Kidney Flashcards
1
Q
What are the 3 functions of the kidney?
A
Excretory
Endocrine - RBC , renin
Metabolic - vitamin D, gluconeogenesis
2
Q
What is the path of the kidney?
A
Afferent (efferent out) - glomerulus -proximal - descending- ascending (water )- distal - collecting duct
3
Q
What does renin do?
A
Vasoconstrict and Na and water retention
4
Q
What gets vasoconstricted from Angio 2?
A
Efferent arteriole
5
Q
Where is aldosterone secreted from?
A
Adrenal cortex
6
Q
What is aldosterone’s role?
A
Resort Na for K and retain water
7
Q
What is ADH job?
A
Retain water
8
Q
What is ANR’s job?
A
Get rid of water
9
Q
If GFR is low what is S Cr?
A
Higher
10
Q
What equation uses GFR and classifies the severity of kidney disease?
A
CKD - EPI
11
Q
What equation uses s Cr?
A
Cockcroft - gault
12
Q
What condition must the patient if are using ckd-epi?
A
CKD duh but must be stable
13
Q
What are the limits of using equations estimate function?
A
Extremes of mass, muscle
14
Q
What does non-indexed or No normalization mean?
A
Adjusted to patients BSA
15
Q
How does bun change in kidney disease?
A
Increases
16
Q
What can also change bun?
A
Eating protein
Gi bleed
Hydration (low h 20 =↑ urea)
17
Q
What are the ACR ranges of albumin?
A
A 1= <3
A2 = 3-30
A3 = > 30
18
Q
What range is microalbuminaria?
A
3 - 30
19
Q
What can cause transient albuminuria?
A
Major exercise , UTI, period,
20
Q
What does a urinalysis look at?
A
Color, turbidity, casts, glucose, pH,
21
Q
What are the most common casts, and what causes it?
A
Hyaline - exercise, looks concentrated
Granular - CKD, brown
22
Q
What is definition of AKI?
A
Sudden decline in renal function
23
Q
True or false: you can use CKD - EPI if they have AKI?
A
False need stable
24
Q
What is lab values for AKI?
A
S Cr > 0.3 in 48 hours or > 1.5 times baseline
Urine < 0.5 ml/kg/hr for 6 hrs
25
What is anuric?
< 50ml/day
26
What is oliguric?
< 500mi/day
27
What is non-oligaric?
> 500mi/day
28
What can change urine output?
Dehydration and diuretics
29
What marker usually shows up first for AKI?
↓ urine output ,s Cr takes 4 days
30
Sx of AKI?
Vomit, ab pain, dark urine. Foamy urine, edema, malaise
31
What can be general causes of AKI?
Mostly Anything that changes blood flow to the kidney- sepsis, trauma, burns, drugs(
32
What can be causes of prerenal azotemia?
blood loss, dehydration, HF, hypotension, low glomerular pressure (ACE/ARB, NSAIDS)
33
WHat are the 4 main types of Intrinsic AKI?
Tubular, intersitial, glomerulonephritis and vascular kidney injury
34
What causes tubular necrosis?
toxins mostly aminoglycosides (micins) and myoglobin
35
WHich type of kidney injury would statins cause?
rhabdomyolysis= tubular necrosis= intrinsic AKI
36
What can cause interstitial nephritis?
idiopathic immune response= NSAIDS and penicillin
37
WHat is a form of vascular kidney injury?
renal artery stenosis
38
WHat are some causes of post renal AKI?
obstruction= kidney stones, prostate, cancer, drugs (sulfonamides, MTX, Acyclovir)
39
What are the general 4 things used to diagnose AKI?
history
Lab data- increased S Cr, BUN, acidosis, hyperkalemia
FEna= % of sodium filtered and excreted
Urinalysis- casts
40
What does a high FEna mean?
tubular damage
41
What does a low FEna mean?
pre renal AKI
42
WHat other things can change FEna value?
RAAS and diuretics
43
If a patient had acute tubular necrosis, what form of cast could they have?
cellular
44
If a patient had increased WBC what can this indicate?
UTI
45
If crystals were present, what form of AKI would the patient have?
post renal
46
How can we treat pre renal AKI?
hydration/ stop diuretics
BP support
perhaps fluid removal
stop/hold nephrotoxic meds
47
How can we treat intrinsic AKI?
stop offender, manage autoimmune
48
How can we treat post renal failure?
catheter, remove obstruction, hydration
49
What is the range of good potassium?
3.5-5.0
50
What are signs of moderately high potassium?
weak, confused, peaked T waves
51
What are signs of severely high potassium?
wide QRS and small p Waves- heart block
52
If a patient came in with mildly high K, what are we doing?
15-60 mg BID-QID of sodium polystyrene or furosemide
53
WHy might furosemide not work to remove K+?
need functional kidneys
54
Why cant sodium polystyrene be used for severe k+?
too slow- one hour
55
If severely high K+ (>7), what are we doing?
calcium gluconate to protect heart
use insulin to drive K into cells
sodium bicarb if metabolic acidosis
then sodium polystyrene
56
What if all else fails to lower K?
dialysis
57
What are our go to agents if fluid overload?
furosemid +/- metalazone
58
Patient arrives to the ER with metabolic acidosis, what will be done to help?
sodium bicarb IV
59
When should dialysis be used to treat AKi (Hint: AEIOU)
A-acidosis
E-electrolytes- high K
I- Toxic ingestions
O- Fluid overload
U- Uremia
TOP 2 for AKI
and BOTTOM for CKD
60
What is the leading cause of CKD?
diabetes and HTN
61
What are the early stage symptoms of CKD?
ASYMPTOMATIC
62
What population in Canada is at risk for CKD and maybe could benefit from increased screening?
First Nations- higher rates of diabetes
63
What is the clinical definition of CKD?
under 60 ml/min GFR WITH or WITHOUT Kidney damage/ACR>3 mg/mmol for at least 3 months
64
How often should you be screened for CKD if the patient is high risk?
annually
65
When should the patient be refered to a nephrologist?
<30 ml/min and > 60 ACR
66
Why is CKD more prevalent in older people?
higher rates of diabetes and HTN
67
At age 30 what happens to your GFR?
lowers by 1 ml/min ish a year
68
Since we know that with age your kidney function declines, if the patient is >80 and has a GFR under 60 will this always be CKD?
No- if no marker of kidney damage
69
Stages of CKD using GFR
G1- >90
G2- 60-90
G3a- 45-60
G3b- 30-45
G4- 15-30
G5- <15/ dialysis
70
Stages of CKD for albuminuria
A1-<3
A2-3-30
A3- >30
71
If we want to determine GFR which equation will we use?
CKD-EPI
72
What is usually the first sign of CKD if the patient is diabetic and poor sugar control?
albuminuria
73
At what stage of CKD does the patient become symptomatic?
>stage 3
74
What are the symptoms of CKD?
fatigue, cloudy urine, edema, SOB, pruritis
75
What is associated with faster progression of CKD?
low GFR and high albuminurea, diabetes, male, african, age
76
Overview of interventions of delaying progression of CKD?
Blood pressure control
RAAs block
SGLT2- diabetic
smoking cessation
avoid nephrotoxins
77
Explain how HTN can cause and be a complication of CKD.
can cause it by damaging the glomerulus
and low GFR can stimulate RAAS to retain more fluids
78
What is blood pressure target for diabetics?
<130/80
79
What is blood pressure target for high risk?
<120/80
80
What is blood pressure target for most people?
<140/80
81
Who wasn't included in the sprint trial?
diabetics= found that <130 is better in a different study
82
Who is considered high risk for blood pressure control? Hint AARF
A-age >75
A-athersclerosis
R-renal (CKD)
F-framingham risk score>15%
83
What would a BP target <120 do for diabetics?
NOT improve progression/ESRD
may even worsen it
84
What is salt restriction for people?
<2 grams. but as much as you can
85
Good technique for BP testing?
sit upright, feet flat, arm su[ported, dont talk or move
86
What is limit for alchol for BP?
1-2 drinks a day
87
What is first line for BP control?
ACE/ARB, diuretic, long acting CCB
88
What is first line for HTN if albuminurea too?
ACE/ARB- is the absolute best!
89
MOA of ACE/ARB
dilate efferent arteriole
90
When should ACE/ARB not be used?
angioedema, renal artery stenosis= >30% decrease of GFR when starting, pregnant, hypotension and high K+
91
What monitoring for ACE/ARB?
BP, SCr, K, ACR
92
If patient is at target BP but not yet max dose of ARB what is the next step?
keep increasing dose and maybe back off other BP meds
93
A patient has been on perindopril for 10 years and has just now got a GFR under 30 ml/min. What should be done?
DO NOT SWITCH/ STOP- just monitor more
94
Is it okay to combo ACE/ARB?
NO- hurts kidneys (K+),
95
What is an example of a direct renin inhibitor?
aliskiren
96
Compare with ACE, how does Aliskiren stack up?
more s/e such as stroke, renal issues, hyper K, hypotension
97
What benefits are given when adding a MRA?
lower proteinuria, slow progression,
98
Cons of MRA?
MORE hyper K and gynecomastia
99
What are the steroidal MRAs?
spirinolactone, eplerenone (less s/e)
100
What are the non steroidal (selective) MRAs?
finerenone- much less side effects better for diabetics
101
Since finerenone is so good. Can we use this for HF instead of steroidal ones?
NOOO, dont use
102
When is it an issue for thiazides?
<30 ml/min- go to a loop now
103
What are DHP-CCB and what benefit do they have?
amlodipine- better BP control and preffered than thiazides in diabetics NOT FOR KIDNEY
104
What is an issue with amlodipine?
May cause fluid retention and edema
105
What are Non-DHP CCBs and what benefit do they have?
diltiazem, verapamil
decreases proteinuria, no renal adjusting
106
Issues with Non-DHP CCB?
lots of DI and CI, constipation
107
Is beta blockers a good addition?
it can yes, but may need to renal adjust under 30 ml/min
108
Is alpha 2 agonists good? what is one?
clonidine- adjuctive, CNS side effects
109
Is alpha 1 blockers good? what is some?
terazosin, adjunctive
110
What is role of direct vasodilators and what is the drug?
hydralazine- adjunct- may cause fluid retention
111
What is average protein loss in urine?
40-80 mg
112
What is level that is considered proteinuria?
>150
113
What is nephrotic syndorme?
hyper lipids, low albumin, edema, embolism risk
114
How can lupus effect your kidneys?
increase proteinuria
115
What is role for SGLT2i?
lowered mortality and GFR decline, more for HF
116
Issue with SGLT2i?
dapagliflozin well tolerated but volume depletion may be an issue
117
If a diabetic person was to keep their sugars in check how does it reduce their risk?
40% less albuminuria
37 less complications
118
What is general A1C target?
<7 maybe <6.5 if patient is VERY healthy
119
What is an issue with looking at A1C in CKD
at stage 4-5 less accurate
120
When do you have to discontinue metformin?
<30 ml/min
121
If needing adjuct sugar control and is already on metformin and SGLT2 what is the next agent?
GLP-1 agonist
122
Pros of metformin
cheap, no hypoglycemic, NO weight gain
123
Why do we have to adjust dose or discontinue metformin if low GFR?
risk of lactic acidosis= 50% mortality
124
What is kidney benefit of SGLT2i?
protects kidney, narrows afferent
125
Patient is at target A1C but not at optimal SGLT2i dose what is next step?
keep increasing but lower other meds
126
How far down can dapa be used for?
can start at >25, if already started= until dialysis
127
Can SGLT2i cause AKI?
prob not but theoretical
128
Pros of GLP-1?
weight LOSS, low hypoglycemic
129
What are GLP-1 agonists?
semaglutide
130
What does smoking do to your kidneys?
increases BP and HR, and lower renal flow
131
What are some nephrotoxic drugs?
NSAIDS, lithium, aminoglycosides, calcineurin
132
What is sad mans
S-SU
A-ACE
D-diuretics
M-metformin
A-ARB
N-NSAIDs
S-SGLT2i
133
What is the leading cause of death of people with CKD?
CVD
134
When should statins be given for CKD?
>50 and GFR<60 regardless of LDL
135
Can you be on a statin if also doing dialysis?
yes if initiated before
136
What is recommended dose for statins of dialysis?
atorvastatin=20
Rosuvastatin=10
137
What is recommended dose for statins of general people?
ator 80 and rosuvastatin 40
138
Which statin is renally eliminated?
rosuvastatin
139
Is ASA useful?
not for 1* prevention
140
Which has lower mortality, dialysis or transplant?
trasnplant
141
When do we need RRT?
serositis (electrolyte issues), cant control BP, malnutrition even with supplements, cog impairment
GFR=10
142
What is most common dialysis?
hemodialysis
143
Explain hemodialysis.
blood taken out, filtered and returned
3 x a week for 3-5 hours each time
144
What vascular access is given for HD?
AV fistula
graft
catheter in neck
145
What is always given to patients on HD?
anticoag during procedure
and renal vitamin
146
What is benefit of home HD?
better tolerated but more frequent
147
Complications of HD?
fatigue, hypotension, N/V, loss of water sol vitamins (B+C)
148
Explain peritoneal dialysis
use own peritoneal membrane to act as a filter
149
What is difference between continuous ambulatory PD and automated PD?
CAPD- manual exchange 4-5 x a day
APD- at night and may also need CAPD
150
Pros of PD?
more freedom and less visits and preserves kidneys
151
Complication of PD?
inflammation and infection of peritoneal
152
When is CRRT done?
for hemodynamically unstable patients
153
At what stage does sodium and water imbalance begin to take shape?
stage 4
154
What corrections can be done for water and Na imbalance?
salt and water restriction
diuretics
155
When can we not use thiazides?
GFR<30
156
How much Na loss occurs with loops vs thiazides?
25% and 4%
157
What monitoring should be done for diuretics?
electrolytes=K+ every 3-6 months once stable
158
How does metabolic acidosis occur from CKD?
no ammonia to buffer the H+
159
How can we treat metabolic acidosis?
325-500 mg BID-TID of sodium bicarbonate
160
What are we concerned about with treatment for metabolic acidosis?
if kidneys are not functioning well the drug will cause sodium loading
161
What is normal range of K+?
3.5-5
162
WHich drugs are we concerned about hyperkalemia?
potassium sparing diuretics, ACE, NSAIDS
163
What drugs can we give to lower K+
sodium polystyrene sulfonate (kayexalate), patiromer, soidum zirconium cyclosilicate
164
Which K binder is the fastest? What about slowest?
SZC
Patiromer
165
Which K binder uses Ca?
patiromer
166
Which K binder is selective for K+
SZC
167
Which K binder is the least tolerable?
Gi really bad with SPS
168
What is the mechanism for CKD-MBD?
more serum phosphate due to less excretion and it binds to Calcium
low absorption due to less vitamin D as it binds to phosphate and less activated
No calcium= PTH to resorb bone and try to get kidney to resorb calcium and get rid of phosphate
Calcium can also calcify in the blood
169
When should we monitor bone in CKD?
stage 4-5
170
What will labs show for CKD-MBD?
high phosphate
Low calcium
High PTH
171
If low calcium is present is it okay to just load up on calcium?
No hypercalcemia is really bad=CV
172
What is symptoms of low calcium?
numb, tingly, myalgia
173
What are the three Lab calciums?
ionized= Active
Total= all, misleading
corrected- estimated active
174
What is target PTH in dialysis and what is too high PTH?
2-9 x upper limit
50 x
175
What does adynamic bone disease mean?
low bone turnover= low pth
176
What all stims more PTH?
too much phosphate
low vitamin D
low Calcium
177
What does FGF-23 do?
Maintain Ca and PO4
suppress formation of vitamin D to lower phosphate in Gi
causes Po4 excretion and increases PTH
178
What is calciphylaxis?
calcification of small bnlood vessels= sepsis, ulcers, gangrene
179
What foods are high in phosphates?
packaged meat, peanut butter, nuts, cola
180
Is it okay to add K binder to orange juice to drink it?
NOOOOO it has K+ in it
181
When do you take phosphate binders?
beginning of a meal so nothing gets absorbed
182
Is phosphate binders enough?
No must restrict diet too
183
What are the general phosphate binders and what info about each?
Calcium(carbonate) based-tums, 500 with meals, be careful of too high Ca and constipation
Sevelamer HCl- bad GI effects, $$
Lanthanum- same as above but chewable
Sucroferric oxyhydroxide- iron base= black stool
184
For a K+ binder is it okay to use calcium citrate?
No- increases aluminum and toxicity
185
How can Vitmain D therapy help MBD?
stims absorption of calcium from Gi and suppress PTH
186
WHat is the evidence for vitamin D therapy?
VERYYYYYY uncertain, dont use unless severe
187
What are our vitamin D analogues?
calcitriol and alfacalcidol
Dose= 0.25-1 mcg daily
188
Is nutritional Vitamin D good?
can suppress but less so AND less hyper Ca and PTH
189
How does calcimimetics work and what is an example?
increase sensitivity of Parathyroid
Cinacalcet- for dialysis
190
Do calcimimetics raise Ca and PO4?
no
191
What are s/e of calcimimetics?
N/D/V, HYPOCALCEMIA
192
What are the antiresorptive treatment?
Prolia
Alendronate- caution under 35ml/min
193
How often should labs be monitored if MBD-CKD?
MONTHLY
194
If no drugs are working what can we do for people with bone issues?
partial removal of parathyroid
195
What issue can arise after operation for parathyroid?
hungry bone syndrome, will build a bunch of bone
196
How can adynamic bone disease occur?
too much treatment for PTH
= no remodeling
197
How can osteomalacia occur with CKD?
softens due to no calcitriol or aluminum deposition
198
How can vascular calcification occur?
smooth muscle change into osteoblast like cell
199
WHen is ferritin not accurate?
raised in inflammation
200
What is level of anemia in males and females?
<130 for men and < 120 for females
201
What do RBC's look like in CKD anemia?
normal. just not enough
202
How does anemia happen in CKD? and at what GFR levle?
<10 ml/min
loss of EPO
OR
iron low due to low Gi absorb
203
What tests show Iron is low?
low TSAT and low ferritin
204
If ferritin is increased what can this mean?
anemia of chronic and iron supp not helpful
205
WHat is hemoglobin, TSAT, ferritin goal if anemic
100-110
>20%
>100 if no dialysis
>200 if HD
206
Why isnt hemoglobin goal higher?
CVD risk
207
If on ESA what else is needed?
Iron supplementation
208
How long must you be on oral iron therapy before IV
1-3 months
209
What is dose of iron a day?
100-200 daily in 2-3 doses
210
What are the iron formulations?
Oral: Gluconate, sulfate, fumerate
IV: Sucrose, sodium ferris, isomaltoside
211
What are the side effects of IV iron?
WELL tolerated
maybe some hypotension- lower infusion rate
212
What stims EPO production?
low O2 in blood
213
WHat is difference between Epoetin and Darbepoetin?
E= shorter, 50-100 2-3 x weekly
D= longer, 0.45 weekly
214
Why do we wait 1-2 months before adjusting EPO dose?
because delay of 2-6 weeks with Hemoglobin
215
If HGB rise is too low (<10) after 4 weeks what do we do?
increase dose by 25%
216
If HGB rise is too high (>10) after 2 weeks what do we do?
lower dose by 25%
217
What are side effects of EPO?
hypertension, flu like, CVD
218
What is pure red cell aplasia?
s/e of EPO
antibodies against EPO
219
When is it considered EPO resistance?
eprex doses>300 U/kg/Week
Aranesp > 1.5 mcg/kg/week
220
What camn cause EPO resistance?
iron deficiency, inflammation, bleeding
221
How do HIF-PHIs work and whats an example and what is a S/E?
inhibit hypoxia factor= more iron mobilized= more EPO
Daprodustat
malignancy
222
What is the most common heart abdnormality with CKD?
LVH
223
How do we treat neuropathy/ neurological complications of CKD?
dialysis
224
What is the main concern with pruritis in CKD?
effect sleep
225
How can we treat pruritis?
gabapentinoids, capsaicin, antihistamines, DIfelikfalin
226
How does Difelikefalin work?
It is a kappa opiod agonist for severe pruritis
227
S/e of kappa opiod agonists?
dizzy, somnolence, mental changes
228
True or false. Drug induced kidney disease is reversible?
True
229
What is the state of the kidney in drug induced kidney disease when the drug is not present?
HEALTHY
230
What are the signs and sx of DIKD?
metabolic acidosis, proteinuria, changes to electrolytes, low urine, more SCr, malaise, nausea, SOB
231
What is indirect nephrotox?
Pre renal
232
What is obstructive nephrotoxicity?
Post renal
233
What drugs cause indirect nephrotoxicity?
ACE
SGLT
NSAIDs
Calcineurin inhibitors
234
What are some calcineurin inhibitors?
cyclosporin and tacrolimus
235
What are the three mechanisms of direct nephrotoxicity?
Acute tubular necrosis, interstitial nephritis, glomerulonephritis
236
What drugs can cause acute tubular necrosis?
Aminoglycosides, calcineurin, cisplatin
237
How can we lower the chance of tubular necrosis?
hydration and go slow
238
What drugs can cause interstitial nephritis?
Penicillin, Ciprofloxacin, NSAIDs, PPi, loop diuretics, phytoin
239
What is the MOA of interstitial nephritis?
immune mediated injury
240
WHen does interstitial nephritis present? what about for NSAIDs?
7-14 days
6 months
241
What will be present in the urine if interstitial nephritis?
eosinophils, pyuria
242
What can happen with continuous interstitial nephritis? What drugs can cause chronic?
can become progressive and irreversible
lithium and calcineurin
243
What drugs cause obstructive nephropathy?
Sulfonamides, acyclovir, MXT, ciprofloxacin
244
How can we lower obstructive nephropathy?
water because it super saturates and makes urine more acidic if no water
245
What formula do we use to alter drug dosing in renal failure?
cockroft and gault
246
When do we generally start to adjust dosing in renal failure?
<60 ml/min GFR
fe >0.5
247
Is it always necessary to adjust dose renally? When do we not have to?
NO
if liver is primary
if drug is fairly safe
if immediate need for it
tirtation?
248
What are the steps for drug dosing?
Get med history
find out degree of impairment
asses drug
choose less nephrotoxic
appropriate dose
monitor
249
Are Scr levels always accurate?
not in extremes of weight
can lag, both for disease and treatment
not in dialysis
250
Which types of AKI resolve the quickest?
Pre renal and post renal
251
Which type of molecules does HD remove?
unbound, small molecules
252
Do we have to worry about drug removal in PD?
NO
253
Which drug do we not necessarily follow the drug monograph for? why?
ACE and ARBs because they are so good. may use them below 30 ml/min but must monitor
