Exam 3: Renal CKD and Stones Flashcards
Chronic Kidney Disease:
Disease that progresses ______
Takes months to years to develop
Chronic Kidney Disease:
Is a disease that progresses slowly overtime
months to years to develop
CKD is defined as GFR < 60 for three months irrespective of cause
CKD Stages
Explan the following stages of CKD depending on GFR
1. Normal > 90
- Due to age 60-89
3A
3B
4
5.
- Normal GFR > 90
- Due to age GFR: 60-89
3A. Minimal Risk: 45-59
3B Increased CV Risk: 30-44
- Increased risk of ESRD: 15-29
- Requires renal replacement therapy < 15
Nowadays, clinicians are suggested not to only measure GFR when evaluating the stage of a patient’s CKD, but also include _____
What combo is bad?
GFR and albumin are looked at
Low GFR and high urine albumin are BAD
Most common cause of CKD?
Most common cause of CKD is diabetes
Analgesic Nephropathy:
CKD due to use of _____ meds
Presentation: ____, _____, _____, ____
Caused by what mechanism?
How to treat analgesic nephropathy?
Analgesic Nephropathy:
CKD due to use of NSAIDs
Presentation: anemia, HTN, headaches, pyuria (WBCs in urine)
Caused by renal papillae necrosis- scarring of capillaries
Treat by discontinuing NSAID use
Explain other causes of CKD
Most common is ____
Second leading cause is _____
Glomerular disease - immune mediated
Genetic diseases: example is ______
Kidney obstruction
Medications, acute kidney injury (if ____)
Other causes of CKDL
- main: diabetes
- Second leading cause: hypertension
- Glomerular disease: immune mediated
- Genetic Disease: polycystic kidney disease (leading genetic cause of CKD, large sac filled things on kidneys only treatment is transplant or dialysis)
- Kidney obstruction
- Medications, acute kidney injury if left untreated
One of the first outcomes of CKD is volume overload:
What is the cause of volume overload due to CKD?
What are the symptoms?
Volume overload is one of the first concequences of CKD
Causes of volume overload: decreased functional nephrons, decreased ability to excrete salt, high salt diets make it worse
Symptoms: hypertension, edema, heart failure,
After volume overload, another concequence (second on the list) for CKD is hypocalcemia
Explain why hypocalcemia happens in CKD patients?
What other symptoms do you see in CKD patients due to hypocalcemia
- Volume Overload
- Hypocalcemia
The Proximal Convoluted Tubule is where vitamin D is activated to calcitriol via the enzyme 1-alpha hydroxylase. In CKD, that function is impaired.
So symptoms will be
- low vitamin D/calcitriol levels
- low calcium levels
- high PTH levels
- high serum phosphate
- cramps, tingling
The third concequence of CKD is metabolic acidosis
Metabolic acidosis occurs later in the progression of the disease (after HTN and hypocalcemia)
Metabolic Acidosis generally doesn’t show up until the GFR is _____
Why does metabolic acidosis happen?
Metabolic acidosis usually progresses later in CKD
- Volume overload
- hypocalcemia
- metabolic acidosis
Metabolic acidosis doesn’t occur until GFR < 30
This happens because the kidney has a decreased ability to secrete protons by the distal tubule and collecting duct, and also decreased ability to generate bicarb.
NOTE: metabolic acidosis is made worse by western diet high in red meat (more acidic), if patient switches to vegetables and fruits (more alkali)
Hyperkelemia is another concenquence of CKD
Explain why hyperkelemia happens in CKD patients
What are symptoms associated with hyperkelemia?
CKD Concequence Progression
- volume overload
- hypocalcemia
- metabolic acidosis
- hyperkelemia
Hyperkelemia:
- Aldosterone production is impaired in older patients and patients with diabetes.
- Remember, aldosterone reabsorbs sodium but also excretes potassium.
- Drugs that treat hypertension also inhibit aldoesterone production
- symptoms: weakness, fatigue
Which cells secrete potassium in the distal tubule and collecting duct?
PRINCIPAL cells secrete K+
Type 4 Renal Tubular Acidosis:
____renin, ____aldosterone, ____kelemia, and metabolic acidosis
Resistance to aldosterone or not producing aldosterone at all
Seen in older patients with ____ and ___
Type 4 Renal Tubular Acidosis:
HYPOrenin, HYPOaldosterone, HYPERkelemia, and metabolic acidosis
Resistance to aldosterone or not producing aldosterone at all
Seen in older patients with diabetes and CKD
CKD patients also get anemia, when GFR < ___
Why do they get anemia?
How do you treat CKD induced anemia?
Anemia: when GFR < 45/40
CKD patients get anemia because the kidneys produce EPO (which you need to make new RBCs), and with ckd that function is impaired
Treat this with EPOGEN
Uremia:
CKD patients in later stages also get uremia
Uremia is due to accumulation of _____ and other molecules that are waste products in blood
What are early and late signs of uremia?
Uremia:
CKD patients in later stages also get uremia
Uremia is due to accumulation of P-cresol and other molecules that are waste products in blood
Early signs of uremia: fatigue and poor apetitide
Late signs of uremia: uremic frost, coma
The final stage of CKD progression is
ASTERIXIS
what does that mean?
Asterixis:
neurological condition due to build up of uremic toxins
Flapping hand tremors
Requires dialysis
Explain the progression of concequences of CKD
1.
2.
3.
4.
5.
6.
7
Concequences of CKD:
- FLuid and salt retention: hypertension
- Hypocalcemia
3, Acidosis
- Hyperkelemia
- Anemia
- Uremia
- Asterexis
What is the most common type of kidney stone?
Most common types of stones are made of calcium
Calcium oxalate most common
calcium phosphate (less common)
This is due to hypercalcemia, BUT can be due to diet of high calcium OR high PTH levels
Explain ESP/Equilibrium Solubility Product
If the solubility product is < ESP what happens?
If solubility product is > ESP what happen?
At the equlibirum point, stones neither grow nor shrink
Solubility product > ESP, stones will grow
Solubility product < ESP, stones will shrink
_____ and ____ are both inhibitors of stone growth
How does both work?
Citrate and Magnesium are inhibitors of stone growth
Citrate
- binds to calcium and prevents crystallization of calcium oxalate or calcium phosphate
- increases urine pH which decreases precipitation of uric acid
Magnesium:
- forms oxalate and phosphate salts which are more soluble than calcium salts
Calcium Stones:
most common
due to hypercalciuria
increased intestinal _____ of calcium is a common find in patients with calcium stones
Calcium Stones:
most common
due to hypercalciuria
increased intenstinal absorption of calcium is a common find in these patients
How does chronic diarrhea cause stones?
_____ volume urine
____ magnesium level
___ bicarb
____ pH
___citrate
Chronic Diarrhea causes stones due to volume depletion and low volume urine
LOW everything:
low volume urine
low magnesium (inhibitor)
low bicarb
low pH
low citrate
Uric Acid Stones:
uric acid binds to two protons to form ____, which has low solubility in urine
What do they look like under a microscope?
These happen at ___ urine pH
How to treat them?
Uric Acid Stones:
uric acid binds to two protons to form ureate, LOW solubility
Radiotranslucent under microscope
happen at LOW urine pH
treat them with citrate to increase urine pH and dissolve the stones
Staghorn Calculus:
These stones are caused by the compound _______
This is due to the presence of urease splitting organisms (______)
Which infection doesn’t cause staghorn calculus?
Staghorn calculus also happens with pH > 7
These HAVE to be surgically removed
Staghorn calculus:
stones are caused by struviate
Due to the presence of urease splitting organisms (infections)
E.Coli does not cause these stones
Staghorn calculus also happens with ph> 7
Have to be surgically removed
Which stones are seen in high pH
In low pH
How to treat all stones?
Calcium phosphate stones: high pH
Uric acid stones: low pH
Treat all stones by increasing urine volume
