Crr Week 8: Chronic Kidney Disease (Tedesco)

Front 1

How is chronic kidney disease defined?

Back 1

Kidney damage (structural/function) or GFR <60ml/min for >3 months, measured on 2 separate occasions

Front 2

What is the normal GFR?

When does GFR begin to naturally decline, and how quickly does this happen?

Back 2

120 - 130 ml/min

*Declines 1ml/min/yr after 3rd decade of life

Front 3

How much of the normal kidney function is lost when GFR decreases <60 ml/min?

Back 3

Half of normal kidney function is lost

Front 4

What does stage 1 CKD entail?

Back 4

Kidney damage with normal or increased GFR
GFR > 90

Front 5

What does Stage 2 CKD entail?

Back 5

Mild decrease in GFR (60 - 89)

Front 6

What does Stage 3 CKD entail?

Back 6

Moderate decrease in kidney damage (30 -59)

Front 7

What does Stage 4 CKD entail?

Back 7

Severe decrease in GFR (15 - 29)

Front 8

What does Stage 5 CKD entail?

Back 8

Kidney failure
(GFR <15 or dialysis)

Front 9

Which 4 conditions commonly initiate glomerular injury?

Back 9

1. Renal disease
2. Hypertension
3. Diabetes
4. Obesity

Front 10

Which drugs are the most effective in reducing glomerular injury?

Back 10

Renin-angiotensin blockers

Front 11

What sort of lipid abnormalities can result for chronic kidney disease?

Back 11

1. High triglycerides (50%)
2. High IDL and high density lipoproteins
3. Decreased HDL
4. Increased homocysteine

*Total cholesterol and LDL usually normal unless nephrotic

Front 12

What is the effect of CKD on nutrition?

Back 12

Results in malnutrition and vitamin deficiencies
(hypoalbuminemia, BMI <18, anorexia, GI changes..)

*Patient must have high protein, high calorie intake

Front 13

What is the recommended calorie intake for CKD patients based on the stage of the disease?

Back 13

CKD 1-4--> 30 - 35 kcal/day (0.8g/kg/day protein)

CKD 5--> 35 kcal/day (0.6g/kg/day protein)

Front 14

Which vitamin supplements are required for patients with CKD?

Which vitamin should be avoided?

Back 14

1. Folate
2. Ascorbic acid (Vit C)
3. Vit B6
4. Selenium

*Avoid Vitamin A (since it is renally excreted)

Front 15

List 3 clinical manifestations of bone disease in CKD

Back 15

1. Hip fracture
2. Vascular and visceral complications
3. Calciphylaxis

Front 16

List 5 general treatments for disordered bone/mineral metabolism in CKD

Back 16

1. Dietary PO4 restriction (800 - 1000 mg/day)
2. Calcium and non-calcium containing PO4 binders
3. Vitamin D analogs
4. Calcimimetics
5. Parathyroidectomy

Front 17

List some foods/drinks that should be avoided to restrict dietary PO4.

Back 17

1. Dairy
2. Nuts
3. Dark colas
4. Chocolate
5. Beer

Front 18

List some calcium and non-calcium containing PO4 binders used to treat bone/mineral metabolism disorders in CKD.

Back 18

1. Calcium carbonate (TUMS)
2. Calcium acetate (>PO4 binding capacity)
3. 1-2 g elemental Ca2+/ day
4. Sevelamer

Front 19

Give an example of a Vit D analog used to treat bone/mineral metabolism disorders in CKD.

Back 19

Paracalcitol

Front 20

A parathyroidectomy should be performed if the PTH is > ______.

Back 20

> 800

Front 21

When should a parathyroidectomy be performed in a patient with CKD?

Back 21

1. PTH >800
2. Persistently elevated Ca/PO4
3. Calciphylaxis
4. Bone pain/ fracture
5. Transplant candidate

Front 22

List 3 general hematologic manifestations of CKD.

Back 22

1. Anemia
2. Abnormal hemostasis
3. Abnormalities of leukocytes

Front 23

What hemoglobin level indicates anemia?

Back 23

Hgb <13 (men and non-menstruating women)
Hgb <12 (menstruating women)

Front 24

Which hormone is the central regulator of systemic iron homeostasis?

Back 24

Hepcidin

Front 25

How does hepcidin control iron release into the plasma?

Back 25

By downregulating ferroportin (Fe export protein) on absorptive enterocytes, macrophages, and hepatocytes

Front 26

What factors stimulate hepcidin production?

Back 26

1. Iron (via HFE and HJV)
2. Transferrin receptor 2 (TFR2)
3. Inflammation

Front 27

What is the treatment for anemia in CKD?

How is it administered?

Back 27

Eryhthropoeitin stimulating agents (ESA)

IV is recommended (although subcutaneous is more effective)

Front 28

List 3 conditions that can cause ESA resistance?

Back 28

1. Iron deficiency
2. Infection/ inflammation
3. Pure red cell aplasia

Front 29

List 4 neurologic manifestaions of CKD

Back 29

1. Uremic encephalopathy
2. Uremic polyneuropathy
3. Uremic mononeuropathy
4. Autonomic dysfuction

Front 30

Signs and symptoms of uremic encephalopathy occur when GFR < ___%

Back 30

< 10%

Front 31

Distal, symmetric mixed sensory and motor neuropathy is seen in which neurological manifestion caused by CKD?

Back 31

Uremic polyneuropathy

*Stocking and glove distribution

Front 32

Which nerves are most commonly affected by uremic mononeuropathy?

Back 32

Median and ulnar nerves

Front 33

Carpal tunnel can be a result of which neurological disorder caused by CKD?

Back 33

Uremic mononeuropathy

Front 34

What are some signs of autonomic dysfunction caused by CKD.

Back 34

1. Postural/intradialytic hypotension
2. Impotence
3. GI motility

Front 35

A patient should be referred to a nephrologist if GFR <_____ml/min.

Back 35

< 30 ml/min

Front 36

When should a patient with CKD be referred to a nephrologist?

Back 36

1. GFR < 30 ml/min
2. GFR decline >30% over 4 months with no explanation
3. Hyperkalemia despite treatment
4. Resistant HTN
5. High risk of progression
6. Difficult medical management

Front 37

What are the 2 most common causes of chronic kidney disease?

Back 37

1. **Diabetes
2. Hypertension

Front 38

How does Angiotensin II contribute to glomerual damage in the progression of chronic kidney disease?

Back 38

1. Increased efferent arteriole resistance
2. Mediates contraction of foot processes in GBM
3. Proliferation of glomerular cells and fibroblasts --> interstitial fibrosis
4. Upregulation of TGF-B--> increased collagen type IV
5. Inhibits plasminogen activator inhibitor 1--> increases ECM accumulation
6. Upregulation of genes resposible for chemotactic and vasoactive peptides

Front 39

List some clinical manifestations/ complications of CKD

Back 39

1. Cardiovascular disease (CVD)
2. Lipid abnormalities
3. Malnutrition
4. Na and H20 handling
5. K+ handling
6. Bone/mineral abnormalities
7. Hematologic abnormalities
8. Neurologic/uremic/autonomic abnormalities

Front 40

What is the most common vascular cause of death in dialysis patients?

Back 40

Cardiac arrest/ arrhythmia

Front 41

Na/H20 handling is usually not impaired in CKD until GFR < ______ ml/min.

When above this value, how can Na+ balance be maintained?

Back 41

<10 ml/min
(don't usually have to worry about dietary and fluid restriction until this point-- unless they have other comorbidities)

*Increase FeNa

Front 42

K+ should be restricted in CKD patients when GFR < _____ml/min

Back 42

< 10 ml/min
(restrict to 40 -60 mEq/day)

Front 43

Decreased serum Ca2+ levels, stimulate the secretion of which hormone?

Back 43

PTH

Front 44

What are the actions of PTH on the kidney and bone?

Back 44

Kidney:
1. Increased Ca2+ reabsorption
2. PO4 excretion
3. 1-hydroxylase

Bone
Ca2+ and PO4 resorption

Front 45

How often shouls PTH, Ca2+, and PO4 be measured in patients with Stage 3,4, and 5 CKD?

Back 45

Stage 3 --> every 12 months
Stage 4 --> every 3 months
Stage 5 --> PTH every 3 months, Ca2+ and PO4 every month

Front 46

What is the target range for PO4 when treating Stage 3, 4, and 5 CKD?

Back 46

Stage 3,4 --> 2.7- 4.6
Stage 5 --> 3.5 - 5.5

Front 47

What is the target range for the product of Ca2+ and PO4 (Ca x PO4) when treating Stage 3, 4, and 5 CKD?

Back 47

Less than 55 for all stages

Front 48

What factors induce EPO?

Back 48

Hypoxia-inducible factors (HIF-1, HIF-2)

Front 49

What is the effect of hypoxia on hepcidin?

Back 49

Hypoxia inhibits hepcidin

Front 50

What is the effect of erythropoesis on hepcidin?

Back 50

Erythropoesis inhibits hepcidin

Front 51

How often should patients with CKD be screened for anemia?

What is the goal of treatment?

Back 51

Yearly screening

Check iron, TIBC, Tsat, and ferritin

*Goal --> Tsat >20%, ferritin >200

Front 52

What is the target Hgb level in patients with CKD?

Back 52

Hgb 9 -11