Renal/CKD Flashcards
What is considered a good GFR? What does the GFR indicate?
125mL/min/1.73m2 (norm=120-200)
Renal function indicator
What is reabsorbed in the proximal tubule? (Right after the glomerulus)
Na, K, H2O, and aa
Uncontrolled, just happens
What is reabsorbed in the loop of henle and why? How/where is it absorbed?
Urine concentration control: Mostly water b/c of super salty medulla environment (passive)
Descending- Na reabsorbed (active)
Ascending- mostly water again
What is reabsorbed in the distal tubules? (After the loop of henle)
Na and H2O
Secreted= K and H
Variable and controlled based on concentration of urine (urine enters collecting duct from here)
How much blood does the kidney filter everyday? How much urine is produced?
900-1600L blood
1.5 L of urine
What happens at the juxtaglomerular apparatus?
The distal tubule touches the glomerulus and the concentration tells why her or not renin needs to be released
(High osmolality=secrete renin=up H2O)
What is renal function? Renal failure?
Kidneys ability to adequately eliminate N waste
Inability to secrete N waste.
What is azotemia? Oliguria?
High N waste products in blood (kidney not eliminating properly)
Excrete less that 500mL urine/day
What’s renal solute load? What’s it made of?
The amount of N waste and minerals that HAS to be excreted daily.
N (urea), Uric acid, Cr, NH4, K, Na, Cl
What is needed with a high RSL? What is possible range of urine concentration?
More fluid to excrete it.
Normal urine osmolality is from 50-1200 mOsm
What is obligatory urine loss?
Minimum fluid necessary to remove waste materials in urine (this will be higher if you eat a lot of protein)
Depends on how well the kidney can concentrate the urine
What is facultative urine loss?
Urine loss depends on tubular resorption rates and body needs
What is normal adult urine concentration (RSL)?
How do you calculate RSL?
1200-1400 mOsm/L
mOsm= (g Pro * 5.7) + mEq (Na+K+Cl)
What is the endocrine control of body water and how?
ADH/vasopressin (post pituitary gland)
It increases permeability of distal and collecting tubules when osmolality is high so increase H2O reabsorption.
ADH tries to decrease the osmolality
How are SGLT 2 inhibitor drugs (invokana) r/t the kidney?
SGLT is a transporter in the proximal tubule to bring glucose back into the blood.
The drug stops this transporter so glucose is excreted and lowers blood level (DM)
How are ACE inhibitors r/t kidney function?
ACE inhibitors block ADH to stop water reabsorption to keep BP low (CVD). Sometimes we don’t want that because we want urine to be the correct concentration.
Describe the renin-angiotensin? What does it control?
Controls BP
BV is low, kidney secrete renin to make angio into aldosterone (adrenal glands) which reabsorbs Na. Higher osmolality will increase water reabsorption and up BV and BP.
How is RBC production controlled?
Kidney producing EPO
Deficiency common with chronic renal anemia
Where does aldosterone act?
On the distal tubule to controllably increase Na reabsorption. (Active)
What are the 3 main hormone/Vit and 3 main areas of calcium-phosphorus homeostasis?
PTH, calcitonin, and vitamin D
In the kidneys, bones, and intestine
How is PTH triggered and what are its 3 main effects?
Low Ca=high PTH
- kidney increases Ca reabsorption
- osteoclasts break bone to release Ca and phosphorus
- kidneys convert Vit D to active form (calcitonin increases Ca absorption in gut)
What are the 4 classic renal indicators?
High BUN
High creatinine
High phosphorus
High potassium
Normal and CKD range of BUN?
10-20mg/dL
CKD: 60-80 mg/dL (dialysis and eating protein)
Normal and CKD range for creatinine?
M: .5-1.1 mg/dL
F: .6-1.2
CKD: 2-15 mg/dL (muscle mass, GFR, and dialysis clearance)
Normal and CKD values for phosphorus?
3.0-4.5 mg/dL
CKD: 3.5-5.5 mg/dL (towards normal)
Normal and CKD values for potassium?
3.5-5.0 mEq/L (or mmol/L)
CKD: 3.5-6.0 mEq/L
Albumin normal and CKD values? Issues with albumin?
3.5-5.0 g/dL
CKD: >4 g/dL
Albuminuria- marker
Protein is lost with dialysis so if alb
Normal and CKD Prealbumin levels? Why is it typically elevated with CKD? What are its disadvantages?
15-36mg/dL, CKD: >30 mg/dL
Higher because kidney can’t degrade it like normal
PAB= neg acute phase (so high with inflammation and dialysis), not nutritionally correlated, and high wth CKD
Normal and CKD serum creatinine values? Used to measure what? Controlled by what?
.5-1.2 and CKD= 2-15.0 mg/dL
Shows extent of failure at Dx and used to monitor Tx ( ms breakdown usually excreted in urine)
Controlled with dialysis
What does creatinine clearance measure? What does it indicate? Is it high or low with CKD?
Indicates GFR
Measures renal damage and used to stage CKD
Usually low with CKD
What does BUN indicate? What is it influenced by? Why is it higher with disease?
Extent of renal failure
Influenced by hydration, too much Pro, GI bleed, low kcals or hypercatabolism
Higher because N or urea aren’t excreted well
What is CRF and stage 4/5 CKD BUN:Cr ratio?
15 is pro intake high, catabolic, dehydration
What happens with high K levels? How is K managed? What is a risk of dialysis?
Over 7 mEq/L- cardiac arrhythmia
Diet, drugs, and dialysis
Dialysis can cause hypokalemia
What drugs should be avoided to help control K levels?
K sparing diuretics
Spironolactone and triamterene because they retain K and K is already being retained
Why are Ca levels usually low with CKD? What is a goal range for Ca with CKD?
High phosphate levels mean lower Ca levels
Lower Vit D metabolism by kidney means less absorption in the GI
9-10.5 mg/dL
How are high levels of phosphate managed? What should the value always be under?
Diet and phosphate binders
Keep under 6 mg/dL
How much Ca is bound to albumin?
What calculation do you need to use for corrected serum Ca when albumin is low?
60% Ca is bound to alb
[(4 g/dL - reported albumin)*0.8] + reported calcium
What is calciphlaxis? What measurement (and its value) is used to find higher risk for it?
Disease- calcium and phosphorus deposition in soft tissues
Calcium- Phosphorus Product:
>55. (-75) is increased calcification risk
NO Ca SUPPLeMENTS.
What blood and lipid values could be off and why?
TG and cholesterol high due to high meat diet. Keep it below 200mg/dL with CKD
Hct and Hb levels slightly lower if controlled
Sodium goal and reasons for fluctuations.
136-145 mEq/L
If wt stable- urine Na from intake
If wt changing- Na retention and fluid fluctuations.
What is dry weight?
Edema free body weight
Wt with normal hydration, normal BP and no edema (WNL Na)
With dialysis pt- dry weight is after dialysis
What does standard body weight indicate?
How do you find %SBW?
Nutritional status
(Actual BW/SBW)*100
What are obese and malnutrition classifications with SBW?
Over 115% and under 90%
What is the calculation for adjusted BW?
BW ef + [(SBW- BW ef) * 0.25]
Use when less than 95% and > 115 %
Define CKD.
Irreversible nephron damage
How is the severity of CKD measured?
Low creatinine and urea clearance
(Shows high serum Cr and Urea)
EsRD= ClCr less than 10
Stage 1 CKD
GFR- 90 or above
No Sx
No special diet
Stage 2 CKD
GFR 60-89
Mild azotemia
High BUN and Cr
No diet
Stage 3 CKD
GFR 30-59
Moderate azotemia
High BUN and Cr
Phosphorus restriction and emphasize B and C vits (maybe D Zn and Fe)
Stage 4 CKD
GFR 15-29 Restrict protein (0.6g/kg) 30-35 kcal Phosphorus restriction Ca- stay under 2000mg/day
Stage 5 CKD
Permanent Oliguria or anuria GFR less than 15 Need dialysis Protein .6-.75g/d (without dialysis)
Leading cause and some others of CKD.
DM
Low PTH
High Ca and high K
Vascular disease
3 stages of Tx profession for CKD
Diet and drugs (conservative management)
Dialysis
Transplant
Adjusted ef BW formula and when to use it.
Use if SBW over 115 or under 95.
BWef + [(SBW-BWef) * 0.25]
Dry weight (or edema free) is when (4 things)
Normal BP
Normal serum Na
No edema
Normal hydration
(Or right after dialysis)
Name a drug to control hyperkalemia and some of its dietary SA.
Kayexlate
Increase Mg and Ca losses, raises serum Na
Use with low K diet
(It’s a cation exchange resin)
What is a V supp used for CKD
Nephrovite
High in water soluble vitamins and low in fat soluble vitamins
What drug stimulates RBC production? What else is taken with it?
EPO
If iron stores low (need ferritin over 100 ng/mL), give Fe supplement
Do NOT take Ca supp at same time as Fe supp
What drugs control hyperphosphatemia? What are the forms?
Phosphate binders bind phosphate in GI tract.
Take within 1/2 hour of eating.
Liquid, calcium based, or aluminum based (only use short term!)
3 examples of Al phosphate binders and when are they used?
Basaljel, alternagel, amphojel
Use of phosphate over 6.0 and only use for 1 month
3 examples of Ca phosphate binders and when should they be avoided?
Ca acetate, Phoslo, Tums
No if serum phosphate over 6.0 or if calcium phosphate product is over 60.
What is Rocaltrol? What is the IV version?
Active Vit D supps
Help maintain serum Ca WNL and lower PTH levels
Calcijex (IV)
When to not give active vitamin D?
Phosphate over 6.0 mg/dL
Calcium over 11.5 mg/dL
Calcium phosphate product over 60
Intact PTH less than 150
3 common ACE inhibitors and action and SA?
Capoten, vasotec, altace, or “ril”
Stop aldosterone from being made so less Na reabsorption in distal tubule.
Can cause high K
Restrict diet K if on ACE and serum K over 5.6
What are protein levels for the following GFR?
.6-.8 (adj if obese)
.6 (adj if obese)
.8
1.2
What is a high Na food? What are Na recs based on fluid output?
400mg/serving Over 1 L output = 2-4g Na Less than 1L output= 2g Na Typical US diet= 4-8g General rule= less than 2.4 g/day
When does K usually need restricted?
What are HD K guidelines?
If GFR under 15 or late CKD
If one ACE inhibitor
HD: 2-3g/day
When is phosphate restricted and to what? When is Ca usually too low?
If GFR
3 main groups high in phosphorus?
Meats, legumes, dairy
Phosphorus is controlled with DIET!!
How do you limit interdialytic wt gain during HD? (Fluid intake)
> 1 L fluid output = 2L intake
Fluid recs for edema on HD?
Fluid output + 500 mL
What main nutrients are modified for pre-dialysis pt?
Protein (stage 4)
K (4 or 5)
Phosphorus (4)
Fluid (later CKD)
What main groups are modified for dialysis pt?
Kcals (35) Protein (1.2) Na (if low urinary output) K (2-3G/day) Phosphorus (800-1000) Fluid (based on urinary output) Vits- B, C, D Minerals- Fe, Ca (less than 2g/d) Fats- TLC??
5 high K food sources and what’s high?
Over 200mg per serving
Avocado, cooked broccoli or mushrooms, Brussels sprouts, fresh apricot, dates
5 foods low in K and what is low?
Less than 200 mg/serving.
Canned apricots, berries, apples, brassica family, fresh broccoli, zucchini cooked
What are protein levels for the following GFR?
.6-.8 (adj if obese)
.6 (adj if obese)
.8
1.2
What is a high Na food? What are Na recs based on fluid output?
400mg/serving Over 1 L output = 2-4g Na Less than 1L output= 2g Na Typical US diet= 4-8g General rule= less than 2.4 g/day
When does K usually need restricted?
What are HD K guidelines?
If GFR under 15 or late CKD
If one ACE inhibitor
HD: 2-3g/day
When is phosphate restricted and to what? When is Ca usually too low?
If GFR
3 main groups high in phosphorus?
Meats, legumes, dairy
Phosphorus is controlled with DIET!!
How do you limit interdialytic wt gain during HD? (Fluid intake)
> 1 L fluid output = 2L intake
Fluid recs for edema on HD?
Fluid output + 500 mL
What main nutrients are modified for pre-dialysis pt?
Protein (stage 4)
K (4 or 5)
Phosphorus (4)
Fluid (later CKD)
What main groups are modified for dialysis pt?
Kcals (35) Protein (1.2) Na (if low urinary output) K (2-3G/day) Phosphorus (800-1000) Fluid (based on urinary output) Vits- B, C, D Minerals- Fe, Ca (less than 2g/d) Fats- TLC??
5 high K food sources and what’s high?
Over 200mg per serving
Avocado, cooked broccoli or mushrooms, Brussels sprouts, fresh apricot, dates
5 foods low in K and what is low?
Less than 200 mg/serving.
Canned apricots, berries, apples, brassica family, fresh broccoli, zucchini cooked
