Jan18 M2-Chronic Kidney Disease Flashcards
2 common CKD dx and how to distinguish them
glomerulosclerosis
diabetic nephropathy
(distinguish with proteinuria)
2 urine protein tests to check
microalbumin
urine protein/Cr
what microalbumin in urine test tells us
endothelium health
less 1.9 = healthy
more 1.9 = might not be healthy
what urine protein/Cr ratio tells us (if convert it to g/day)
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
less 1g protein a day points to what etiology for the CKD
glomerulosclerosis (same as ischemic sclerosis or hypertensive nephropathy)
how does U protein guide us for biopsy
less 1g a day: no biopsy
1-3g + bad GFR + hematuria = biopsy
more 3g a day = biopsy (except diabetic)
hypertensive glomerulosclerosis pathophgy
htn alters the endoth cells. ats and scarring follow, capillaries collapse
how to differentiate a diabetic nephropathy from a glomerulosclerosis
diabetes has its own clinical presentation
5 chronological steps in diabetic nephropathy
- microalbuminuria
- albuminuria (1g, 2g, ..)
- 3g+/day nephrotic proteinuria
- rise in Cr
- renal failure
special charact on histo for diabetic nephropathy (if ever you would do a biopsy)
Kimmelstiel Wilson lesions (nodular sclerosis)
number 1 cause for needing dialysis in the world
diabetic nephropathy
type 1 diabetes vs type 2 diabetes: how diabetic nephropathy differs and why
type 1 is worse. more KW lesions and more end up needing dialysis. something goes wrong on genetic level
how is proteinuria related to Cr in diabetic nephropathy
once you reach the 3g mark, Cr starts to rise a lot
how can you check if it’s a diabetic nephropathy with protein and Cr values
check if they correspond. if big rise in Cr but didn’t go over the 3g threshold, it’s not diabetic nephropathy
glomerulosclerosis: things to be careful about (4)
- volume depletion
- nephrotoxins
- no NSAIDs
- dose meds
glomerulosclerosis vs diabetic nephropathy prognosis
prognosis of diabetic nephropathy is much worse
GS has good prognosis
3 examples of chronic glomerulonephritis diseases and which has worst prognosis
- IgA nephropathy, -FSGS (worst)
- membranous nephropathy
ADPKD how does it change with time
higher risk of dialysis as age increases
most important thing to control in CKD and why
htn. accelerates the loss of renal fct. affects proteinuria
how to control htn in CKD + what it also helps for
ACEi. also helps for the proteinuria
how BP affects Cr
if proteinuria 1g+ a day, higher BP = risk to double Cr
less 1g a day = no link
how long between onset of DM and microalbuminuria
10 yrs
pathophgy of diabetes
glycoproteins insert in the BM and BM damage occurs (really when microalbuminuria starts)
how to reverse proteinuria in diabetic patients
control BP below 120/75 and give ACEi/ARB
BP goal in uncomplicated htn
less 140/90
BP goal in CKD with proteinuria +1g a day
less 130/80
BP goal in diabetic with albuminuria
less 130/80
6 pillars of CKD (things that the kidney normally checks but that we have to check below GFR of 30)
Anemia Increased K Acidosis Bone disease (Ca/PO4/PTH) Volume overload HTN
Anemia, why happens in CKD and how to treat it + target
- not enough EPO made
- give ESA (erythrocyte stimulating agents)
target: 100-120 Hb
how to avoid hyperK in CKD
low diet K
kayexelate
avoid K increasing meds
why acidosis happens in CKD
kidney can’t generate bicarb
why secondary PTH happens in CKD
no calcitriol, high PO4 (bc less excreted). low Ca (bc PO4 sequesters it) + low calcitriol stimulate PTH
management of hyperPTH non pharma and pharma
low PO4 diet
binders: sevelamer, lanthanum, CaCO3 (this will also raise Ca)
vit D when PO4 controlled
cinacalcet (occupies CaSR on PT)
how to control volume overload in CKD and what to be careful about
fluid resitrction, furosemide. be careful about pre-renal AKI
how to control htn in CKD
ACEi. reach the targets
how to plan for dialysis
fistula placement in the arm, at least 8 weeks before dialysis
criteria for starting dialysis
GFR and how patient feels** (loss of appetite, nausea/vomiting, feeling unwell, trouble concentrating: uremic symptoms)
when to refer to a nephrologist in CKD (5 scenarios possible)
- 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
how to prevent AKI in CKD
prevent volume contraction.
NO NSAIDs if they’re on ACEi/ARB
