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49 Cards in this Set

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aka for Chronic Renal Failure (CRF)?
Chronic Kidney Disease (CKD) is preffered/new
-also End Stage Renal Disease
Define Chronic Kidney Disease,CKD?

What is Uremia?
Long-standing, IRREVERSIBLE impairment of Renal Function

Uremia: Clinical Syndrome Resulting from Profound loss of Renal Function--ie will have Azotemia (high BUN lab) plus systemic symptoms
What is used to measure GFR?
2 ways
Inulin--but lab needs to be setup for it. and have it to give IV

whereas
Creatine Clearance: 24 hour Urine Sample measured and related to Serum Creatinine
--
What is MDRD
Modified Dietary approach to Renal Disease
--use to correct GFR
---special formula, dont worry about it unless given
What is KDOQI
Kidney Disease Outcomes Quality Initiative
--way to get MDRD or
What is Cockcroft-Gault Eqn?
Used for GFR, not as accurate as MDRD
What are the 5 stages of CKD?
give associated GFRs
1. Kidney Damage with NOrmal or Inc. GFR: >90
2. Mild Dec in GFR: 60-90
3. Moderate Dec in GFR: 30-59
4. Severe Dec in GFR: 15-29
5. Kidney Failure--aka ESRD --<15 GFR or on Dialysis


Have to know these
What is Name and GFR of Stage 3 CKD?
memory Trick?
3 for 30
Stage 3/Moderate has miimum GFR of 30
3. Moderate Dec in GFR: 30-59
What is name and GFR for Stage 2 CKD?
Stage 2: Mild: 60-89
just parameters of Stage 3 (low is 30) and add 30 (29 really)
What is Stage 1 CKD?
Kidney Damage with Normal or Increased GFR >/= 90
What is Stage 4 CKD?
Memory trick?
Stage 4: Severe Decrease
15-29

Know that 4 is just before ESRD, which is GFR less than 15
What is Stage 5 CKD
Kidney failure
aka ESRD
<15 GFR OR on Dialysis
What is worry in Early stage CKD, ie if symptom free/overall fxn intact?

NOTE: for at least next 10 flash cards, Kirilas slides/explanations fucking blew. Also her slides and speech confused Azotemia and Uremia as if interchangeable, but did not say where its correct/incorrect
Reserve Functionis diminished
--ie a small assualt can throw into failure

----so just read these next 10 guys, perhaps even think about them. but thats all. You're number 1! dave kramer is gay
Case 1: 58y/o Female, Hx of Sarcoidosis, intermittant HTN, Elevated Blood sugars when on Steroids for sarcoid
-eGFR: 80 = stage?
-ACE-I to protect kidney
-Azotemia
-Dec Reserve--sudden stress, ie UTI could trigger failure
Stage 2 CKD: 60-89
What is the effect of the following?
Inc. ICF Na+
Dec ICF K+
Ibx of Ca+ flux?
Reduction of Transmembrane Voltage
--ie, here these are Uremic Toxins
---Note: Uremia and its effects are largelu reversible with dailysis
Name some common effects of Uremic Toxins on Whole body Composition
Osmotically Induced Overhydration of Cells
--Inc 3rd Spacing--aka inc EC Volume
--Malaise, Anorexia, N/V/D
----Pr & Calorie Malnutrition
----Neg Nitrogen balance
---Profound loss of Lean body mass and fat deposits

--shitty slide just read this
Unusual Effects of Uremic Toxins on Metabolism include?
Hypothermia: dec in active Na transport
-ICF K+ deficits
-Metabolic Acidosis
What are Uremic Toxins' effects on nitrogen and Lipids
Protein intolerance
--inc catabolism in uremia
--dec elimination

HyperTG-emia, dec HDL, Normal Cholesterol
--dec removal by LipoPr Lipase
--inc lipogenesis (plus lose lean mm mass)
--may have inc. production of LDLs
Effects of Uremic Toxins on Na and Volume Homeostasis
Total Body content of Na and Water are increased modestly --in stable CKD

-Excessive Salt Ingestion can lead to :
CHF, HTN, Ascites, Edema
What might be restricted from diet before dialysis?
Protein Restriction
---due to Nitrogen/protein intolerance
--results from inc catabolism in uremia
What is fluid intake for pre-dialysis?
Urine Output plus 500ml/Day
Describe the K+ effects in CKD?

When goes bad, what happens?
Normal until Late Stages

Inc. K+ = Cardiac Arrys
What are some drugs that cause Increase in K -- aka
AntiKliuretic Drugs?
Spironolactone
Tramterene
Amiloride
TMP
Pentamidine

ACEs
Beta Blockers

NOte: Spironolactone--diuretic also used as anti-androgen
What are some extrerenal fluid loss mechanisms
GI Syndrome
Vomiting, Diarrhea, Fever,
--cause volume depletion
---result in Dry Mucous mems, dizziness, syncope, Tachy, dec. JVP, Orthostasis, CV Collapse
What is most complication of ESRD?
HTN as a result of Primary Renal Dz or effects of Kidney from Systemic Dz

-Chronic Dialysis Pts also have a higher incidence of Accelerated Atherosclerosis which contributes to the HTN
What if Pt is ESRD and does NOT have HTN
Consider:
Salt Wasting Form of renal Dz

volume depletion
Or
ON Anti-HTN Meds at time
Commonest Pulmonary complication of CKD?

X ray feature
Pulmonary Congestion (can have even in absence of volume overload--unique)
--due to Normal or mildly elevated Intracardiac or Pulmonary Wedge Pressures

-CXR: Butterfly Wing distribution--peripheral vascular congestion
--due to increased permeability of alveolar caps
What is another heat condtion assc/ CKD?
any Itis
ie, Pericarditis
Pleuritis
--less frequent in early dialysis
---think viral if present while on dialysis
Associated Conditions, hematologic?
Normocyte, normochromic anemia

-hemolysis--can be in uremic pts

occasionally hypersplenism
How might the be immune compromised?
Focus on fact just that they are
but reasons can be
--Lymphocytopenia
--atrophy of lymphoid strs
--Uremia impairs fxn of all leukocytes
Specific disease to bone with uremia?
Most common Osteopenia and Osteomalacia , but

Renal Rickets --widened osteod seams at growth margins
plus
--Osteitis Fibrosis cystica--2nd to Hyperparathyroidism (bone resorption)
--Osteosclerosis
What compounds must certainly be avoided in long term dialysis with regard bone problems?
Aluminum and Magnesium containing compounds
--can buildup and lead to bone problem
---not cleared in pre-dialysis pts
--Mg in Many Antacids

note: dialysis can cause amyloidosis
Case #3: 42y/o Fem. inc fatigue, dyspnea, poor appetite, BP rising, Lipids and swelling of extremities.
Labs: RBC casts, inc K, Low Albumin and eGFR = 20 (=stage 4, severe (15-29))
Proteinuria
FHx with kidney probs
+ diabetics in fam

Diagnosis?
Idiopathic Nephrotic Syndrome

-not pt is not diabetic, no prior HTN
Case continued:
Biopsy showed FSGS which compromises 15% of Nephrotic Syndromes
---this progresses and is difficult to reverse
What is Tx?
NO proven tx,
Steroids +/- cytotoxic agents can be tried
--Start Dialysis
List Indications of Dialysis?
Unresponsive to Conserv Mesures
-Volume overload refract to diuretics
-Hyperkalemia
-Encephalopathy otherwise unexplained
-Pericarditis, Pleuritis...itises
-Severe Metabolic Acidosis compromising Resp or Circulatory Fxn
-Need for Fluids/Drugs also a consideration??
What are 2 sorts of Dialysis?
Hemodialysis or Peritoneal Dialysis

Hemodialysis--uses A/V Fistula
Complications from Peritoneal Dialysis?

fluids drained and reput in peritoneum
Peritonitis
Hyperglycemia
HyperTG-emia
Obesity
HypoPr-emia
Dialysis related Amyloidosis
-Insuf Cl due to vascular dz, etc

DONT worry about all these
Name a few unique Physical Exam findings on these patients?
JVD
Pericardial friction rub
-Mm wasting
-Asterixis---hands flow
-Exocoriations & Ecchymoses

--Urochrome on skin--ITCHY
What are the Labs that are usually high in ESRD?
Potassium
Phosphate
Uric Acid
What are the labs most often low in ESRD
Calcium
Albumin (serume0
Hemoglobin

pH will be low too
What are some conservative Tx for ESRD?
Aggresive HTN meds
Diuretics, VOlume Restrictions
EPO--recombinant
-Restrict Protein

note: at certain point diuretics wont work
What are some conservative Tx for ESRD regarding GI syndromes?
Bicarb
--helps with acidosis, and helps bind Phosphate, which is often high
What med binds K+ to lower ?
Kayexalate
-sodium polystyrene sulfonate
or just restrict potassium
What are 2 potassium Wasting
ie NON Antikalemuretics
Lasix or Furosamide

--albutoral inhaled can lower potassium w/o changing fluid status
What are the 2 methods (timing) for Dialysis?
PD: peritoneal dialysis, cycler
IHD: intermittent--most used for ARF, CKD wil get 3x perwk
-Night time dialysis= home dialysis
What is CRRT
Continuous Renal Replacement Therapy
--used if intolerant to IHD
--or in extremely unstable ICU pts
not emphasized, but
Complications of Hemodialysis?
Hypotension
Accelerated Vasc Dz
Rapid Loss of Residual Renal Fxn
Access Thrombosis
Access Catheter Sepsis
-Amyloidosis
-Protein-Calorie Malnutrition
-Hemorrhage
-Dyspnea/hypoxemia
-Leukopenia
What are Contraindications for Renal Transplant
Active Glomerulonephritis
Active Infection
Active or Very Recent Malignancy
HIV
Hep B Surface Antigenemia
Severe Cormobities (vascular disease)

just read em/consider them
--kramers penis is smaller than mine
What are some RELATIVE contraindications for Renal Transplant?
Age > 70 yrs
Severe Psychiatric Dz
Moderately Severe Comorbs
-Hep C with chronic Hepatitis
or cirrhosis
Noncompliance with dialysis or other Tx
Immunosuppression/neoplasm

Other Primary Renal Dzz