilization, mild improvement, difficulty removing causes thus frustration
c. Severe disease (stages IV, V): progressive but delayed decline, improvement in health while on dialysis

Question 6

What are the risk factors for CKD?

Answer 6

a. SAD, obesity, smoking, sedentariness

b. Main etiologies are: diabetes, HTN, glomerulonephritis, idiopathic, cystic kidney disease

Question 7

What is the overall goal of diet in patients with stage III or less CKD?

Answer 7

Whole-food, plant centered diet. Consider low carb/high protein but lower iron diet in patients w/ diabetic nephropathy

Question 8

When should you intervene to limit potassium in a CKD patient’s diet? What other intervention besides potassium limitation can be used to reduce serum potassium?

Answer 8

a. Limit K in late stage disease (IV, V)

b. Other intervention: Glycyrrhiza glabra

Question 9

When should you intervene to limit phosphorous in a CKD patient’s diet? What other interventions besides a lower phosphorous diet can be used to reduce serum phosphorous and iPTH?

Answer 9

a. Also recommended in late stage disease (IV, V)

b. Other ways to decrease phosphate: calcium acetae or carbonate, sevelamer, and lanthanum, niacinamide (B3)

Question 10

How is calcitriol safely utilized? How are patients taking calcitriol properly monitored?

Answer 10

a. Calcitriol is indicated when 1,25D3 is low & iPTH is high
b. Target spot urine Ca2+ is <350 mg

• Intact parathyroid hormone levels higher than 50 pg/mL in patients with stage 3 or 4 CKD are associated with an increased risk of death or need for renal replacement therapy.
• *iPTH is Secreted when the calcium level is low.

Give Calcitriol–>b/c–>Dec. Ca2+=>Dec. Vit. D=>Inc. iPTH=> >50 = Death & renal replacement therapy)

Question 11

How is the renin-angiotensin-aldosterone axis dysregulated in patients with CKD? What can be done to offset this?

Answer 11

In CKD, the renin-angiotensin aldosterone system is causing too much aldosterone to be formed, leading to too much water and sodium retention; this will cause GFR to decrease.

Question 12

Be familiar with ACE inhibitor and angiotensin receptor blocker (ARB) drugs.

ACE INHIBITOR–> slows (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced.

Answer 12

• **ACE inhibitors: benazepril, captopril, enalapril, quinapril, Ramipril most studied in CRF.
  1. SE: cough main one, rare ones are hypotension, hyperkalemia, elevated SCr
  2. Natural ACEi: lespedeza capitata (Round-headed Bush Clover), crataeus spp.(Hawthorn), allium sativum, gandoerma lucidum (reishi mushroom), hibiscus sabdarifa (Roselle), quercetin (flavonol)
• **ARB: losartan, irbesartan, candesartan, valsartan
  1. SE: orthostatic hypotension, HA, hyperkalemia, increased SCr

Question 13

How do G and A stages differ for characterizing CKD? Who defined these stages?

Answer 13

G refers to GFR

A refers to albuminuria

Question 14

What are the different GFR staging #’s?

Answer 14

G1a, >105 (Norm)--> (Norm GFR: >100 men or >90 women)
G1b, 90-104 (Slightly low)
G2a, 75-89 (Mild)
G2b, 60-74 (Mild)
G3a, 45-59 (Mild-Moderate)
*G3b, 30-44 (Mod-Sev)
*G4, 15-29 (Sev)
*G5, <15 (Kidney failure)

Question 15

What are the A ( albuminuria) staging #’s?

Answer 15

A1a= <10mg/g
A1b= 10-29
A2= 30-299
A3a= 300-1,999
A3b= >2000

Question 16

When should dietary protein be restricted in patients with CKD?

Answer 16

From Brignall: when patient transitions to Stage 4

Question 17

What are nephroprotective herbs? When are they indicated? How do they work?

Answer 17

a. Urtica dioica (seed), rheum palmatum, parietaria officinalis, Silybum marianum (seed), orthosiphon stamines
b. They are indicated in early stage kidney disease
c. Some are kidney trophorestoratives, mild diuretics, increase creatinine

Question 18

What parameters should you monitor in patients with stage III CKD and worse? How often? How about stage I and II CKD?

Answer 18

Stage 1 & 2: Bun/creatinine, albumin, GFR

Stage 3: In addition to above; Sodium, potassium, calcium, phosphate; blood pH, carbon diozide

Question 19

Should patients with CKD take vitamin D3? Why or why not?

Answer 19

Start to have Ca wasting at Stage 3 and PTH will go up as a response. Once this happens, activated D3 is recommended.

Question 20

Why do patients with late-stage CKD have anemia? How is this remedied? Is this a problem in early-stage CKD?

Answer 20

a. Nephron loss causes endocrine dysfunction causing loss of EPO leading to anemia
1. Can be remedied w/ EPO (but high toxicity)
2. Adaptogens & bone marrow herbs: panax, atracytylodes macrophala, wolfipori cocos, Glycyrrhiza, angelica sinensis, astragalus

b. Can be a problem in early stage CKD, but need differentiate what the cause is

Question 21

What is the potential toxicity of erythropoietin and similar agents? What is the target hemoglobin in anemic patients with late-stage CKD?

Answer 21

a. EPO potential toxicity is increasing CV events when used

b. Hemoglobin target: 10-12 g/dl

Question 22

What is an appropriate overall protocol for patients with stage I and II CKD? How does etiology change this protocol?

Answer 22

Treat the cause and prevention. Treat diabetes, HTN to prevent CKD from progressing. Focus on whole foods, plant based diet, exercise, stress reduction.

Question 23

What is an appropriate overall protocol for patients with stage III CKD? How does etiology change this protocol?

Answer 23

Still manage causative factors, calcium wasting, electrolyte balances, kidney tonics, etc.

Question 24

What is an appropriate overall protocol for patients with stage IV and V CKD? How does etiology change this protocol?

Answer 24

Limit potassium, sodium, etc. Likely to switch to more carbohydrate based nutrition. Monitor closely for when dialysis will be used.

Question 25

Management issues in earlier stages: Calcium Homeostasis:

Answer 25

Ca wasting begins in stage 3 of kidney failure 1. PTH levels go up-->inc. phosphorus absorption from food 2. Treating w/calcium or activated Vit. D can cause hypercalcemia-->HTN-->worsening kidney disease

Question 26

Management issues in earlier stages: Anemia Management:

Answer 26

Ferritin >70 makes IDA (Iron deficiency anemia) unlikely. <70=>National kidney foundation recommends EPO “erythropoietin"

Question 27

Management issues in earlier stages: Protein Intake Management: * Low protein diets have been traditional in treatment of mild-late stage renal failure * No benefit from protein restriction was seen ** As disease progresses, whole food diets can be a concern d/t potassium**

Answer 27

Dietary protein elevates GFR, you’ll see quick but small drop in GFR Biological value protein: Speaks to digestibility of protein + rate limiting essential amino acid in proportion to an index protein source (generally egg albumin) *Management: (Choose mineral management over protein management) *Limit to 0.6 g/kg/day. Sourced from high biological value protein (generally egg albumin) 1. Animal foods have highest biological value 2. Dairy & eggs over 90% 3. Meat & fish tend to be 70-80%

Question 28

Management issues in earlier stages: Sodium restriction:

Answer 28

1. Benefits of sodium restriction magnified; d/t risk for edema & need for BP medications 2. Aim for 2 g/day ***Caution: if on restriction & develop hypotension or creatinine goes up, stop restriction

Question 29

Management issues in earlier stages: Medications worsen kidney disease

Answer 29

Fluroquinolone antibiotics, NSAIDs, opiates, chemotherapy, contrast media, ACEi or ARBs, protease inhibitors, diuretics, street drugs

Question 30

Management issues in Advanced Stages: (progressing 4-->5) Alkali management: recommended for CO2 <22mM

Answer 30

a. TX: sodium citrate or sodium bicarbonate | b. Shown to slow nephropathy & important for bone mineralization

Question 31

Management issues in Advanced Stages: (progressing 4-->5) Electrolyte balancing:

Answer 31

1. Potassium abnormalities indicate end stage renal failure a. K <6 can be managed w/ low K diet b. K >6 urgent and dialysis may be imminent 2. Phosphorus restrictions below 1g/day 3. Hyperchloremia may occur secondary to bicarb loss 4. Hypermagnesium can occur late stage a. GFR <15 want to avoid supplements

Question 32

Management issues in Advanced Stages: (progressing 4-->5) Dialysis:

Answer 32

1. Assessing need: either stage 5, symptomatic or difficult to control stage 4 2. Electrolyte imbalances a. Sodium & phosphorus restriction are important 3. Protein calorie malnutrition a. 1.2-1.5 g/kg/day (1/2 biological value protein) 4. Vitamins a. B, C, D, Ca likely to be at risk b. Phosphorus, K, A likely to be very high

Question 33

Biotin (Vitamin B7)

Answer 33

1. Cofactor for carboxylation enzymes. Needed for histones & DNA replications 2. Dietary sources: legumes, nuts, root vegetables 3. Functions: utilization of insulin, elongation of fatty acids 4. Major uses: blood glucose regulation, pregnancy 5. Other uses: diabetic neuropathy, hemodialysis support, hypertriglyceridemia, brittle nails, loss of sense, cradle cap 6. Dosing: 30 mcg/day

Question 34

Folate (Vitamin B9)

Answer 34

1. Dietary sources: legumes, FDA fortification, green vegetables 2. Functions: proper genetic replication, production of normal blood cells, NOS system, one carbon metabolism, production of neurotransmitters 3. Major uses: prevent neural tube defects, high homocysteine, cancer prevention, cognitive decline 4. Other uses: depression, RLS, gingivitis, HTN, fatigue, osteoporosis, schizophrenia, bipolar 5. Negative results: stroke prevention, end stage renal disease/mortality 6. Toxicity: 1000 mcg/day

Question 35

Renal Failure Symptom management:

Answer 35

1. Fatigue (exercise, L-carnitine) 2. HTN (do not use K heavy diets, Na restriction) 3. Cardio risk (N-acetylcysteine) 4. Depression (folic acid/B12/B6) (be wary of SJW) 5. Leg cramps (Vitamin C, E) 6. Dysgeusia (Zinc) 7. Herkalemia (glycyrrhetinic acid) 8. Pruritis (Omega 3, activated charcoal, UV light therapy, topical capsaicin) 9. Uremic neuropathy (B6, B12, biotin, low AGE diet)