Jan18 M2-Chronic Kidney Disease

Question 1

2 common CKD dx and how to distinguish them

Answer 1

glomerulosclerosis
diabetic nephropathy
(distinguish with proteinuria)

Question 2

2 urine protein tests to check

Answer 2

microalbumin

urine protein/Cr

Question 3

what microalbumin in urine test tells us

Answer 3

endothelium health
less 1.9 = healthy
more 1.9 = might not be healthy

Question 4

what urine protein/Cr ratio tells us (if convert it to g/day)

Answer 4

less 1g=some prot and tubules can’t reabsorb it bc too much but prob not in tubules
1-3g = non dx
more 3g = glomerular

Question 5

less 1g protein a day points to what etiology for the CKD

Answer 5

glomerulosclerosis (same as ischemic sclerosis or hypertensive nephropathy)

Question 6

how does U protein guide us for biopsy

Answer 6

less 1g a day: no biopsy
1-3g + bad GFR + hematuria = biopsy
more 3g a day = biopsy (except diabetic)

Question 7

hypertensive glomerulosclerosis pathophgy

Answer 7

htn alters the endoth cells. ats and scarring follow, capillaries collapse

Question 8

how to differentiate a diabetic nephropathy from a glomerulosclerosis

Answer 8

diabetes has its own clinical presentation

Question 9

5 chronological steps in diabetic nephropathy

Answer 9

1. microalbuminuria
2. albuminuria (1g, 2g, ..)
3. 3g+/day nephrotic proteinuria
4. rise in Cr
5. renal failure

Question 10

special charact on histo for diabetic nephropathy (if ever you would do a biopsy)

Answer 10

Kimmelstiel Wilson lesions (nodular sclerosis)

Question 11

number 1 cause for needing dialysis in the world

Answer 11

diabetic nephropathy

Question 12

type 1 diabetes vs type 2 diabetes: how diabetic nephropathy differs and why

Answer 12

type 1 is worse. more KW lesions and more end up needing dialysis. something goes wrong on genetic level

Question 13

how is proteinuria related to Cr in diabetic nephropathy

Answer 13

once you reach the 3g mark, Cr starts to rise a lot

Question 14

how can you check if it’s a diabetic nephropathy with protein and Cr values

Answer 14

check if they correspond. if big rise in Cr but didn’t go over the 3g threshold, it’s not diabetic nephropathy

Question 15

glomerulosclerosis: things to be careful about (4)

Answer 15

• volume depletion
• nephrotoxins
• no NSAIDs
• dose meds

Question 16

glomerulosclerosis vs diabetic nephropathy prognosis

Answer 16

prognosis of diabetic nephropathy is much worse

GS has good prognosis

Question 17

3 examples of chronic glomerulonephritis diseases and which has worst prognosis

Answer 17

• IgA nephropathy, -FSGS (worst)

- membranous nephropathy

Question 18

ADPKD how does it change with time

Answer 18

higher risk of dialysis as age increases

Question 19

most important thing to control in CKD and why

Answer 19

htn. accelerates the loss of renal fct. affects proteinuria

Question 20

how to control htn in CKD + what it also helps for

Answer 20

ACEi. also helps for the proteinuria

Question 21

how BP affects Cr

Answer 21

if proteinuria 1g+ a day, higher BP = risk to double Cr

less 1g a day = no link

Question 22

how long between onset of DM and microalbuminuria

Answer 22

10 yrs

Question 23

pathophgy of diabetes

Answer 23

glycoproteins insert in the BM and BM damage occurs (really when microalbuminuria starts)

Question 24

how to reverse proteinuria in diabetic patients

Answer 24

control BP below 120/75 and give ACEi/ARB

Question 25

BP goal in uncomplicated htn

Answer 25

less 140/90

Question 26

BP goal in CKD with proteinuria +1g a day

Answer 26

less 130/80

Question 27

BP goal in diabetic with albuminuria

Answer 27

less 130/80

Question 28

6 pillars of CKD (things that the kidney normally checks but that we have to check below GFR of 30)

Answer 28

``` Anemia Increased K Acidosis Bone disease (Ca/PO4/PTH) Volume overload HTN ```

Question 29

Anemia, why happens in CKD and how to treat it + target

Answer 29

- not enough EPO made - give ESA (erythrocyte stimulating agents) target: 100-120 Hb

Question 30

how to avoid hyperK in CKD

Answer 30

low diet K kayexelate avoid K increasing meds

Question 31

why acidosis happens in CKD

Answer 31

kidney can't generate bicarb

Question 32

why secondary PTH happens in CKD

Answer 32

``` no calcitriol, high PO4 (bc less excreted). low Ca (bc PO4 sequesters it) + low calcitriol stimulate PTH ```

Question 33

management of hyperPTH non pharma and pharma

Answer 33

low PO4 diet binders: sevelamer, lanthanum, CaCO3 (this will also raise Ca) vit D when PO4 controlled cinacalcet (occupies CaSR on PT)

Question 34

how to control volume overload in CKD and what to be careful about

Answer 34

fluid resitrction, furosemide. be careful about pre-renal AKI

Question 35

how to control htn in CKD

Answer 35

ACEi. reach the targets

Question 36

how to plan for dialysis

Answer 36

fistula placement in the arm, at least 8 weeks before dialysis

Question 37

criteria for starting dialysis

Answer 37

GFR and how patient feels** (loss of appetite, nausea/vomiting, feeling unwell, trouble concentrating: uremic symptoms)

Question 38

when to refer to a nephrologist in CKD (5 scenarios possible)

Answer 38

- CrCl of 30 or less (GFR less 30) - U prot 2-3 g/day - 5% risk at 5 years - U Alb/Cr 100 - hematuria + any renal insufficiency

Question 39

how to prevent AKI in CKD

Answer 39

prevent volume contraction. | NO NSAIDs if they're on ACEi/ARB