W3 Chronic Kidney Disease (CKD)

Question 1

a 65-year-old male with shortness of breath, loss of appetite, and fatigue. He denies any chest pain but states that his wife noticed his legs appear swollen. Medical history is significant for diabetes, hypertension, and obesity. On physical exam, there is decreased tactile fremitus and dullness to percussion of the chest wall. There is pitting edema in the lower extremities. His blood pressure is 160/98 and temperature is 99.9°F. On laboratory testing, his glomerular filtration rate (GFR) is 45 mL/minute/1.73 m2. His urinalysis reveals broad waxy casts.

What is the diagnosis?
Associated with?

Answer 1

Chronic Kidney Disease
Anemia of chronic disease (d/t lack of EPO production)

Question 2

In CKD, there is a decreased excretion of what electrolyte?

Answer 2

Phosphate

Question 3

CKD eGFR?
For how long?
Plus which 4 other possible things?
What are they top 3 causes

Answer 3

Diagnosis of chronic kidney disease is based on eGFR < 60 mL per minute per 1.73 m2 for three months or any of the following:

—albuminuria (urine albumin-to-creatinine ratio > 30 mg/day)
—proteinuria (urine protein-to-creatinine ratio > 0.2)
—hematuria or abnormal findings on urinalysis
—structural renal abnormalities, including solitary kidney; a history of abnormal renal histology; or history of renal transplantation.

Top three causes are:
1. Diabetes is the most common cause (30% of cases)
2. HTN is responsible for 25% of cases
3. Chronic GN accounts for 15% of cases
4. Interstitial nephritis, polycystic kidney disease, obstructive uropathy
5. Any of the causes of AKI may lead to CKD if prolonged and/or if treatment is delayed

Question 4

What are the stages of CKD ?

Answer 4

Stage 1: normal GFR (≥ 90 mL/min/1.73 m2) plus either persistent albuminuria or known structural or hereditary renal disease
Stage 2: mild GFR 60 to 89 mL/min/1.73 m2
Stage 3: moderate GFR 30 to 59 mL/min/1.73 m2
Stage 4: severe GFR 15 to 29 mL/min/1.73 m2 (symptomatic stage)
Stage 5: kidney failure GFR < 15 mL/min/1.73 m2

Question 5

What is the gold standard diagnosis of CKD?
Which is the marker for kidney damage
What appears early in disease
Which 2 things are elevated
Which electrolyte imbalances?
Low ______ levels ?

Answer 5

Measurement of GFR is the gold standard - The Cockcroft - Gault formula (requires age, body weight, and serum creatinine) or Modification of Diet in Renal Disease (MDRD) equation

—Proteinuria is a marker for kidney damage, —microalbuminuria appears early in the disease
—BUN and creatinine are elevated
—Hemoglobin and hematocrit, serum electrolytes, and urinalysis are abnormal
—CKD results in hyperphosphatemia (lack of urinary secretion) and hypocalcemia along with hyperkalemia and acidosis
—Will have low EPO levels

Question 6

Treatment of CKD
Which med to slow the progression?
Which comorbidity should you be managing ?
How do you maintain a Hgb of 11-12?
Which dietary recommendations?
Which vaccination?

Answer 6

—ACE inhibitors and ARBs: slow the progression of renal dysfunction, particularly in proteinuric patients
—Managing comorbidities: Hypertensive control (< 140/90 JNC8 or <130/80 ACC/AHA), tight glycemic control (A1C 6.5-7.5%), cholesterol control, tobacco cessation
—Maintain Hemoglobin at 11 -12 g/dl: erythropoietin, iron supplementation, and antiplatelet therapy
—Dietary management: protein restriction, calcium, and vitamin D supplements, limitation of water, sodium, potassium, and phosphorus
—Need for hemodialysis or kidney transplant should be coordinated with a nephrologist
—Pneumococcal vaccination