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57 Cards in this Set
- Front
- Back
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Definition of CKD
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Based on measurement of GFR
Annual decline in GFR is about 1ml/minute/1.73m2 after ages 25-30 GFR less than 60 is indicative of CKD Defined as a structural of functional abnormality of the kidney that lasts greater than 3 months Manifestations of damage include abnormalities in blood, urine or imaging tests |
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CKD staging
Stage 0 |
Description- Increased risk
GFR- >90 w risk factors Action- screening with risk reduction |
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CKD staging
Stage 1 |
Description- Damage with normal GFR
GFR- >90 Action- DX and treat Slow progresion Treat comorbidities |
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CKD staging
Stage 2 |
Description- Mild decrease GFR
GFR- 60-89 Action- DX and treat Slow progresion Treat comorbidities |
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CKD staging
Stage 3 |
Description- Moderate decrease GFR
GFR- 30-59 Action-RX complications |
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CKD staging
Stage 4 |
Description- severe
GFR- 15-29 Action-Prepare for renal replacement therapy |
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CKD staging
Stage 5 |
Description- na
GFR- <15 Action- dialysis |
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What CDK stage?
Description- Increased risk GFR- >90 w risk factors Action- screening with risk reduction |
Stage 0
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What CDK stage?
Description- Damage with normal GFR GFR- >90 Action- DX and treat Slow progresion Treat comorbidities |
Stage 1
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What CDK stage?
Description- Mild decrease GFR GFR- 60-89 Action- DX and treat Slow progresion Treat comorbidities |
Stage 2
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What CDK stage?
Description- severe GFR- 15-29 Action-Prepare for renal replacement therapy |
Stage 4
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What CDK stage?
Description- na GFR- <15 Action- dialysis |
Stage 5
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What CDK stage?
Description- Moderate decrease GFR GFR- 30-59 Action-RX complications |
Stage 3
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Prevalence of CKD, what stage?
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Stage 3
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Calculating the GFR
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Cockcroft-Gault Equation-
(140-age)(weight in kg)/72Xserum Cr. Multiply times .85 for female MDRD formula (modif of diet in renal disease) Serum creatinine is commonly used but imperfect Up to 15% of Creatinine is secreted and as renal function declines a greater proportion is secreted, thereby overestimating filtration Inulin is filtered but not secreted or absorbed, and is more accurate but requires an IV injection and therefore not readily available Several equations available to help estimate GFR |
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Formulas for GFR Estimation
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Cockcroft-Gault Equation-
(140-age)(weight in kg)/72Xserum Cr. Multiply times .85 for female MDRD formula(modification of diet in renal disease) GFR(ml/min/1.73m2) = 1.86 X (Serum Creatinine)-log1.154x(age)-log0.203x(0.742if female)x 1.210 if African American). Now considered the gold standard for GFR less than 60 |
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GFR- how much cr males/females excrete?
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24 hour urine is an accepted alternative.
Volume is irrevelant Need to measure total creatinine in urine in order to determine completeness of collection Males excrete 20-25mg creatinine per kg of body weight; females 15-20 Patients must be steady state to estimate GFR utilizing any of these methods |
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Progression of CKD
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Pathologic process that causes loss of functioning nephrons and leading to hyperfiltration
Initially this mechanism helps preserve GFR but eventually leads to capillary stretch and glomerular injury This can lead to upregulation of RAAS and further glomerular hypertension Excessive protein excretion is a result of this hyperfiltration and increased glomerular permability |
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Risk Factors for CKD Progression
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Hypertension
Diabetes Mellitus High Protein Diet Elevated Lipids Smoking Proteinuria |
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Hypertension and CKD
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Clearly associated with disease progression
Hypertension is second most common cause of ESRD Hypertension hastens the decline in CKD in both diabetic and non-diabetic patients JNC VII recommends in patients with CKD and protein <1g/day goal BP less than 130/85; >1g 125/75 Inhibition or RAAS is effective in lowering BP, reducing proteinuria and slowing progression of renal disease in both diabetic and non-diabetic patients |
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Diabetes and CKD Progression
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Most common cause of ESRD
Intensive insulin therapy can reduce disease progression by 30% in Type I Diabetes Intensive insulin therapy to maintain HgbA1c around 7 reduces progression of kidney disease Use antihypertensives that work in RAAS to reduce disease progression and protein excretion |
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Dietary Protein Restriction
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Low protein diet seems to decrease glomerular hyperfiltration in animals and slow disease progression
Less clear in humans Concern is for malnutrition High protein diets likely detrimental Recommend balanced diet; 0.8-1g protein per kg body weight |
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Lipid Reduction in CKD
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LDL lipids may be toxic to mesangial cells
Statins seem to reverse this process Studies are small and inconclusive Lipid lowering may reduce cardiac risk in CKD patients |
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Smoking Cessation in CKD
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Smoking is independent risk factor for progressive CKD
May raise BP Increases single nephron GFR and hyperfiltration Smoking raises aldosterone levels, further raising BP Increases the risk of albuminuria in diabetic patients Counsel smoking patients to quit |
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ACE Inhibitors, usage, SE
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(-prils)
Block conversion of angiotensin I to II Drug of choice in Type I diabetics with HTN and also Type I diabetics with proteinuria and normal BP SE angioedema and dry cough Likely to be beneficial in Type II diabetes |
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ARB Agents
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Newer than ACE inhibitors but with apparent similar beneficial effects.
Block Angiotensin receptors blocking the effect of Angiotensin II thereby lowering the systemic blood pressure and intraglomerular pressures No cough associated side effect noted. Drugs include -Candasartan(Atacand),Irbesartan(Avapro), Olmesartan(Benicar), Valsartan(Diovan),and Losartan(Cozaar). NO SE! |
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Diuretics (w. fluid restriction)
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Diuretics are commonly used in CKD
Many patients suffer from fluid retention as a result of their kidney disease Patients frequently are in HCTZ as diuretic but as renal failure progresses, pts will require more potent loop diuretics. These medications include Bumetanide(Bumex), Furosemide(Lasix), and Toresemide(Demadex) Metalozone(Zaroxlyn) frequently added to loop diuretic given frequent development of diuretic resistance in CKD |
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Direct renin Inhibitors
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Newest class that work in RAAS
Reduce proteinurea in DM Outcome data lacking Aliskiren is the only 1 available in the class Lower protein excreation in different places Some outcome data is less favorable, unclear whether combination is beneficial or detrimental ARB+ACEi- don't combine- ARF |
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Diuretics SE
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Side effects include cramping, dry mouth, dizziness.
May or may not need potassium supplement If prescribed a diuretic, do not “push” the fluids, as the diuretic is designed for fluid removal and high intake of salt and water will negate the effects of the diuretics Weighing yourself each day will be the best guide of fluid status |
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Lipid Medications
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Elevated lipids are very common in renal patients
As with the general population, cardiac diseases remains the most common cause of death Kidney patients, especially those with proteinuria, frequently have elevated lipids as part of the nephrotic syndrome Diet alone will not generally lower lipids to the “normal range in patients with significant protein excretion Reduction of protein excretion will frequently help lower lipids (ACE/ARB agents frequently used) Dietary counseling still a mainstay of therapy, as is exercise Fibrates- Tricor, Gemfibrozil(Lopid)- monitor liver function, muscle enzymes, gallstone development. Lower primarily triglycerides Statins- Lipitor, Mevacor, Pravachol, Crestor, Zocor- most commonly prescribed, lower both triglycerides and cholesterol. Frequently used in patients with proteinuria and nephrotic syndrome |
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Bone Metabolism
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Low phosphate diet will at least early in the process, prevent bone disease
Phosphate binders can be given with meals to reduce phosphorus absorption GI side effects with these medications common; bloating, constipation, diarrhea, nausea Can bind other medications given concomitantly Calcium containing binders- Calcium carbonate(Tums, Oscal, Caltrate). Available OTC, good Calcium absorption, inexpensive but not as an effective a phosphate binder as calcium acetate Calcium acetate- Phoslo; Rx product. Less calcium absorption but better phosphate binding. Some increased complaint of nausea Calcium citrate- better calcium absorption but less phosphate binding Not recommended as it can enhance aluminum absorption which can accumulate in renal failure Aluminum based binders/antacids- very effective binders but not utilized much as aluminum ca accumulate in renal failure Aluminum binders include Alternagel, Amphogel, Alu-caps. Concern is aluminum absorption and subsequent deposition in bone, brain etc. Short term use OK, but not generally used longer term Antacid of choice prn in renal faliure Sevelamar(Renagel)- non-calcium, non-aluminum phosphate binder primarily used in ESRD Effective phosphate binder without concern for calcium excess Does not provide needed calcium in calcium deficient patients Can induce metabolic acidosis General approach to binder use Low phosphate diet Calcium carbonate in mild hyperphosphatemia Calcium acetate in more severe cases; limit amount of calcium ?3grams/day to avoid calcification of blood vessels Renagel alone or in combination with calcium containing binders inmore sever cases In patients with low normal calcium some calcium supplement needed In addition to calcium and phosphorus, the kidneys make the active form of Vitamin D As renal function worsens, vitamin D deficiency develops, thereby leading to hyperparathyroidism Supplementing vitamin D suppresses PTH, but can lead to increased calcium and phosphorus absorption from the GI tract Three available vitamin D supplements Calcitriol(Rocaltrol)- available generically, less costly; ? Increased phosphorus absorption over the others Doxercalciferol(Hectorol)- newer than calcitriol Paracalcitriol(Zemplar)- likely comparable to Hectorol in efficacy These medications are titrated to keep PTH levels 2-3X normal to avoid over or under suppression of parathyriod glands |
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Metabolic Acidosis
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Renal failure leads to metabolic acidosis which can lead to bicarb absorption from bones
This leads to further renal bone disease Bicarb supplements in the form of tablets or baking soda can be given to buffer the acid build up |
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Anemia
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The kidneys are responsible for erythropoietin production and with progressive renal failure anemia worsens.
Less prominent in PKD due to renal mass. Available synthetically as Procrit, Epogen or Aranesp Given as sub q injection as often three times/week of infrequently as once monthly Procrit/Epogen- shorter acting and generally requiring more frequent dosing than Aranesp Must have adequate iron stores to be effective Oral iron supplements not generally adequate Side effects include- hypertension, increase blood viscosity and risk of clots Most clinicians will attempt to reach Hct og 35-37% or Hgb of 12 per new black box warnings with concern about increased incidence of thrombosis Will generally prevent the need for blood tranfusions which previously were the norm in renal patients Iron supplements- needed for EPO to have maximal effects Goal iron sat is over 30% Oral iron not generally effective alone in maintaining adequate iron sats Old IV iron preps with many side effects Ferrilicit, Venofer the most utilized IV iron preparations used today Lower incidence of side effects Test dose not required but frequently given Nephrologist preference Generally given weekly on outpatient basis until iron stores adequate |
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Hyperkalemia***
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As renal failure progresses, potassium secretion by the kidneys decline
Hyperkalemia is the most acutely life threatening risk of kidney failure Dietary restriction of high potassium foods is the mainstay of therapy Tomatoes, potatoes, certain fruits, salt substitutes are high potassium sources |
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How do you reduce serum K levels?
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Sodium bicarb supplements will lower potassium by correcting acidosis and promoting potassium excretion
Many diuretics will also promote potassium excretion Kayexalate can be given in sorbitol orally or rectally. It causes sodium and potassium exchange in the colon and can lower potassium levels in 3-4 hours |
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Conclusions-Main points
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Early referral to nephrology can slow or prevent many of the complication of renal disease
Dietary compliance is a mainstay of therapy Taking your medications as prescribed very important Avoid OTC medications without discussing safety with your physician/nephrologist first. |
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indicative of CKD if GFR is___
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< 60
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Scr increases in ___
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ARF
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MC cause of ESRD and 2 cause of ESRD
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1. DM
2. HTN |
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Slow of pregression of CRD
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Antihypertensive drugs and
insulin theraphy |
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Risk Factors for CKD Progression
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Hypertension
Diabetes Mellitus High Protein Diet Elevated Lipids Smoking Proteinuria |
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What Stage CKD frequently is when renal bone disease begins
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3
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Bone metabolism- kidneys involved with
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calcium and phosphate metabolism and vitamin D production
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As renal function worsens, ___ accumulates___ declines and renal bone disease begins
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As renal function worsens, phosphorus accumulates, calcium declines and renal bone disease begins
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What diet will at least early in the process, prevent bone disease
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Low P
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Phosphate binders can be given with meals to reduce ___
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phosphorus absorption
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Available OTC, good Calcium absorption, inexpensive but not as an effective a phosphate binder as calcium acetate
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C carbonate (Tums, Oscal, Caltrate)
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Less calcium absorption but better phosphate binding. Some increased complaint of nausea
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Ca acetate
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better calcium absorption but less phosphate binding
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Ca citrate
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Not recommended as it can enhance aluminum absorption which can accumulate in renal failure
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Ca citrate
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Can induce metabolic acidosis
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Sevelamar
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In addition to calcium and phosphorus, the kidneys make the active form of
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Vitamin D
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As renal function worsens, vitamin D deficiency develops, thereby leading to ____
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hyperparathyroidism
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Supplementing vitamin D suppresses____, but can lead ______from the GI tract
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PTH
to increased calcium and phosphorus absorption |
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Three available vitamin D supplements
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Calcitriol(Rocaltrol)- available generically, less costly; ? Increased phosphorus absorption over the others
Doxercalciferol(Hectorol)- newer than calcitriol Paracalcitriol(Zemplar)- likely comparable to Hectorol in efficacy These medications are titrated to keep PTH levels 2-3X normal to avoid over or under suppression of parathyriod glands |
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_____will lower potassium by correcting acidosis and promoting potassium excretion
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Sodium bicarb supplements
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______can be given in sorbitol orally or rectally. It causes sodium and potassium exchange in the colon and can lower potassium levels in 3-4 hours
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Kayexalate
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