Renal: Complications And Management Of Ckd

Front 1

ESRD can be caused by damage to the ___1___ or ___2___

Back 1

glomerulus
tubulointerstitium

Front 2

Urea serves as a direct uremic toxin and a......

Back 2

marker of the buildup of other nitrogenous wastes

Front 3

1) Most important symptom of CKD that we need to manage in order to slow damage.
2) How do we do this?

Back 3

1) HTN

2) ACE-I or ARB

Front 4

Name 7 complications of CKDB
1) __emia
2) ___kalemia
3) metabolic ____osis
4) Alterations in the metabolism of
5) ____disorders
6) _____ dysfunction
7) altered _____ metabolism

Back 4

1) Anemia
2)Hyperkalemia
3) Metabolic acidosis
4) Alterations in Ca/PO4 metabolism
5) Nutritional Disorders
6) Endocrine dysfunction
7) ALtered drug metabolism

Front 5

How is the anemia of CKD described?

Back 5

Normocytic, normochromic, with low reticulocyte count.

Front 6

Why does CKD cause anemia
1) primary reason
2) secondary reasons

Back 6

1) Insufficienct productio of erythropoietin
2) Bone marrow fibrosis due to hyperparathyroidism
3) Shortened RBC lifespan due to unidentified uremic factors
4) repeated Blood loss due to dialysis

Front 7

1) What secondary deficiency is caused in CKD anemia

Back 7

1) Iron deficiency

Front 8

1) How to we Tx CKD anemia?
2) WHat is the target Hemoglobin levels

Back 8

1) With Recombinant Erythropoietin (Erythropoiesis stimulating agents) (Procrit, Epogen)
2) 11-12

Front 9

1) What symptoms of anemia are reduced by ESAs?
2) WHat is the only known side effect of using ESAs to increase hemogobin?

Back 9

1) Decreased bleeding tendancy
Increased exercise tolerance
Nurtition
Cognitive Fxn
Reduced LVH
enhanced sex function (menses and Erection)

2) loss of BP control

Front 10

1) Why do people on dialysis have low iron?

2) How do we Tx?

Back 10

1) low dietary iron
frequent blood draws
blood loss due to dialysis
2) Iron supplementations

Front 11

1) Poor response of anemia to ESA signals what problem?

Back 11

1) Iron deficiency

Front 12

in CKD,
1) one kind of high turnover osteosystrphy can occur. describe
2) two kind of low turnover osteosystrphy can occur. describe

Back 12

Osteitis fibrosis cystica- Due to High PTH. both osteoclasts and blasts are stimulated. They lay haphazardly formed bone.

2)Osteomalacia- osteoid deposition exceeds mineralization
Adynamic bone disease- bothosteoid and mineralization are severely rreduced

Front 13

Levels after homeostatic response in early secondary hypoparathyoidism
1) PTH
2) PO4
3) Ca++'
4) D3

Back 13

1) high
2) WNL
3) WNL
4) high
The latter two are kept WNL by increasing PTH.

Front 14

Describe how Renal deficit causes a change in PO4, Ca++, PTH, and D3

Back 14

1) As REnal function declines, PO4 excretion is impaired. This causes high phosphate
2) High phosphate complexes Ca++ and leads to low free Ca++.
3) Low Ca++ and high PO4- cause PTH secretion.
4) PTH inhibits PO4 reabsorbtion by the PCT, and increases Ca++ reasborbtion in the C and MCD.
5) By favoring Vitamin D hydroxylation in the kidney, it also causes Ca++ reabsorption in the gut
6) PTH also stimualte Ca++ release from the bone matrix.

Front 15

What can a person with CKD do to prevent secondary hyperparathyrodism?

Back 15

Phosphate restricted diet

Front 16

1) Why does D3 fall in moderate-severe kidney failure?
2) What is the consequence of this?
3) What causes PTH to go up even more here?

Back 16

1) Inhibitory effect of PO4 on PCT cells and reduced renal mass.
2) decreased Gut absorption of Ca++
3) Hyperphosphatemia causes resistance of parathyroid chief cells to D3 inhibition. They will hypertrophy.

Front 17

1( WHat effect, other than Ca++ liberation, does PTH have on bone?
2) what bone condition does this combo cause?

Back 17

1) Increases bone collagen deposition
2) Osteitis fibrosis cyctica and fibrosis of marrow cavity

Front 18

What two things must be elevated to cause Calciphylaxis?

Back 18

Ca x P must be >55-60

Note: This is not just free Ca++ here, it counts the stuff complexed to PO4.

Front 19

How can CKD cause LOW bone turnover disease

Back 19

1) Low D3
2) Aluminum deposition at the mineralization front
3) poor response to PTH

Front 20

4 steps in controlling Ca++/PO4 metabolic problems in CKd

Back 20

1) Lower PO4 with diet and phosphorus binders. CaCO3 at meal time.
2) Increase free Ca++. Use CaCO3 between meals
3) Vitamin D replacement or analog to enhance gut Ca++ absorbtion
4) Surgical parathyroidectomy for levels of PTH >1000

Front 21

Target levels in CKD
1) Phosphate
2) Ca++
3) PTH should be below this or parathyroidectomy is indicated

Back 21

1) 3.5-4,5
2) 9-9.5
3) 1000

Front 22

risk of calcium supplementation

Back 22

hypercalciemia

Front 23

How does low D3 contribute to high PTH aside from its inability to allow Ca++ reabsorbtion.

Back 23

Decreased Ca++ feedback receptors on parathyroid chief cells so PTH is unregulated. No amount of Ca++ iberated will be enough to shut off PTH.

Front 24

Under what circumstances is surgical parathyroidectomy indicated

Back 24

Cannot supress PTH using medical therapy
PTH >1000
OR
Calciphylaxis

Front 25

1) CKD can give rise to chronic metabolic ___osis.
2) If this is early the __1__osis will be __2__
3) Later is can be ___3___
4) Tx?

Back 25

1) Acidosis
2) Hyperchloremic
3) Anion Gap
4) NaBicarb

Front 26

1) __1__kalemia is common in CKD
2) Wishy-washy cause
3) Tx?

Back 26

1) Hyperkalemia
2) Inadequate filtration and global dysfunction
(goes along with metabolic acidosis)
3) Dietary restriction, Loop diuretic

Front 27

Nutritional recommendations in CKD

Back 27

Reduce Salt
Reduce K
Reduce Phosphate
0.8 g/kg/protein/day until dialysis
1.2 kg/day on hemodialysis
1.5 g/kg/day on peritoneal dialysis

Front 28

Why do we increase protein intake in people on dialysis?

Back 28

It can cause protien loss in the fluid

0.8 g/kg/protein/day until dialysis
1.2 kg/day on hemodialysis
1.5 g/kg/day on peritoneal dialysis

Front 29

Low dietary protein is supposed to lower uremic symptoms, and thus delay CKD preogression? Why is a low proetein diet controversial?

Back 29

Doctors worry about malnutrition which predisposes to infection an hospitalization

Front 30

Why do we manage obesity (restrict calories) in people with CKD?

Back 30

because obesity predisposes to DMIII and HTN which both worsen CKD.

Front 31

Why do we give Statins to people with CKD?

Back 31

The are predisposed to high choleterol and triglycerides.

Front 32

What is the GFR cutoff where we switch from diet/lifestyle, vaccines (pneumococcus, HEPB, flu), and education to more insensive course with dialysis and transplant?

Back 32

<30 mL/min

Front 33

Indications for dialysis

Back 33

1) uremic syndreom
2) pericarditis
3) intractable fluid overload
4) Intractable metabolic acidosis
5) Poor nutrition of unexplained weight loss
6) Intractable hyperkalemia