Clinical CKD Flashcards
Are classic symptoms of kidney disease seen in the early stages of CKD?
nope - these are non specific and frequently not there
What 3 things define CKD grading?
- cause
- GFR
- albuminuria
When is the modification of diet in renal disease formula less accurate?
When GFR is over 60 (i.e. stages 1 and 2)
How is CKD progression defined?
- decline in GFR category 2. 25% drop or greater in eGFR from baseline
How is rapid progression defined in CKD?
Rapid progression is defined as a sustained decline in eGFR of more than 5 ml/min/1.73 m2/yr.
Why is it unlikely that increased work on remaining nephron mass is NOT the only reason for kidney disease progression?
It is generally thought that once damaged, kidney disease will progress over time, due to increased work of the remaining nephron mass. However, it is likely that people who do have progression after reduced nephron mass have some other pathophysiologic process occurring as some patients do not progress with decreased kidney mass, and the classic population would be a kidney transplant donor.
What are patients in stage1 through 4 of CKD most likely to die from?
other causes not related to CKD that occur BEFORE they go on dialysis
How often should GFR and albuminuria be assessed in CKD patients?
annually - more often for individuals at high risk of progression or when levels will impact management decisions
In stage 1 and 2, what should be done to manage CKD?
diagnose, delay progression, reduce CV risk and reduce proteinuria
in Stage 3, what should be done to manage CKD?
diagnose, delay progression, reduce CV risk and proteinuria, and assess for complications
in Stage 4, what should be done in addition to diagnosis, delaying progression, reducing CV risk, and reducing proteinuria?
assess for complications and discuss RRT
What is the target A1c for managing CKD?
< 7 %
What should be managed in all patients with CKD?
blood pressure RAAS inhibition (ACE/ARBs) glycemic control (SGLT2 inhibitors) Salt intake acidosis (bicarb replacement) protein intake (balanced) mineral metabolism anemia
. Therapy to slow or delay the progression of chronic kidney disease includes
A. Treatment with phosphate binders to lower phosphate to below normal range to prevent vascular calcification B. Treatment with fluids and albumin to improve hemodynamics
C. Treatment with sodium/glucose cotransporter 2 inhibitors in patients with an eGFR of 45 ml/min/1.73m2
D. Treatment with erythropoietin to keep hemoglobin 14 mg/dl
E. Treatment of secondary hyperparathyroidism with parathyroidectomy
Answer: C
There are very few therapies that have been proven effective in delaying the progression of chronic kidney disease other than treatment of the underlying cause of kidney disease. Some evidence that bicarbonate levels > 22 meq/dl may slow the progression of kidney disease. Sodium/glucose cotransporter 2 (SGLT2) inhibitors have shown benefit in reducing progression of CKD to ESRD in patients with CKD and diabetes. Ongoing studies in individuals with CKD but without diabetes are ongoing.
The following patient is at greatest risk for progression of their chronic kidney disease
A. 35 year old male with a history of membranous nephropathy with an MDRD eGFR of 55ml/min/ 1.73m2 and 7 grams of protein on two 24 hour urine collections.
B. 45 year old female with a history of IgA nephropathy and MDRD eGFR of 40 ml/min/1.73m2 and less than <30 mg of protein on two 24 hour urine collections.
C. 60 year old male with a history of heart failure with MDRD eGFR of 50 ml/min/ 1.73m2 and 300 mg of protein on two 24 hour urine collections.
D. 35 year old male who has a creatinine increase from 1.0 mg/dl (MDRD eGFR 90 ml/min/1.73m2) baseline to 1.9 mg/dl after a gastrointestinal illness who has now fully recovered from his illness.
Answer: A
Patients A, B, and C all have stage 3 chronic kidney disease. However, patient A has persistently increased proteinuria placing him at risk for progression of his chronic kidney disease. Treatment at this stage of kidney disease for all three patients would be to minimize proteinuria if possible (ACE inhibitors, treatment of underlying cause of chronic kidney disease if possible, and place on bicarbonate therapy if appropriate. Treatment also consists of monitoring fluid balance, electrolyte abnormalities of hyperkalemia, hyponatremia, hyperphosphatemia, accessing mineral metabolism disorders (secondary hyperparathyroidism, vitamin d deficiency) and assessing hematologic parameters (iron stores and anemia). In addition, control of blood pressure and other comorbidities to reduce cardiovascular morbidity. Patient D does not fit criteria for chronic kidney disease.
