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Flashcards in CKD Deck (60)
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How common is kidney disease in the US? ESRD?

- 9th leading cause of death in the US
- 1 out of 9 adults, less than 2% progress to ESRD, most pts die of CV event before they progress to ESRD
- pts remain asx until their disease has sig progressed


What are over 70% of cases of late stage CKD due to? Less common causes?

- diabetes and HTN

- 12% due to:
glomerulonephritis, cystic disease, and other urological diseases (BPH)
- 15% of pts have other or unknown causes


Definition of CKD?

- GFR of less than 60 ml/min for greater than or equal to 3 months with or w/o kidney damage
kidney damage for greater or equal to 3 months with or w/o decreased GFR


Progression of CKD?

- rarely reversible and leads to progressive decline in renal fxn
- reduction in renal mass leads to hypertrophy of remaining nephrons (kidneys working harder, nephrons trying to compensate: get worn out) - leads to progressive glomerular sclerosis and interstitial fibrosis


RFs for CKD?

- older age
- family hx of CKD
- pt population (Native americans, african americans, alaskan natives, asians)
- autoimmune disease: SLE
- drug toxicity
- systemic infection (shock) - decreased perfusion to the kidneys
- urinary obstruction: stones


Pathophys of CKD?

- 1 kidney = 1 mill nephrons
- with destruction of nephrons, this causes hyperfiltration and compensatory hypertrophy
- blood urea and Cr start to show measurable increase only after GFR has dropped by 50%
- plasma Cr will approx double with 50% reduction in GFR


initial assessment of a pt with suspected kidney disease?

- confirm primary renal dx
- establish chronicity
- ID reversible factors
- detect co-morbid factors
- est a baseline database


Stages of CKD?

- normal: 120-130
- stage 1: kidney damage with normal or increased GFR (greater than 90)
- stage 2: mild reduction in GFR (60-89 ml/min)
- stage 3: mod reduction in GFR (30-59)
- stage 4: severe reduction in GFR (15-29) - sxs
- stage 5: kidney failure (GFR less than 15 ml/min or dialysis)

* stage 1-3 CKd freq asx
clinical manifestations appear in stage 4-5 (indication for kidney transplantation)


Measurement of renal fxn?

- serum creatinine alone isn't an accurate measure of GFR
- creatinine is secreted by renal tubules, and as renal fxn worsens the amt secreted increases
- normal ranges for serum creatinine are misleading b/c they don't account for age, sex, race or wt of pt


Cockcroft Gault formula?

- adjust creatinine for age, wt and gender
- Male: (140-age)x IBW kg)/(serum Crx72)
- in females - top equation x 0.85


What 2 tests should be used together to improve prognostic accuracy?

- GFR and albuminuria
- microalbuminuria: key parameter for measuring nephron injury and repair, early sign of kidney disease


AER staging of CKD?

- A1: less than 30 (normal-mild increase)
- A2: 30-300 (mod increased)
- A3: greater than 300, severly increased


What is azotemia? types?

- condition characterized by high levels of nitrogen containing compounds in the blood
- types:
prerenal azotemia (hypoperfusion)
primary renal azotemia (glomerulonephritis)
postrenal azotemia: blockage - stones, BPH, cancer

- azotemia can lead to uremia if left untx


What is uremia?

- condition resulting from advanced stages of kidney failure in which urea and other nitrogen containing wastes are found in the blood
- sxs may not occur until 90% of nephrons are destroyed
- more commonly develops in later stages of CKD


Sxs of uremia?

- general: fatigue, weakness, breath (fishy odor)
- skin: pruritus, easy bruising
- ENT: metatallic taste in mouth, epistaxis
- pulmonary: dyspnea, pulmonary edema
- CV: dyspnea on exertion, retrosternal pain on inspiration (pericarditis)
- GI: anorexia, N/V, hiccups
- GU/GYN: ED, amenorrhea
- NM: restless legs, numbness, cramps
- neuro: irritability, inability to concentrate


Signs of uremia?

- general: sallow appearing, chronically ill
- skin: pallor, ecchymosis, excoriations, edema, yellow
- ENT: urinious breath
- eye: pale conjunctiva
- pulm: rales, pleural effusion
- CV: HTN, cardiomegaly, friction rub, displaced PMI
- neuro: stupor, asterixis (hand flap), myoclonus, periph neuropathy


What will labs look like in uremia?

- elevated BUN/creatinine
- CBC: anemia (can stim EPO)
- CMP: hyperphosphatemia, hypocalcemia, hyperkalemia
- serum albumin levels
- lipid profile: risk for CVD
- urinalysis: broad waxy cast cells

- evidence of renal bone disease can be evidenced on:
serum phosphate
25-hydroxyvitamin D
intact PTH levels


Imaging for uremia?

- renal U/S: small echogenic kidneys bilaterally
- CT: tumor?
- MRI/MRA: use for pt that can't have contrast
- retrograde pyelogram: can't find cause, maybe an obstruction? put stents in


When is a renal bx indicated? complications?

- indicated: when renal impairment is present and dx is unclear after extensive work up
- complication: bleeding


Complications of uremia/kidney disease?

- hyperkalemia: esp when GFR drops below 10 ml/min, kidneys have decreased ability to secrete K+
can be seen sooner in K+ rich diet
can get ECF shift of K+ with acidemia and decreased insulin
- metabolic acidosis:
damaged kidneys unable to excrete the 1 mEq/kd/d of acid generated by metabolism of dietary proteins
this limits prod of ammonia and limits buffering of H+ in urine
- excess H+ ions buffered by large calcium carb and calcium phosphate stores in bone so this contributes to renal osteodystrophy of CKD


Cardiovascular complications of CKD?

- pericarditis: can be comp by tamponade
- CHF and pulmonary edema
- heart disease: LVH, ischemic heart disease (alot of these pts have arteriosclerosis, at high risk for MI)


Hematologic complications of CKD?

- anemia: normocytic, normochromic
- due to decreased epo production
- Iron def present as well

- coagulopathy: due to platelet dysfxn, platelet counts are mildly decreased but hsow abnormal adhesiveness and aggregation - leed to thrombi and abnorm bleeding


Neuro complications?

- uremic encephalopathy
- peripheral neuropathy
- sub-arachnoid hemorrhage


Compllications of mineral metabolism?

- hypocalcemia
- hyperphosphatemia
- disorders of calcium, phosphorus and bone are referred to as renal osteodystrophy: hyperphosp leads to hypocalcemia - PTH stim and this leads to osteitis fibrosa cystica, have higher level of bone turnover


Causes of renal osteodystrophy?

- ability to excrete phosphate is lost
- decreased prod of 1,25 dihydroxyvitamin D leads to decrease intestinal absorption of Ca
- hypocalcemia triggers PTH prod and release
- secondary hyperparathyroidism leads to Ca mobilization from bone and increase renal phosphate excretion to maintain electrolyte homeostasis



- there is a decreased conversion of 25-hyroxycholecalciferal to 1,25 dihydroxy form:
gut absorption of Ca is diminished and aluminum deposition in bone

- will cause bony pain and proximal muscle weakness


Skin disorders - complications from CKD?

- dry
- yellow-brown color
- fingernails become thin and brittle
- uremic frost - dry on skin after sweating


Effective CKD management?

- approp screen and dx early CKD
- be aware of CKD complications and comorbidities:
anemia, bone and mineral abnormalities, CV and renal risk, diabetes

- consult a nephrologist in a timely manner

- delay or halt progression by:
tx underlying condition
aggressive BP control: ACEI or ARB
tx hyperlipidemia
aggressive glycemic control
avoid nephrotoxins
tx hypocalcemia: calcium supplements
volme overload: loop diuretics
metabolic acidosis: oral alkali supplements


Recommendations for HTN control?

- HTN w/o CRF: less than 130/85
- HTN with CRF and proteinuria - less than 1 g/day
less than 130/80
- HTN with CRF and proteinuria: greater than 1 gram/day less than 125/75


Dietary considerations with CKD?

- maintain balance of electrolytes, minerals, and fluid in pts who are on dialysis. SPecial diet impt because dialysis alone doesn't always effectively remove all waste products. These wast products can also build up b/t dialysis tx
- must dialysis pts urinate very little or not at all. Therefore fluid restriction b/t txs is very impt. W/o urination fluid will build up in the body and lead to excess fluid in the heart, lungs and ankles
- protein restriction: 1 gram/kg/day
- salt and water restriction: reduce overload
- K+ restriction
- iron supplements