#37 - CKD

Question 1

CKD =

Answer 1

chronic kidney disease

Question 2

Define stage 1 CKD

Answer 2

GFR >90, with kidney damage (eg, proteinuria)

no symptoms

Question 3

Define stage 2 CKD

Answer 3

GFR 60-89

no symptoms

Question 4

Define stage 3 CKD

Answer 4

GFR 30-59

Symptoms start!!

Question 5

Define stage 4 CKD

Answer 5

GFR 15-29

symptoms present.

Question 6

Define stage 5 CKD

Answer 6

GFR

Question 7

What is the blood pressure target for ALL patients with CKD?

Answer 7

less than 140/90.

This is the same for diabetics and non-diabetics.

Question 8

What does hyperphosphatemia do in CKD?

Answer 8

it causes increased CV events/ increased mortality. Probably due to deranged calcium homeostasis/ calcific vessels.
High phosphate also increases PTH.

Question 9

Patient comes in for a follow up checkup. His GFR was 55 a month ago (his first abnormal GFR test). Today it is 50. What is his CKD stage?

Answer 9

He cannot be staged yet!
Low GFR or proteinuria must be present for 3 months.

-if his GFR stays the same for 2 more months, he would be stage 3.

Question 10

T/F Mortality from CV disease in CKD patients is 5x the level in non-CKD patients

Answer 10

False. It is 8-10 times higher.

Question 11

T/F Once CKD is present, the risk for CV is the same no matter the stage.

Answer 11

False. the worse the CKD, the more likely a CV event.

Question 12

What are the major 4 risk factors for development of CKD?

Answer 12

• diabetes
• hypertension (these 2 account for ~75% of disease)
• family history
• ethnicity

Question 13

T/F Those over 65 years old are at the greatest risk for CKD.

Answer 13

True. Increasing age = increasing risk of CKD. But it can happen in younger pt’s.

Question 14

relationship of serum creatinine with GFR.

Answer 14

serum creatinine relates inversely with GFR -

the higher the serum creatinine, the lower the GFR.

Question 15

T/F Creatinine is an accurate indicator of GFR.

Answer 15

FALSE. It depends on many factores.

Question 16

Name 5 factors which affect creatinine levels, independent of GFR.

Answer 16

• muscle mass
• age
• diet
• gender
• race

Question 17

Cockcroft-gault equation

Answer 17

• calculates GFR
• based on age, weight, gender, and serum creatinine
• not used in clinic
• used in pharmaceuticals, for drug dosing.

Question 18

What equation is used clinically for GFR?

Answer 18

• the epic derivation (automatically calculated)

- it is based on age, woman, black, serum creatinine

Question 19

limitations of using EPIC’s automatic GFR calculation

Answer 19

it is accurate for GFR

Question 20

At what stage should treatment for CKD begin?

Answer 20

Stage 1!!!

Question 21

At what stage do symptoms of CKD start?

Answer 21

Stage 3!!!

Question 22

evaluation of anemia in CKD

Answer 22

Always rule out other causes, especially in stage 1 or 2, but also in stage 3-5. If other diagnoses are excluded, give synthetic EPO.

Question 23

What are the 2 most important things to control to slow progression of CKD?

Answer 23

• blood pressure / hypertension.

- proteinuria (use ACEi’s or ARBs)

Question 24

7 things which slow progression of renal disease.

Answer 24

• control of BP
• control of proteinuria (ACEi)
• smoking cessation
• glycemic control
• control of anemia
• correction of dyslipidemias
• control of metabolic acidosis.

Question 25

Treatment for hypertension in CKD patients

Answer 25

-Low salt diet! (

Question 26

Treatment of proteinuria in CKD patients.

Answer 26

ACEi’s or ARBS.

• Note: ACEi reduces GFR, but that is acceptable
  because it helps protect the GFR from high pressures, which are damaging.
  also reduces proteinuria

Question 27

Evaluation of proteinuria in CKD patients

Answer 27

• use dipstick

- if dipstick is negative in high risk pt’s (diabetes hypertension), order a urine microalbumin

Question 28

what is the normal protein/creatinine ratio?

Question 29

What symptoms are commonly present in stage 3 CKD?

Answer 29

anemia, early bone disease.

Question 30

What symptoms are commonly present in stage 4 CKD?

Answer 30

-fatigue, swelling, nausea vomiting.

Question 31

list the conditions/ complications in CKD which you need to evaluate for.

Answer 31

• bone mineral disorders (high PTH, kidney can’t activate Vit D)
• hyperkalemia
• Cardiovascular disease
• anemia

Question 32

diet restrictions in CKD patients- differences b/t CKD and ESRD?

Answer 32

for regular CKD

Question 33

Treatment of hyperkalemia in CKD.

Answer 33

• low K diet!!
• control of hyperglycemia (hyperglycemia causes K to come out of the cell into the ECF)
• control metabolic acidosis w/ bicarbonate (H+ traded for K+ in acidosis)

-if these don’t control hyperkalemia, K wasting diuretics or Kayexalate, a K resin, may be used.

Question 34

Why is control of metabolic acidosis important in CKD?

Answer 34

• increases bone resorption
• increases protein degradation,
• increases muscle wasting

Question 35

Goal of treatment for metabolic acidosis in CKD

Answer 35

treat if bicarb 22.

Question 36

treatment for metabolic acidosis in CKD

Answer 36

baking soda, or sodium bicarbonate tabs.

Question 37

What are the lab manifestations of a bone mineral disorder in a CKD patient?

Answer 37

• low Ca
• high PTH
• high Phosphate

-mainly due to the inability to activate Vit D

Question 38

Treatment of hyperphosphatemia in CKD patients

Answer 38

phosphate binders with meals

Question 39

Target levels for PTH in CKD patients.

Question 40

30-20-10 rule

Answer 40

-at GFR 30, refer to nephrologist
-at GFR 20, start looking at access placement for dialysis
at GFR 10, start dialysis.

Question 41

When should referral for kidney translplant be made?

Answer 41

ideally, before dialysis. Results with transplant are much better than dialysis.