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57 Cards in this Set

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Definition of CKD
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
CKD staging
Stage 0
Description- Increased risk
GFR- >90 w risk factors
Action- screening with risk reduction
CKD staging
Stage 1
Description- Damage with normal GFR
GFR- >90
Action- DX and treat
Slow progresion
Treat comorbidities
CKD staging
Stage 2
Description- Mild decrease GFR
GFR- 60-89
Action- DX and treat
Slow progresion
Treat comorbidities
CKD staging
Stage 3
Description- Moderate decrease GFR
GFR- 30-59
Action-RX complications
CKD staging
Stage 4
Description- severe
GFR- 15-29
Action-Prepare for renal replacement therapy
CKD staging
Stage 5
Description- na
GFR- <15
Action- dialysis
What CDK stage?
Description- Increased risk
GFR- >90 w risk factors
Action- screening with risk reduction
Stage 0
What CDK stage?
Description- Damage with normal GFR
GFR- >90
Action- DX and treat
Slow progresion
Treat comorbidities
Stage 1
What CDK stage?
Description- Mild decrease GFR
GFR- 60-89
Action- DX and treat
Slow progresion
Treat comorbidities
Stage 2
What CDK stage?
Description- severe
GFR- 15-29
Action-Prepare for renal replacement therapy
Stage 4
What CDK stage?
Description- na
GFR- <15
Action- dialysis
Stage 5
What CDK stage?
Description- Moderate decrease GFR
GFR- 30-59
Action-RX complications
Stage 3
Prevalence of CKD, what stage?
Stage 3
Calculating the GFR
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
Formulas for GFR Estimation
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
GFR- how much cr males/females excrete?
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
Progression of CKD
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
Risk Factors for CKD Progression
Hypertension
Diabetes Mellitus
High Protein Diet
Elevated Lipids
Smoking
Proteinuria
Hypertension and CKD
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
Diabetes and CKD Progression
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
Dietary Protein Restriction
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
Lipid Reduction in CKD
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
Smoking Cessation in CKD
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
ACE Inhibitors, usage, SE
(-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
ARB Agents
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!
Diuretics (w. fluid restriction)
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
Direct renin Inhibitors
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
Diuretics SE
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
Lipid Medications
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
Bone Metabolism
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
Metabolic Acidosis
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
Anemia
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
Hyperkalemia***
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
How do you reduce serum K levels?
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
Conclusions-Main points
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.
indicative of CKD if GFR is___
< 60
Scr increases in ___
ARF
MC cause of ESRD and 2 cause of ESRD
1. DM
2. HTN
Slow of pregression of CRD
Antihypertensive drugs and
insulin theraphy
Risk Factors for CKD Progression
Hypertension
Diabetes Mellitus
High Protein Diet
Elevated Lipids
Smoking
Proteinuria
What Stage CKD frequently is when renal bone disease begins
3
Bone metabolism- kidneys involved with
calcium and phosphate metabolism and vitamin D production
As renal function worsens, ___ accumulates___ declines and renal bone disease begins
As renal function worsens, phosphorus accumulates, calcium declines and renal bone disease begins
What diet will at least early in the process, prevent bone disease
Low P
Phosphate binders can be given with meals to reduce ___
phosphorus absorption
Available OTC, good Calcium absorption, inexpensive but not as an effective a phosphate binder as calcium acetate
C carbonate (Tums, Oscal, Caltrate)
Less calcium absorption but better phosphate binding. Some increased complaint of nausea
Ca acetate
better calcium absorption but less phosphate binding
Ca citrate
Not recommended as it can enhance aluminum absorption which can accumulate in renal failure
Ca citrate
Can induce metabolic acidosis
Sevelamar
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____, but can lead ______from the GI tract
PTH

to increased calcium and phosphorus absorption
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
_____will lower potassium by correcting acidosis and promoting potassium excretion
Sodium bicarb supplements
______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
Kayexalate