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Pathophysiology I > Pathophysiology: Chronic Kidney Disease > Flashcards

Pathophysiology: Chronic Kidney Disease Flashcards

1
Q

Functions of the kidney

A
  • Excretory
  • Endocrine/Metabolic
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2
Q

Excretory function of the kidney

A
  • blood is filtered through glomerulus -> tubules fine tune solutes -> urine output
  • homeostasis of: water, electrolytes, acid-base, toxins
  • via: filtration (passive), secretion (active), reabsorption
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3
Q

Endocrine/metabolic function of kidney

A
  • renin production
  • erythropoetin production
  • vitamin D activation
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4
Q

Chronic Kidney Disease (CKD)

A
  • abnormalities of kidney structure or function
  • must be present for more than 3 months!
  • classified based on cause, GFR category, and albuminuria category (CGA)
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5
Q

CKD Workup

A
  • Urinalysis
  • Labs: CMP
  • Biopsy
  • US, CT, nuclear flow scan
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6
Q

What percentage of kidney loss to get to late stage CKD?

A
  • 90% kidney function
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7
Q

CKD Prevalence

A
  • More than 1 out of 10 adults has some level of CKD
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8
Q

Primary cause of ESRD

A
  • Diabetes Mellitus (49%) and Hypertension (28%)
  • pts in hemodialysis are the most common
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9
Q

ESRD incidence and prevalence in CKD

A
  • more pts going on dialysis and CKD as time goes on
  • pts with CKD have a higher mortality
  • heart disease is the number 1 disease in the US
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10
Q

What is used for staging CKD?

A
  • Modification for Diet in Renal Disease (MDRD)
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11
Q

Modification for Diet in Renal Disease (MDRD)

A
  • estimates GFR
  • preferred for staging CKD
  • more accurate than Cockcroft-Gault when staging CKD
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12
Q

Cockcroft-Gault Equation

A
  • estimates Creatinine Clearance
  • preferred for drug dosing in CKD
  • no longer used for staging CKD
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13
Q

CKD Epidemiology Study group (CKD-EPI)

A
  • also estimates eGFR
  • more accurate in pts with GFR >60mL/min/1.73m²
  • is the preferred formula since there is no race variable
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14
Q

Stage 3 CKD

A
  • is subdivided to 3a and 3b
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15
Q

What is the relationship between GFR and the staging of CKD?

A
  • depending on how low the GFR is, the higher or worse the staging for CKD is
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16
Q

Which stage of CKD do symptoms start?

A
  • Stage 3 CKD
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17
Q

Stage 1 and Stage 2 CKD

A
  • asymptomatic
  • best time for preventative care
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18
Q

Stage 5 CKD

A
  • when pts are on dialysis
  • almost all pts have NO urine output
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19
Q

CKD Staging: Albuminuria

A
  • aka proteinuria
  • 24-hour urine collection
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20
Q

“Spot” urine sample

A
  • Albumin-to-Creatinine Ratio (ACR)
  • most accurate way to measure albumin
  • often provided with laboratory test results
  • used as an estimate
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21
Q

Urine dipstick

A
  • NOT reliable
  • done in 5 minutes
  • Yes or No if you have proteinuria
  • does NOT quantify AER or ACR
  • NOT used
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22
Q

Stage A1: Albuminuria

A
  • AER: <30 mg
  • ACR: <30 mg/g
  • Normal to mildly
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23
Q

Stage A2: Albuminuria

A
  • AER: 30-300 mg
  • ACR: 30-300 mg/g
  • Description: Moderately
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24
Q

Stage A3: Albuminuria

A
  • AER: >300 mg
  • ACR: >300 mg/g
  • Description: Severely
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25
Q

Why do we need to stage someone with CKD?

A
  • the worst staging of CKD and higher A3 means the higher the proteinuria
  • so we can keep track overtime
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26
Q

Efferent arteriole

A
  • blood flow outward
27
Q

Afferent arteriole

A
  • blood flow inward
28
Q

The loss of nephron mass results in?

A
  • changes in the efferent and afferent side which changes the surface area
  • reduced GFR
  • compensatory hypertrophy
29
Q

Key elements of CKD

A

1) Loss of nephron mass
2) Glomerular capillary hypertension
3) Proteinuria
4) Progressive nephron loss

30
Q

Glomerular capillary hypertension

A
  • mediated by angiotensin II
  • increased filtration fraction
  • altered membrane permeability
31
Q

Proteinuria

A
  • promotes inflammatory and vasoactive cytokines and complement
  • direct tubular toxicity
32
Q

Progressive nephron loss

A
  • Glomerulosclerosis
  • Interstitial fibrosis
  • Reduced GFR
33
Q

What is not a risk factor for CKD?

A
  • alcohol use
34
Q

CKD Risk factors: Susceptibility to CKD

A
  • advanced age
  • reduced kidney mass
  • low birth weight
  • racial/ethnic minority
  • family history
  • low income or education
  • systemic inflammation
  • previous acute kidney injury
  • exposure to certain drugs or chemicals
35
Q

CKD risk factors: progression of CKD

A
  • Diabetes
  • Hypertension
  • Proteinuria
  • Obesity (BMI: equal or more than 30)
  • smoking
  • Dyslipidemia
36
Q

What is the number one leading cause of CKD?

A
  • Diabetes
37
Q

Diabetes Mellitus 1 (DM1):

A
  • 80% will develop overt nephropathy
38
Q

Diabetes Mellitus 2 (DM2)

A
  • 20-40% will progress to CKD
39
Q

Diabetes MOA in CKD

A
  • risk increases with mean glucose (A1C) and proteinuria
  • Mechanism: hyperglycemia -> mesangial expansion, glomerular basement membrane thickening, podocytopathy, impaired filtration/proteinuria
40
Q

Hypertension in CKD

A
  • # 2 leading cause of CKD
  • result of CKD (fluid overload)
  • risk of CKD increase with BP and proteinuria
  • Mechanism: increased intraglomerular pressure -> glomerular injury -> impaired filtration/proteinuria
41
Q

Cause of Kidney disease with chronic use of:

A
  • NSAIDs
  • Salicylates
  • Lithium
  • Calcineurin inhibitors
42
Q

Clinical Manifestation of CKD

A
  • Fluid and Electrolyte Disturbances
  • Acid-base disturbances
  • Osteodystrophy
  • Calcium Homeostasis
  • Mineral and Bone disorder
  • Calcium, Phosphorus & the Cardiovascular System
  • Calciphylaxis (uremic arteriolopathy)
  • Cardiovascular abnormalities
  • Anemia of CKD
  • Other
43
Q

Impaired tubular excretion of Na+

A
  • results in extracellular fluid volume expansion
  • influenced by dietary sodium intake
  • hypertension, peripheral and pleural edema, weight gain
44
Q

Impaired reabsorption of Na+ (when needed for extrarenal fluid losses)

A
  • prone to ECFV depletion
  • acute-on-chronic kidney failure
45
Q

Impaired tubular excretion of K+

A
  • hyperkalemia
  • risk for life threatening arrythmias
  • influenced by diet, drugs, transfusion, hemolysis and acidosis
46
Q

Impaired tubular excretion of Mag++

A
  • mild hypermagnesemia
47
Q

Impaired tubular excretion of [PO4-]

A
  • contributes to development of mineral-bone-disorder and hyperparathyroidism
48
Q

Acid-Base disturbances

A
  • decreased GFR leads to retention of organic acids
  • hyperkalemia decreases ammonia production, reducing urinary buffer and bicarbonate regeneration
    = Anion-gap metabolic acidosis
    = Protein catabolism
49
Q

How is Ca++ maintained?

A

-by Calcitonin and PTH
- needs to maintain [Ca++] 10mg/100mL

50
Q

What happens when there is too much Ca++?

A
  • will trigger calcitonin secretion
51
Q

Calcitonin role in the bone

A
  • will continue to produce until [Ca++] levels are in homeostasis
52
Q

PTH role in calcium homeostasis

A
  • tells kidneys to activate Vitamin D
  • stimulate Ca++ release from bones
  • increase Ca++ uptake in the intestines
53
Q

Overtime, the release of PTH

A
  • will cause increase Ca++ mobilization from the bone
  • increase renal Ca++ reabsorption
  • decrease phosphate
54
Q

What occurs in the later stages of CKD?

A
  • secondary hyperparathyroidism = hypocalcemia
  • the result of another condition that lowers the blood calcium, which then affects the gland’s function
  • result in kidney failure and Vit D deficiency
55
Q

Progressive kidney disease leads to

A
  • decrease phosphate excretion = hypocalcemia
  • decrease Calcitriol (Vitamin D3) production = hypocalcemia
  • increased PTH
56
Q

What happens when there is decreased phosphate excretion?

A
  • there will be phosphate retention which can lead to hypocalcemia
  • OR increased calcium phosphate crystals which leads to Soft Tissue Calcification
57
Q

increased PTH

A
  • is caused by hypocalcemia
  • which leads to:
    1) increased Ca++ mobilization from bone
    2) increased renal Ca++ reabsorption
    3) decreased renal phosphate reabsorption
58
Q

Decreased Calcitriol

A
  • decreased GI Ca++ absorption = Hypocalcemia or impaired bone mineralization
59
Q

impaired bone mineralization

A
  • Osteomalacia
60
Q

Calciphylaxis

A
  • blood vessel occlusions with extreme vascular and soft tissue calcification: skin necrosis and poor wound healing
  • associated with Warfarin therapy and calcium-based phosphorus binders
  • very poor prognostic factor
  • stops blood flow altogether
61
Q

Anemia of CKD

A
  • low hemoglobin
  • reduce transport of blood oxygen
  • decreased erythropoietin
  • Folate(B9) and/or Cobalamin (B12) deficiencies
  • pernicious anemia
  • iron deficiency
  • megaloblastic anemia
62
Q

Other clinical manifestation of CKD

A
  • uremic bleeding (platelet dysfunction)
  • reduced insulin elimination
  • reduced estrogen, testosterone
  • dry, itchy skin
63
Q

Decreased levels of ____ is the cause of this anemia.
a) Erythropoietin
b) Iron
c) PTH
d) Vitamin D

A

Erythropoietin

64
Q

______ levels of _______ would cause bone disease in CKD.
a) increased; calcitonin
b) decreased; calcitonin
c) increased; PTH
d) decreased; PTH

A

increased; PTH

Pathophysiology I (4 decks)

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