CKD

Question 1

CKD

Answer 1

• GFR < 60 ml/min for more than 3 months
• persistent proteinuria*, hematuria, or abnormal urinary sediment
• progressive nephrosclerosis, irreversible reduction in nephron number

Question 2

major function of nephron

Answer 2

• glomerular filtration
• tubular reabsorption (passive)
• tubular secretion (active, mainly K)

Question 3

hyperfiltration and CKD

Answer 3

• DM or HTN causes hyperfiltration to maintain GFR
• causes hypertrophy of viable nephrons
• increased pressure and flow -> distortion glomerular architecture, sclerosis, loss of remaining nephrons

Question 4

RAAS and CKD

Answer 4

• RAAS and AII get activated to maintain GFR with hyperfiltration
• AII causes altered pore sizes -> increased permeability -> protein leak -> microalbuminuria
• AII and aldosterone are also proinflammatory and profibrotic independently

Question 5

proteinuria and CKD

Answer 5

• excessive proteins in urine are directly toxic to tubules

- causes tubular injury, inflammation, scarring

Question 6

GFR

Answer 6

• measure of how well kidneys are removing waste and excess fluid from blood
• based on SCr, age, weight, gender, body size

Question 7

normal GFR

Answer 7

• > 90

Question 8

GFR suggesting kidney dysfunction

Answer 8

• < 60

Question 9

GFR that qualifies for dialysis or transplant

Answer 9

• < 15

Question 10

serum creatinine

Answer 10

• waste product from normal wear and tear produced by muscles at constant rate
• excreted unchanged in kidneys
• as kidney function decreases Cr levels rise

Question 11

high serum creatinine levels

Answer 11

• > 1.2 in women

- > 1.4 in men

Question 12

BUN

Answer 12

• measure of amount of nitrogen in blood that comes from waste product urea
• urea made when protein is is broken down
• as kidney function decrease, BUN increases

Question 13

normal BUN

Answer 13

• between 7-20

Question 14

sx of CKD

Answer 14

• no sx until stage 3 or 4
• anemia, weakness, fatigue
• decreased appetite with progressive malnutrition
• sleep problems
• decreased mental sharpness/ encephalopathy
• muscle twitches/ cramps
• pruritis
• uremic syndrome

Question 15

complications of progressive CKD

Answer 15

• anemia
• metabolic acidosis
• derangement in vit d, ca, and p metabolism
• volume overload
• hyperkalemia
• uremia
• CV consequences*

Question 16

approach to pt with new renal dysfunction

Answer 16

• consider pre-renal, renal, and post-renal etiology
• careful H&P
• SCr/GFR
• urine dipstick, microscopy, spot protein- proteinuria one of first signs
• renal US, advanced imaging
• urinalysis
• consider checking for MM

Question 17

lab data for CKD

Answer 17

• 24 hour urine test*- compares urine Cr to SCr
• urinalysis- protein/ albumin
• urine microscopy- cells/ casts/ crystals

Question 18

microalbuminuria definition

Answer 18

• 30-300 mg/L

Question 19

macroalbuminuria definition

Answer 19

• > 300 mg/L

Question 20

proteinuria

Answer 20

• > 150-160 mg
• 1-2 suggests kidney abnormality
• > 3.5 in nephrotic range

Question 21

anemia and CKD

Answer 21

• due to decreased EPO production
• dx of exclusion- r/o all other causes
• can give EPO stim agents if Hgb falls < 10

Question 22

vitamin D def and CKD

Answer 22

• secondary to decreased active vit d (1,25- OH), very short half life
• kidneys take vit D storage form (25-OH) and active it
• measure storage vit D to assess kidneys- longer half life

Question 23

metabolic acidosis and CKD

Answer 23

• secondary to decreased bicarb resorption and generation by kidneys
• treat with bicarb supplementation

Question 24

bone disease and CKD

Answer 24

• secondary to abnormalities in complex interaction between vit d, p, ca, and PTH
• excessive bone resorption
• state of bone quiescence- adynamic bone disease
• results in fragile bone matrix and increased risk fx

Question 25

uremia and CKD

Answer 25

- hundreds of toxins accumulate - urea and Cr elevated, used as surrogate marker for toxins - systemic inflammation increases

Question 26

Risk factors for dev CKD

Answer 26

- DM* - HTN* - autoimmune disease - older age - AA or hispanic - family hx - previous episode AKI - proteinuria - abnormal urinary sediment - structural abnormalities of urinary tract

Question 27

stage I kidney disease

Answer 27

- GFR > 90

Question 28

Stage II kidney disease

Answer 28

- GFR 60-89

Question 29

stage III kidney disease

Answer 29

- GFR 30-59

Question 30

Stage IV kidney disease

Answer 30

- GFR 15-29 - difficult to control HTN- require loop diuretics - hyperkalemia* - +/- uremia - refer to nephrologist

Question 31

Stage V kidney disease

Answer 31

- GFR < 15 or dialysis - need renal replacement/ transplant - discuss end of life - once on dialysis > 50% mortality within 5 years

Question 32

what do most CKD pts die from

Answer 32

- CV complications

Question 33

most common causes of ESRD

Answer 33

- diabetic glomerular disease* - HTN nephropathy* - glomerulonephritis - autosomal dominant polycystic kidney disease - other cystic and tubulointerstitial nephropathy

Question 34

treatment for CKD

Answer 34

- primary prevention - treat underlying disorder - dialysis - transplant

Question 35

when to refer pts to nephrologists

Answer 35

- GFR < 30 - rapidly progressive CKD - poorly controlled HTN despite four agents - rare or genetic causes CKD - suspected renal artery stenosis

Question 36

what is the leading cause of ESRD

Answer 36

- DM

Question 37

DM and CKD

Answer 37

- damages BV in kidneys - elevated blood glucose rises beyond kidneys capacity to resorb glucose - glucose concentration remains high in fluid -> increasing urine volume

Question 38

what is the goal hbA1C to reduce risk of CKD

Answer 38

- < 7

Question 39

treatment for DM and CKD

Answer 39

- primary prevention- diet/ exercise, weight loss - tight glucose control < 7 - BP control < 130/80- delays onset of microalbuminuria

Question 40

diabetic nephropathy

Answer 40

- diabetic pts with dev of renal injury | - first sign= microalbuminuria

Question 41

treatment for diabetic nephropathy

Answer 41

- ACEI/ARB as first line tx even if normotensive | - diuretics are second line to aide in BP control

Question 42

what is the second leading cause of ESRD

Answer 42

- HTN

Question 43

treatment for HTN and CKD

Answer 43

- salt and water restriction - BP < 130/80 - weight loss - pharm therapies- ACEI/ARB

Question 44

why should you be cautious when treating HTN nephropathy with ACEI/ARB

Answer 44

- recommended CKD stages 1-3 - expect worsening of Cr in up to 30% of pts or reduction in GFR 20% from baseline - if values continue to drop consult nephrology - contribute to hyperK