Nephro - Chronic kidney disease - Online MedEd

Question 1

3 things you need to know about chronic kidney disease

Answer 1

1) Stage and recognize when dialysis necessary
2) Prevent progression
3) Manage complications

Question 2

CKD

Answer 2

Decreased glomerular filtration rate
Measure Cr
-Many equations use Cr to assess GFR if Cr is stable
-So CKD can use these equations because assume Cr is stable

Question 3

5 stages of CKD

Answer 3

1) >90 GFR, action is to prevent progression (for all stages)
2) 60-89 GFR, not really many complications
3) 30-59, see complications
4) 15-29, see complications, prepare hemodialysis (put in AV fistula which needs to mature before use)
5) <15 GFR, ESRD, must have dialysis

Question 4

2 different types of dialysis

Answer 4

Hemodialysis - fistula/graft.. usually 3x/week, 4 hours each time
Peritoneal - every night when patient asleep, 6-8 hours (cheaper)
*Patients often switch back and forth

Question 5

Prevent progression of CKD… 3 things

Answer 5

1) HTN - more progressive does better than lenient, goal is <130/80, achieve with ACEi or ARBs (don’t combine the 2). More stringent HTN
2) Diabetes - A1C<7, blood glucose 8-12, with oral meds except metformin (can cause lactic acidosis in CKD), can ultimately use insulin. However, as insulin is cleared by kidneys can cause hypoglycaemia in CKD
3) Proteinuria - covered by ACEi/ARB, diet low in protein

Question 6

Complication management of CKD

Answer 6

1) Anemia of CKD. Kidneys make EPO. So nothing to tell bone marrow to make more blood cells. Rule out other causes of normocytic anemia and check vitamin B12 and folate. Then dx is anemia of chronic kidney disease (dx of exclusion). Treat with Fe supplement (sometimes given in dialysis), give EPO. May need EPO or transfusions, goal to keep Hgb>100
Finding EPO is not a diagnostic step*
2) Secondary hyperparathyroidism
-Elevated phosphorus (kidney cannot eliminate phosphorus in kidney) and low calcium (PTH cannot stimulate 125 vitamin D –> stimulates PTH and resorbs bone. Patient will present asymptomatic. If CaxPhos>35 - calcyhylaxis. Treatment is phosphate binders (reduce phosphorus and reduce PTH). Calcimimetics (act as calcium and reduce PTH excretion). Turn off PTH so don’t resorb bone and replace calcium and vitamin D. If don’t do this will get osteopenia/pathological fractures!
3) Marrow bone disease
-Osteopenia, pathological fractures!
4) Volume overload - don’t pee off. Manage with loop diuretics/furosemide. And/or thiazide. Lasix + Metolazone. Delay onset of HD in stage 4
2) Metabolic acidosis. Bicarb 10-20. Give NaBicarb orally to balance out bicarb.