Chronic Kidney Disease 1St Lec

Front 1

How is CKD defined?

Back 1

Kidney damage for ≥ 3 months, defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either
Pathologic abnormalities, or
Markers of kidney damage, such as abnormalities of the blood or urine, or in imaging tests (but NOT HTN).

Front 2

How is CKD defined via GFR lab value?

Back 2

GFR < 60 mL/min/1.73 m2 for ≥ 3 months with or without kidney damage.

Normal GFR varies according to age, sex, and body size; in young adults it is approximately 120 to 130 mL/min/1.73 m2 and declines with age. A decrease in GFR precedes the onset of kidney failure;

Front 3

What are 4 markers of kidney damage?

Back 3

Proteinuria

Microalbuminuria

Hematuria (especially when seen with proteinuria)
Isolated hematuria has a long differential: infection, stone, malignancy, etc.

Casts (especially with cellular elements)

Front 4

What is the description, GFR and Action of stage 1 kidney disease?

Back 4

kidney damage with normal or increased GFR

90

Diagnosis and treatment, treatment of comorbid conditions, slowing of progression, and cardiovascular disease risk reduction

Front 5

What is the description, GFR and Action of stage 2 kidney disease?

Back 5

Kidney damage with mildly decreased GFR

60-89

Estimation of progression

Front 6

What is the description, GFR and Action of stage 3 kidney disease?

Back 6

Moderately decreased GFR

30-59

Evaluation and treatment of commplications

Front 7

What is the description, GFR and Action of stage 4 kidney disease?

Back 7

Severely decreased GFR

15-29

Preparation for kidney replacement therapy

Front 8

What is the description, GFR and Action of stage 5 kidney disease?

Back 8

Kidney failure (defined as ESRD if renal replacement therapy is needed)

<15

Renal replacement therapy (if uremia is present

Front 9

What are susceptibility Risk Factors?

Back 9

Advanced age
Reduced Kidney mass
African American
Family history
Low income or education
Systemic inflammation
dyslipidemia

Front 10

What are initiation risk factors?

Back 10

DM
HTN
glomerulonephritis

Front 11

What are progression risk factors?

Back 11

Glycemia
HTN
Proteinuria
Smoking
Obesity

Front 12

What is the life expectancy in dialysis patients?

The primary cause of death in ESRD patients is what?

What are strong predictors of mortality in the dialysis population?

Back 12

Life expectancy is four to five times shorter in dialysis patients than in the general population.

The primary causes of death in the ESRD population are cardiovascular diseases and infection

Comorbidities, estimated GFR, and albumin at initiation of dialysis are strong predictors of mortality in the dialysis population.

Front 13

The Patient with early stage CKD is 5 to 10 times more likely to die from a ____ event than ___ __ ___

Back 13

CV

progress to ESRD

Front 14

What 1 thing may contribute to the progressive decline in kidney function?

Loss of kidney function is usually ____

Back 14

Proteinuria, one of the initial diagnostic signs, may also contribute to the progressive decline in kidney function. Loss of kidney function is usually irreversible.

Front 15

How is miroalbuminuria diagnosed according to lab values?

Back 15

Only taken from ALbumin
24-hour collection (mg/d):30-300

Spot urine dipstick (mg/dl): >3

Spot uring albumin: Cr ratio mg/g
17-250 in men
25-355 in women

Front 16

How is Protein Uria Diagnosed according to lab values?

Back 16

Total Protein
24 hours collection: >300
Spot Urine Dipstick: >30
Spot Urine Protein: Cr ratio: >200

Albumin: 24 hour collection> 300
Spot urine Albumin: Cr ratio:
>250 in men
>355 in women

Front 17

Progressive Kidney disease
Each of the following may result in damage to the kidney that leads, over time, to a decrease in functioning nephrons and in total GFR

Back 17

Diabetes (accounts for primary cause in 44% of patients with ESRD)
Hypertension (accounts for primary cause in 26% of patients with ESRD)
Glomerulonephritis--> blood in the urine, foam urine, edema
Cystic kidney disease
HIV (human immunodeficiency virus) nephropathy
Other contributing factors

Front 18

What one sign/symptom indicates proteinuria?

Back 18

foaming of urine

Front 19

How is Microalbuminuria defined?

Back 19

Albumin in the urine in amount of 30-300 mg/d

Front 20

what is albuminuria defined as?

Back 20

albumin in the urine in amounts >300 mg/d

Front 21

What is clinical proteinuria defined as?

Back 21

Total protein in the uring in amounts >300

Front 22

What is a common Etiology that results in CKD?

What are common etiologies for ckd in diabetics?

What are signs and symptoms associated with fluid and electrolyte abnormalities?

Back 22

increased bp

hyperglycemia and glucosuria

hyperkalemia and fluid overload

Front 23

What are 4 developments of secondary complication of CKD?

Back 23

Anemia: Decreased hemoglobin and hematocrit, iron deficiency common

CKD mineral and bone disorder: Increased serum phosphorus, decreased serum calcium (at risk for hypercalcemia as kidney disease progresses), increased intact parathyroid hormone (iPTH), and vitamin D deficiency

Metabolic acidosis: Decreased serum bicarbonate and increased anion gap

Malnutrition: Decreased albumin and prealbumin

Front 24

What stages of CKD is there a vit D deficency?

Back 24

Stages 3 and 4

Front 25

What does active Vit D promote?

Back 25

promotes increased intestinal absorption of calcium and suppresses production of parathyroid hormone by the parathyroid gland; therefore, vitamin D deficiency leads to worsening secondary hyperparathyroidism.

Front 26

What does increased iPTH promote?

Back 26

Decreased phosphorus reabsorption within the kidney
Increased calcium reabsorption by the kidney
Increased calcium mobilization from bone

Front 27

As kidney disease progresse, what 4 components occur?

Back 27

1.Hyperphosphatemia and subsequent hypocalcemia progressively worsen, and secondary hyperparathyroidism becomes more severe.

2.The renal effects of PTH on phosphorus and calcium are no longer maintained, and PTH predominantly stimulates calcium resorption from bone.

3.Decreased production of active vitamin D worsens hypocalcemia and secondary hyperparathyroidism.
In more severe CKD (stages 4 and 5), patients are prone to develop hypercalcemia, in part because of the use of calcium-containing phosphate binders.
Patients with stage 5 CKD are at risk for calcifications and calciphylaxis.

4.Uncontrolled secondary hyperparathyroidism leads to hyperplasia of the parathyroid gland and renal osteodystrophy (from sustained effects of iPTH on bone).

Front 28

What is Metabolic acidosis defined as?

Back 28

Decreased excretion of acid by the kidney
Accumulation of endogenous acids attributable to impaired kidney function (e.g., phosphates and sulfates)

Front 29

What stage does malnutrition develop in?

When assesment needs to be made?

Back 29

Usually develops starting in stage 3 patients

Dietary assessment for protein calorie intake serum albumin

Front 30

When there is a progressive increase in scr what must be considered?

When there is a decrease in GFR what assessment methods should be considered?

Back 30

serum creatinine: > 1.1–1.2 mg/dL for females and > 1.2–1.3 mg/dL for males. Consider factors that may alter serum creatinine, such as decreased muscle mass and nutritional status

Measured creatinine clearance
Cockcroft–Gault equation
Modification of diet in renal disease abbreviated equation

Front 31

By looking at which abnormal serum chemistries can you diagnosis if its Microalbuminuria, albuminuria, or clinical proteinuria?

Back 31

Increased serum creatinine (0.6-1.2) and BUN (8-18)
Increased potassium (3.5-5), decreased serum bicarbonate (22-28), increased phosphorus (2.5-5), and decreased calcium (8.8-10.2 total) (unbound 4.6-5.2)(indicative of secondary complications)

Front 32

What risk factos should we really pay attention to when screening for chronic kidney disease?

Back 32

Diabetes

Hypertension

Family history of chronic kidneydiseases

US ethnic minority status: black, indians, hispanics, asian or pacific island

Front 33

When evaluating for patients for chronic kidney disease, what tests should be run?

Back 33

Measure BP

Serum Creatine to estimate GFR

Protein to creatinine ratio or albumin to creatinine ratio in a first morning or random untimed spot uring specimen

Front 34

What 2 functions is SCR considered to be?

Back 34

S. creatinine is a function of production (muscle mass) and excretion (both GFR and tubular secretion).

Front 35

What factors increase Scr concentrations?

What factors decrease it?

Back 35

Kidney Disease
Ketoacidosis
Ingestion of cooked meat
Drugs:
Trimethoprim (trimadex, proloprim)
Cimetidine (tagmet)
Flucytosine (ancobon)
Some cephalosporins

Ruduced Muscle Mass
Malnutrition

Front 36

What does the MDRD equation estimate?

What does the Cockcroft-Gault equation estimate?

Back 36

The MDRD equation estimates GFR.
eGFR is given per 1.73m2 BSA
The Cockcroft-Gault equation estimates CrCl.
CrCl is best used for drug dosing decisions--drug dosing is usually indexed to CrCl.

Front 37

What is the number 1 rand 2 risk factors for ckd?

Back 37

DM

HPN

Front 38

What has to happen in stage 5 CKD?

Back 38

Dialysis regardless o GFR

Front 39

Guidelines for anemia management in patients with CKD recommend further evaluation for anemia when hemoglobin is what?

Back 39

is < 12 g/dL in females and < 13.5 g/dL in males.

Front 40

For iron deficiency what must be evaluated?

Back 40

For iron deficiency, evaluate red blood cell indices and iron indices to identify iron deficiency as a contributing factor; iron deficiency manifests as a microcytic anemia.

Front 41

What do you do when evaluating cause in iron deficiency?

Back 41

In post-menopausal females and males you have to evaluate for GI blood loss.

In menstruating females, menses is a common cause; the most common cause of anemia overall in females.

Front 42

How do you treat Iron deficiency?

Back 42

Iron replacement can typically be given orally, ferrous sulfate or gluconate 325 mg, 1-3 times a day

Sulfate salt is cheaper but generally less well tolerated

Front 43

During Iron therapy, what SEs may lead to low compliance?

What enhances absorption of Fe?

When should HCT improve, and how long should therapy be continued for?

Back 43

Side effects of oral iron replacement lead to low compliance.
Constipation, stomach upset
May have less symptoms if they take it with food (though this decreases absorption)

Vitamin C enhances absorption

Expect Hct to improve within a few weeks of therapy though pts should continue treatment for 6 mo -1 yr, would like to see ferritin level normalized

Front 44

How is CKD Mineral and Bone disorders diagnosed?

Back 44

Serum phosphorus: > 4.6 mg/dL (> 5.5 mg/dL in stage 5 CKD)

Calcium abnormalities:
Hypocalcemia: Corrected serum calcium < 8.5 mg/dL
Hypercalcemia (a concern in stages 4 and 5 CKD): Corrected calcium = measured serum calcium + 0.8 x(normal serum albumin – measured serum albumin); normal serum albumin = 4.0 g/dL

Elevated calcium x phosphorus product: > 55 mg2/dL2 (elevated product increases risk for metastatic calcifications)

Intact parathyroid hormone: > 70 pg/mL (stage 3 CKD), > 110 pg/mL (stage 4 CKD), and > 300 pg/mL (stage 5 CKD)

Radiographic evidence of bone abnormalities (e.g., osteitis fibrosa cystica)

Front 45

Hot to diagnosis Metabolic Acidosis?

Back 45

Serum bicarbonate (HCO3–) is < 20 mEq/L.

Front 46

What are treatment principles for CKD? KNOW THESE!

Back 46

Control underlying cause of progressive CKD
Meet blood pressure goal: < 130/80 mm Hg for patients with evidence of kidney disease and/or diabetes.
Prevent or minimize microalbuminuria or proteinuria.
Slow the rate of progression of CKD
Address cardiovascular risk factors
Control hyperlipidemia.
Recommend smoking cessation.
Prevent drug-induced causes of kidney disease:
Avoid chronic use of combinations of analgesics.
Minimize use of agents known to cause AKI (patients can develop an acute-on-chronic kidney disease).
Manage secondary complications of CKD (anemia, mineral and bone disorders, and electrolyte abnormalities).
Adjust drug doses on the basis of kidney function.
Avoid medications contraindicated in patients with reduced kidney function.
Prepare patient for renal replacement therapy (i.e., dialysis and transplantation) as needed.
Start dialysis if stable GFR < 15 mL/min/1.73 m2 and based on other indications