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Acute Care Seminar 1 > CKD > Flashcards

CKD Flashcards

1
Q

Renal physiology

A

-Maintains water balance
-Maintains proper osmolality of fluids
-Regulates the quantity & concentration of most ECF
-Maintains proper plasma volume
-Maintains proper acid-base balance
-Excretes metabolites & foreign compounds
-Produces Erythropoietin
-Produces Renin
-Converts Vitamin D to its active form

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2
Q

Erythropoietin

A

hormone that stimulates red blood cell production

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3
Q

Renin

A

hormone that influences salt conversion

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4
Q

RAAS

A
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5
Q

Modifiable Risk Factors for CKD

A

–(HTN)*
-(DM)*
-Smoking
-Frequent NSAID use
-Contrast dye exposure
-Previous acute kidney injury (AKI)
-Presence of proteinuria, abnormal urinary sediment, or structural abnormalities of the urinary tract
-Autoimmune disease

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6
Q

Non-Modifiable Risk factors for CKD

A

-Age > 65 years old
-Minority populations – -African Americans, -Hispanics, Pacific Islanders, American Indians
-Family history of renal disease, DM or HTN
-Acute Glomerulonephritis*

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7
Q

Most common causes of CKD

A

1 Diabetic nephropathy

#2 Hypertensive nephropathy
#3 Acute Glomerulonephritis
-Autosomal dominant Polycystic Kidney Disease (PKD)
-Obstructive Nephropathies
-Autoimmune disease, like Lupus

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8
Q

Glomerular Filtration Rate (GFR)

A

Considered the best index of kidney function
Varies with age, sex, body size and declines with age

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9
Q

Cystatin C

A

Considers age, sex, and race to calculate GFR

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10
Q

Definition/Criteria for CKD

A

-either of the following are present for >3 months
-Markers of kidney damage-(Albuminuria, urine sediment abnormalities, abnormalities detected by histiology, structural abnormalities, hx of kidney transplant)
-Decreased GFR <60mL/min

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11
Q

ESRD

A

accumulation of toxins, fluid excess and electrolytes imbalances results in uremia or uremic syndrome (symptomatic from elevation of waste products in blood)
Ultimately results in death if the toxins are not removed

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12
Q

Diagnostic workup

A

-Check Blood Pressure
-Serum creatinine/GFR (compare to trend)
-CBC & Electrolytes
-Serum protein
-Spot urine for Albumin-to-Creatinine Ratio (ACR = divide albumin concentration in mg by creatinine concentration in grams) to detect albuminuria (1st morning void)

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13
Q

Confirming Disease

A

-Spot urine for ACR x 3 months – ACR > 30mg/g
-GFR < 60 mL/min/1.73 m2
Renal Ultrasound (+/- renal biopsy)

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14
Q

Assessing progression of disease

A

Calcium, Phosphorus, PTH and Alkaline Phosphatase

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15
Q

Screening for CKD in diabetes

A

-Patients with diabetes should be screened annually for CKD

-Initial screening should commence:
—-5 years after the diagnosis of type 1 diabetes
—-From diagnosis of type 2 diabetes

An elevated Albumin/Creatinine ratio should be confirmed in the absence of urinary tract infection with 2 additional first-void specimens collected during the next 3 to 6 months. (B)

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16
Q

Most patients with diabetes, CKD should attributable to diabetes if

A

-Macroalbuminuria is present
-Microalbuminuria is present
-Presence of diabetic retinopathy
-Type 1 diabetes of at least 10 years duration

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17
Q

Stage 1 CKD

A

GFR > 90 ml/min
diagnose & treat comorbid conditions, slow progression, CVD risk reduction (NO SYMPTOMS)

18
Q

Stage 2

A

GFR 60-89 ml/min
estimate and follow progression (NO SYMPTOMS)

19
Q

Stage 3a

A

GFR 45-59 ml/min
Evaluate & treat complications; follow progression

20
Q

Stage 3b

A

GFR 30-44 ml/min
Evaluate & treat complications; follow progression

21
Q

Stage 4

A

GFR 15-29 ml/min
prepare for kidney replacement therapy; treat complications

22
Q

Stage 5

A

GFR < 15 ml/min
Kidney replacement therapy when uremia is present

23
Q

CKD is classified based on CGA (Cause, GFR, Albuminuria)-Albuminuria

A

Moderately increased-30-300 mg/g or 3-30 mg/mmol

Severely increased >300mg/g or >30 mg/mmol

24
Q

CKD Managements

A

-Treat underlying etiology
-Avoid loss of nephrons
-Slow progression of disease (ACE inhibitors or ARBs are renoprotective (no dual RAAS therapy)
-Identify all patients that have a solitary kidney
-Refer to Nephrologist

25
Q

Fluid Overload Complication-Tx

A

Fluid and Na+ restrictions

Monitor daily weights

Diuretics
Need higher doses
Escalate doses

Dialysis

26
Q

Hyperkalemia

A

Potassium restricted diet

Avoid K+ sparing medications

Cautious use of K+ supplements

Cautious use of ACE inhibitors

Adjust K+ bath if dialyzed

Recognize when Hyperkalemia is an emergency

27
Q

Recognize when Hyperkalemia is an emergency

A

diuretics, insulin (take K+ into cells), glucose (D50) to treat hypoglycemia, kayexalate, IV Ca+ gluconate to reduce myocardial irritability

28
Q

Hyperphosphatemia tx

A

Keep Phosphorus < 4.6mg/dL

Restrict Phosphorus to 800-1000mg/day

Phosphate Binders 3 x day with meals
GFR < 20-30 mL/min
Calcium Carbonate or TUMS / Calcium Acetate or Phoslo / Sevelamer or Renagel

Dialysis when ineffective

Increased vascular calcification

Associated with increased CVD mortality*

29
Q

Hyperphosphatemia can lead to what?

A

-Leads to decreased levels of ionized Ca+ resulting in diminished calcitrol production and phosphate retention, which also stimulate PTH production

-Low calcitrol levels contribute to hyperparathyroidism which leads to bone turnover and hypocalcemia

30
Q

Hypermagnesemia

A

Avoid Magnesium and Aluminum containing laxatives & antacids

Cautious use of supplementation

Dialysis if needed

31
Q

Hypocacemia

A

Maintain normal Ca+ 8.5 – 10.2 mg/dL

CALCULATE corrected calcium (correct if less than 6.5 mg/dL)

Corrected calcium (mg/dL) = serum calcium (mg/dL) + 0.8 (4.0 - serum albumin g/dL)

Calcium supplementation as needed

Vitamin D supplementation

Phosphate binders can elevate calcium

32
Q

Protein catabolism

A

Protein restricted diet

Adequate calories

Avoid states that increase catabolism
stress, trauma, infection, immobilization

Multivitamin for renal patients (Dialyvite)

As disease progresses malnutrition worsens
Check Albumin

33
Q

Anemia of chronic disease

A

Iron supplementation
Vitamin supplementation as needed
Erythropoietin stimulating agents 2-3 x week

34
Q

Epoetin dosing

A

-When Epoetin is given SC to adult patients, the dose should be 80 to 120 units/kg/wk (typically 6,000 units/wk) in two to three doses per week.

If the initial administration of Epoetin is IV for hemodialysis patients, the dose should be 120 to 180 units/kg/wk (typically 9,000 units/wk), given in three divided doses.

Monitor Hbg/HCT every 1-2 weeks until target Hbg/HCT and stable dose have been achieved.

35
Q

Treating HTN in CKD

A

-Fluid/Na+ restrictions

Antihypertensives
ACE inhibitor/ARB or Ca+ Channel Blocker if proteinuria present

Consider other compelling conditions

Statin therapy if > 50 yo or high CV risk

36
Q

Dyslipidemia with CKD

A

-Treat with statin

37
Q

Derm conditions with ckd: Pruritus associated c/ uremic state

A

Can improve with initiation of dialysis

May need topical moisturizers, glucocorticoids, oral anti-histamines or ultraviolet radiation

38
Q

Derm conditions with ckd: Calciphylaxis

A

Advanced patches of ischemic necrosis

Extensive vascular and soft tissue calcification

Almost exclusively in patients with ESRD

Limited treatment – stop warfarin, hyberbaric oxygen treatments, experimental treatments

39
Q

Renal transplant considerations

A

-Life expectancy > 5 years
-Asses for CAD and correct
-Rule out underlying neoplasms
-Rule out latent or indolent infections (HIV/Hepatitis)
-ABO compatibility / HLA typing with donor / direct cross matching

40
Q

Immunosuppression post transplant

A

Glucocorticoids - Solumedrol, Decadron, Prednisone

Cyclosporine - Gengraf / Neoral

Tacrolimus - FK506 / Prograf

Azathioprine - Imuran /
Azasan

Mycophenolate mofetil - CellCept

Sirolimus - Rapamune

Acute Care Seminar 1 (31 decks)

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