Exam 2: CKD And Nephrotic Syndrome Flashcards
What defines CKD?
Decreased kidney function or kidney damage for 3 months or more
What is the hallmark of progressive kidney disease?
Declining GFR
What are the leading causes of kidney failure?
DM and HTN
What is uremic syndrome?
Accumulation of metabolic waste products or uremic toxins
What is uremic syndrome often seen with?
A profound decrease in GFR (10-15)
Patient presents with fatigue, malaise, pericarditis, encephalitis, and a GFR of 15. What are you converted about?
Uremic syndrome
What finding on renal US supports diagnoses of CKD?
Small kidneys bilaterally (<9-10cm)
What defines the kidney function/damage seen with CKD?
Kidney function: GFR <60
Kidney damage: Albuminuria (urine albumin to creatinine ratio >30), abnormal imaging, abnormal urinary sediment, and hx of kidney transplant
What is CKD stage 1?
GFR >90, kidney damage with normal or increased GFR
What is CKD stage 2?
GFR 60-89, kidney damage with mildly decreased GFR
What is CKD stage 3a?
GFR 45-59, mildly-moderately decreased GFR
What is CKD stage 3b?
GFR 30-44, moderately-severely decreased GFR
What is CKD stage 4?
GFR 15-29, severely decreased GFR
What is CKD stage 5?
GFR <15, kidney failure
** add D if treated with Dialysis
What is albuminuria stage 1?
ACR (albumin to creatinine ratio) < 30, normal to mildly increased
What is albuminuria stage 2?
ACR 30-300, moderately increased
What is albuminuria stage 3?
ACR >300, severely increased
What is the pathogenesis of CKD?
Progressive decline of GFR, typically over months to years, due to the irreversible destruction of nephrons independent of the cause
What does destruction of nephrons often lead to?
Compensatory hypertrophy and supranormal GFR of the remaining nephrons.
-This leads to overwork injury and progressive glomerular sclerosis and interstitial fibrosis
What labs should you order for patients who are at high risk of developing CKD?
- ACR
- Serum creatinine to estimate GFR
What are some of the complications that may arise from CKD?
- CVD
- HTN
- Dyslipidemia
- anemia
- Mineral and bone disorders
- fluid and electrolyte abnormalities
- uremia
What are the bone disorders that can occur as a complication from CKD?
Osteitis fibrosa cystica, adynamic bone disease, and osteomalacia
What is the typical pattern seen on labs in patients who are developing bone disorders secondary to CKD?
-Hyperphosphatemia, hypocalcemia, decreased vitamin D. This is called secondary hyperparathyroidism!!
What are the reversible factors that cause CKD?
- Infection
- UTI
- Decreased renal perfusion
- nephrotoxic agents
- HF
What is the vital treatment measure in regards to CKD?
Treatment of underlying disease
Why are ACE inhibitors and ARBs used for CKD?
- renal protective
- helpful in slowing the progression of proteinuric CKD (decreases albumin)
What is the target BP in CKD patients without proteinuria?
< 140/90
What is the target BP in CKD patients with Proteinuric CKD?
< 130/80
What it is the one indication that is common to most guidelines about when to refer to patient for CKD?
GFR < 30
Who is dialysis reserved for?
Patients with kidney failure/ESRD.
What are the acute complications of hemodialysis?
-Hypotension, cramps, nausea/vomiting, HA, CP, back pain, itching, fever, and chills
How does hemodialysis work?
- Requires a constant flow of blood along one side of a semipermeable membrane with a cleaning solution (or a dialysate) along the other.
- Diffusion and convection allow the dialysate to remove unwanted substances from the blood while adding back needed components
What are the complications of peritoneal dialysis?
- Peritonitis
- exit site infection
- Poor dialysate drainage
What is the treatment of choice for ESRD?
Kidney transplant
What are the 3 chronic tubulointerstitial diseases of the kidney?
Obstructive uropathy, reflex nephropathy, and analgesic nephropathy
When can ACE inhibitors and ARBs be harmful in CKD?
- Caution in acute kidney injury, may see acute reduction in GFR and hyperkalemia
- Contraindicated in bilateral renal artery stenosis
What are the indications for dialysis?
- uremic symptoms
- fluid overload unresponsive to diuresis
- Refractory hyperkalemia, acidosis, and hyperphosphatemia
You should prepare to initiate dialysis if the GFR is ***.
<30
What is the “dialyzer” in peritoneal dialysis?
The peritoneal membrane
What is tubulointerstitial disease?
Broadly refers to kidney disease that involve tubules and/or interstitium of the kidney and spares the glomeruli
What is tubulointerstitial disease characterized by?
Interstitial scarring, fibrosis, and tubular atrophy leading to chronic renal insufficiency
What are the underlying etiologies of chronic tubulointerstitial disease?
Obstructive uropathy, reflux neuropathy, medications (analgesics), and heavy metals
What are the clinical findings with chronic tubulointerstitial disease?
-polyuria, hyperkalemia (decreased GFR and distal tubules are aldosterone resistant), and urinalysis is nonspecific (proteinuria <2 and broad waxy casts)
What is obstructive uropathy?
Prolonged (or recurrent) obstruction of the urinary tract
-chronic reduction in GFR and impaired tubular function
What is the clinical presentation of obstructive uropathy?
Pain, change in urine output, HTN, hematuria, increased serum creatinine
What is seen on UA in a patient with obstructive uropathy?
Hematuria, pyuria, and bacteriuria is often bland
What is seen on US of obstructive uropathy?
Used to detect masses, hydroureter, and hydronephrosis
What is reflux nephropathy?
The consequence of VUR or other urologic anomalies in childhood
What is the sequence of events in reflux nephropathy?
1) retrograde passage of urine from the bladder to the upper urinary tract
2) urine can extravasate into the interstitium
3) Inflammatory response develops
4) Fibrosis occurs
Who is reflux nephropathy typically diagnosed in?
Young children with a history of recurrent UTIs
What two tests are helpful in diagnosing reflux nephropathy?
renal US (evaluate for scarring and hydronephrosis) and Voiding Cystourethrogram (VCUG, helpful for evaluating VUR and the anatomy of the lower urinary tract)
What is the pathogenesis in obstructive uropathy?
Tubular atrophy, interstitial fibrosis, and eventually irreversible renal injury
What can cause obstruction and lead to obstructive uropathy?
Prostatic disease, ureteral calculus in a single functioning kidney, bilateral urethral calculus, carcinoma of the cervix colon or bladder, and retroperitoneal tumors or fibrosis
What are the abnormal labs you will see with analgesic nephropathy?
-Elevated serum creatinine, UA showing hematuria or sterile pyuria, mild proteinuria, and anemia
What can be seen in CT scan in a patient with Analgesic nephropathy?
Renal papillary necrosis and calcification
What is analgesic nephropathy?
CKD caused by long term consumption of analgesic, often when taken in combination with other medications (Tylenol and NSAIDs)
What is the treatment for chronic tubulointerstitial disorders?
- ID underlying disorder
- Medical management
- Relief of obstruction
- Withdrawal of all analgesics
- Referral to nephrology
What is nephrotic syndrome?
Non inflammatory damage to the glomerular capillary wall (podocyte or GBM).
Can be primary or in association with systemic disease
Distinct constellation of clinical and lab features of renal disease
What is the nephrotic spectrum?
Diseases that present primarily with proteinuria and bland urine sediment
What are the abnormal labs that are seen with nephrotic syndrome?
Nephrotic range proteinuria (<3.5), hypoalbuminemia, edema, and hyperlipidemia
What are the signs of nephrotic syndrome?
- Edema
- Ascites
- foamy urine
What are the symptoms of nephrotic syndrome?
- Malaise
- Anorexia
- Dyspnea
- Abdominal distention
- Weight gain
- Orthostatic hypotension
What are some of the complications seen with nephrotic syndrome?
- Protein malnutrition
- hypercoagulability
- Vitamin D deficiency and hypocalcemia
- infection
- anemia
What will be seen on urine microscopy in a patient that with nephrotic syndrome?
Oval fat body
What is the management of nephrotic syndrome?
- ACE and ARB
- Statin therapy
- Loop diuretics
- sodium and fluid restriction
- Anticoagulants
- Immunosuppresive therapy
- Nephrology referral
What is the most common cause of nephrotic syndrome in children?
MInimal change disease (MCD)
What is MCD often associated with?
Following a URI, hypersensitivity reactions, medications (lithium) and malignancies
What is the first line treatment for MCD?
Prednisone
What is the etiology of primary Membranous nephropathy (MN)?
Thought to be immune mediated, autoantibodies directed against antigen found on podocytes
What is the etiology of secondary MN?
Hep B, autoimmune disease, thyroid is its, malignancy, drugs, etc
Patients with MN are at high risk for ***.
Hypercoagulable state
What is the treatment for MN?
Supportive, immunosuppresive agents, transplant
What is pathogenesis of MCD?
Primarily affects podocytes, diffuse podocyte foot process fusion
Focal segmental glomerulosclerosis (FSGS) has a *** pattern of kidney injury.
Histological
What is the clinical presentation of FSGS?
> 70% present with nephrotic syndrome
Patients with MN are at higher risk for *** vein thrombosis.
Renal
What is the pathogenesis of FSGS?
Glomerular injury resulting from damage to podocytes.
Sclerosis in parts of at least on glomerular
What is the etiology of primary and secondary FSGS?
Primary- idiopathic
Secondary- obesity, infections, inflammation, toxins, healed previous glomerular injury, reflex nephropathy, HTN, etc
What is the treatment for FSGS?
- supportive
- immunosuppresive antes (primary)
- Disease specific treatment (secondary )
What patients have poor outcomes with FSGS?
Patients with nephrotic range proteinuria, African American Race, and renal insufficiency
What is the most common cause fo ESRD in the US?
Diabetic nephropathy
