Clin Med - CKD

Question 1

What labs should you get before CKD appt?

Answer 1

• CBC
• RFP (or CMP/BMP)
• Intact PTH
• UA
• Random urine for protein and creatinine (need ratio)
• Renal US

*Old labs are VERY important

Question 2

Causes of CKD (many)

Answer 2

-Diabetes and HTN are 2 MCC!

• Polycystic kidney disease
• Heart Disease (CHF)
• Sarcoid
• NSAIDs/other nephrotoxins
• Vasculitis (including SLE, anti-GBM, ANCA)
• Connective tissue diseases (including CREST, SLE, RA, scleroderma)
• Renal Artery stenosis
• Benign hematuria

Question 3

CKD can cause…

Answer 3

• Anemia
• Mineral and Bone Disorders (MBD)
• Impaired immunity
• Volume Overload
• Hyperkalemia
• Metabolic Acidosis
• Hypertension
• Dyslipidemia
• Sexual Dysfunction

Question 4

Anemia seen with CKD is d/t

Answer 4

• reduced production of erythropoietin and shortened red cell survival.
• Normocytic, normochromic - anemia of chronic disease

Question 5

What do you have to do before treating anemia in CKD?

Answer 5

Rule out all other non-renal causes. Often won’t treat until Hgb is below 10

Question 6

What GFR is anemia common in?

Answer 6

GFR below 60 mL/min

Question 7

Mineral and bone disorders seen with CKD

Answer 7

• Secondary hyperparathyroidism
• Hyperphosphatemia
• Hypocalcemia

Question 8

Volume overload and sodium relationship

Answer 8

Less able to respond to rapid intake of sodium, therefore prone to fluid overload

Question 9

Where is the fluid seen in volume overload?

Answer 9

Often in lower extremities, occasionally in abdomen, lungs

Question 10

Tx of volume overload

Answer 10

Usually respond well to dietary sodium restriction and diuretic therapy with loop diuretic daily

Question 11

What is the KDIGO sodium intake recommendation?

Answer 11

KDIGO (Kidney Disease: Improving Global Outcomes) recommends sodium intake be restricted to <2 g/day

Question 12

Cause of hyperkalemia in CKD

Answer 12

Numerous, but often have high potassium diets

Question 13

Tx of hyperkalemia

Answer 13

Start with low-potassium diet (1500-2700 mg/day)

Question 14

Meds for hyperkalemia

Answer 14

kayexalate and fludrocortisone

Question 15

Why do CKD patients get metabolic acidosis?

Answer 15

CKD patients tend to retain hydrogen ions leading to progressive metabolic acidosis

Question 16

When is serum bicarb stabilized?

Answer 16

Between 12 and 20 mEq/L, rarely < 10

Question 17

Tx for metabolic acidosis

Answer 17

May treat with sodium bicarbonate unless significant edema/CHF

*monitor volume status carefully

Question 18

Other complications of CKD

Answer 18

• Impaired Immunity
• Dyslipidemia
• Sexual dysfunction

Question 19

Management of CKD - meds

Answer 19

ACEi and ARB

Question 20

Common nephrotoxins

Answer 20

NSAIDs and PPIs

Question 21

Diet/lifestyle recommendation for CKD

Answer 21

Heart healthy, ~4oz protein/meal, low sodium

Stop smoking!!

Question 22

What can you recommend to replace NSAIDs for arthritis in CKD?

Answer 22

Tylenol arthritis strength

Question 23

Renal ultrasound is used to

Answer 23

used to rule out obstruction, masses, polycystic kidney disease

Question 24

Large kidneys on renal US, think…

Answer 24

infiltrating diseases (Amyloid, DM, PCKD)

Question 25

Small kidneys on renal US, think...

Answer 25

indicate long term CKD, frequently found with HTN

Question 26

What is normal kidney size?

Answer 26

11-15cm

Question 27

Biggest indication for kidney biopsy

Answer 27

Proteinuria in the absence of diabetes

Question 28

Do all patients get a biopsy?

Answer 28

No, biopsy is the exception, not the rule. Renal US are the norm, every patient gets them.

Question 29

Indications for further blood work

Answer 29

- Proteinuria in absence of diabetes - Pre-biopsy - Unexplained hematuria *blood work ordered before every appointment

Question 30

CKD Stage 1

Answer 30

Stage 1---GFR 90-120

Question 31

CKD Stage 2

Answer 31

GFR 60-90

Question 32

CKD Stage 3

Answer 32

GFR 30-60

Question 33

CKD Stage 4

Answer 33

GFR 15-30

Question 34

CKD Stage 5

Answer 34

CFR < 15

Question 35

ESRD --- GFR

Answer 35

< 15 with uremic symptoms

Question 36

Pearls - when to send to nephrologist

Answer 36

- Hematuria after urology evaluation - Proteinuria - Progressive insufficiency - Acute worsening - CKD 3 (early stage 3, make patient aware of disease; definitely refer < 45)

Question 37

Pearls - urine studies

Answer 37

(don’t order 24 hr) | Estimated protein excretion ratio is recommended test for eval of proteinuria

Question 38

Example of CKD Plan

Answer 38

- Control DM, HTN - Return to clinic in 3 months with labs: CBC, RFP, iPTH, UA, random urine for protein/creatinine - Low salt diet - Diuretic

Question 39

Cockcroft-Gault Equation

Answer 39

CrCl (mL/min) = [140(age) x ideal bodyweight (kg)] / [0.815* x serum creatinine] *use 0.85 for females

Question 40

Select the target goal for protein restriction in patients with normal serum albumin and CKD

Answer 40

4oz protein/meal