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Flashcards in CKD Deck (60):
1

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

2

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

3

Definition of CKD?

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

4

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

5

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

6

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

7

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

8

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)

9

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

10

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

11

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

12

AER staging of CKD?

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

13

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

14

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

15

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

16

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

17

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
ALP
intact PTH levels

18

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

19

When is a renal bx indicated? complications?

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

20

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

21

Cardiovascular complications of CKD?

- HTN
- 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)

22

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

23

Neuro complications?

- uremic encephalopathy
- peripheral neuropathy
- sub-arachnoid hemorrhage

24

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

25

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

26

Osteomalacia?

- 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

27

Skin disorders - complications from CKD?

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

28

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

29

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

30

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

31

Who should be screened for CKD?

- pts with clinical factors:
diabetes, HTN, first degree relative of pt with HTN, diabetes, or CKD
- Socio-demographic factors:
US ethnic minority:
African american (ESRD family hx greater in this group than any others with ESRD)
american indian
asian
pacific islander

- metabolic syndrome and smoking may also be risk factors for CKD
- undetected CKD has also beeen shown to be frequent in pts greater than 65, with assoc CV risk factors and normal creatinine

32

Screening of CKD?

- GFR: doesn't reqr 24hr urine collection fo CrCl, eGFR - est by MDRD study equation
- screening should also include urine dipstick for proteinuria
- screening for proteinuria, albuminuria and microalbuminuria can reveal a decrease in kidney fxn when GFRs are normal
- albuminuria is more sensitive when excretion is above normal range but below level of detection by routine tests for urine protein

33

overall Tx of CKD

- restriction of daily protein to 1 g/Kg/d
- daily caloric intake of 40-50 cal/kg/day
- fluid restriction
- control of HTN, diabetes, lipids
- sodium restriction to 2-4 g/d
- K+ restriction
- Ca and phosphorus control
- management of metabolic acidosis
- management of anemia
- vascular access for dialysis
- transplantation

34

Health maintenance for CKD?

- approp screen and dx early CKD:
diabetics
HTN pts
1st degree relative of pt with HTN, diabetes, or CKD
- older age
- african american
- Native american
- asian
- pacific islander

35

Indications for dialysis?

- hyperkalemia
- severe metabolic acidosis
- pericarditis

36

Hemodialysis?

- 3 times/week
- takes 3-5 hrs
- vascular access: arteriovenous shunt (can be used 6-8 weeks or more after surgical construction), or prosthetic graft: watch for infection, thrombosis, aneurysm formation, staph aureus most common
or temp indwelling caths: picc lines

37

Problems during hemodialyis?

- hypotension (pulling too much fluid)
- N/V
- muscle cramps
- complain of CP, dizziness, HA

38

What is peritoneal dialysis?

- peritoneal membrane is the dialyzer
- cont cyclic peritoneal dialysis utilizes a cycler machine to auto perform exchanges
- permits greater pt autonomy (can do at home)
- minimizes sx swings observed in hemodialysis pts
- phosphates better cleared

39

Complications of peritoneal dialysis?

- peritonitis:
N/V/D, or constipation
abd pain
fever

- staph aureus most common organism

40

What are the considerations for transplant?

- pt must have condition which transplantation is considered an effective tx
- pt must have severe or progressive disease
- pt must be willing to accept risks of surger and subsequent medical tx
- pt must be physically and emotionally capable of undergoing surgery and subsequent medical tx

41

Requirements for kidney transplantation?

- pre-transplant exam
- CXR
- complete medical and surgical hx
- EKG
- U/S with doppler exam
- blood tests
- PFTs
- viral testing: hepatitis, CMV, EBV, HIV
- need to rule out cancer

42

Pretransplant eval?

histocompatibility:
- blood typing
- tissue typing
- crossmatch testing
- PRA (panel reactive antibody)

43

Recipeints that are excluded?

- older than 70
- high risk pts for major surgery: severe CV disease
- high risk pts for cancer, acute or chronic infections
- surgical impediments: calcified vessels, bladder diseases (neurogenic, BPH)

44

Preparation as the recipient?

- general biochem
- hematology
- viral studies (HBs ag, HCV, HIV, EBV, HSV) Abs or DNA accordingly
- hormones: PSA, CEA, AFP, CA 9-19, CA 125)
- imaging: US abdomen, plain abdomen and pelvis, CXR
- specialized eval: ECG, cardiach echo, stress test, urodynamics)
- any other test or specialized eval if indicated

- pre-transplantation immunosuppression:
protocol used - 24 hrs before tx:
steroids - 5 mg/kg in divided doses
mycophenolate mofetil 500-1000 mg BD
- 1 hr before tx: basiliximab (simulect) 20 mg IV
- to be repeated on day 4 after tx
- all recipeints are started on gancyclovir, and broad spectrum abx prohphylaxis before surgery

- usuallly 7-10 days after initial dosing, doses of immunosuppresants are adjusted to obtain desired levels
- drug serum levels depond on protocol (combo of immunosuppressants) used
- Special attention to other drugs influencing serum levels of immunosuppressants
- drug monitoring should be scheduled and performed periodically together with pt f/u

45

Donor preparation?

- gen biochem
- hematology
- viral studies
- hormones: PSA, CEA, CA 9-19, CA 125, AFP
- urine (routine, culture, 24 hr protein, Crcl)
- imaging: US, IVP, MRA, CXR
- specialized eval: EKG, cardiach echo, stress test
- any other test or specialized eval if indicated

46

What donors/recipients are excluded?

- older than 70
- carriers of chronic infections: HIV, Hep B, Hep C
- carriers of chronic diseases: diabetes, cancer, amyloidosis, vascular pts, autoimmune diseases, renal dysfxn

47

Complications in kidney transplantation?

- medical immediate or chronic complications:
rejection: hyperacute, acute, chronic
infection: viral, bacterial, mycotic, opportunistic
CV: CAD, CHF, CVA, HTN
cancer: skin, blood, solid organs
diabetes, cataract, hirsutism, alopecia, gum hypertrophy, obesity, impotence
- drug toxicity

48

F/U schedule for Transplant pts?

- 1st month: 3x a week
- 1-3 months: 1/week
- 3-6 months: 1/2 weeks
- 6 months - 2 years: once a month
- 2 years and over: every 2 months

49

What should the f/u schedule include?

- hematology
- general biochem
- urine (MSU, 24 hr collection)
- drug level monitoring
- detailed clinical exam
- dx imaging (when necessary)
- bx (when necessary)
- special attention to: CV disease, neoplastic disease, infection, and parathyroid fxn

50

Clinical signs of rejection?

- malaise
- fever
- oliguria
- HTN
- graft tenderness
- serial creatinine measurements:
elev of 20% over baseline triggers further eval
rule out non-immunologic causes
renal scarring, percutaneous bx

51

Causes of CKD?

- most common: HTN and diabetes
other: autoimmune, birth defects (polycystic kidney disease)
certain toxic chemicals, glomerulonephritis, injury or trauma, nephrolithiasis, problems with arteries to or inside of kidneys, pain meds and some abx

52

What does CKD lead to? effect on body?

- leads to ESRD/uremia
- effects:
BP control
RBC production
Vit D and bone health

53

Sxs of early CKD?

- appetite loss
- general ill feeling and fatigue
- HAs
- itchy and dry skin
- Nausea
- wt loss without trying to lose wt

54

What sxs may develop as kidney function worsens?

- abnorm dark or light skin
- bone pain
- brain and nervous system
- breath odor (fishy)
- easy bruising, bleeding or blood in stool
- excessive thirst
- frequent hiccups
- decreased libido
- amenorrhea
- SOB
- sleep problems such as insomina, RLS, and OSA
- edema of feet and hands
- ** HTN almost always present during all stages of CKD

55

Most impt labs to order in CKD screening?

- microalbumineria, and GFR

56

Causes of CKD may be seen on what types of imaging?

- abdominal CT
- abdominal MRI
- abdominal US
- renal bx
- renal US

57

Tx of CKD?

- control HTN (130/80 or below)
with ACEIs or ARBs

58

Prevention of CKD?

- no tobacco
- meals that are low in fat and cholesterol
- reg exercise
- lower lipids if needed
- control glucose, HgbA1c
- avoid salt or K+

59

What vaccinations should pts with CKD have?

- H1N1
- Hep A
- Hep B
- influenza vaccine
- PPV

60

Possible complications of CKD?

- anemia
- myalgias and jt pain
- changes in glucose
- peripheral neuropathy
- dementia
- pleural effusion
- high phosph levels
- cardiac and vessel complications:
CHF, CAD, HTN, pericarditis, stroke
- Hyperkalemia
- hyperparathyroidism
- hepatic damaeg
- malnutrition
- miscarroages and infertility
- seizures
- edema