Chronic Kidney Disease

Question 1

Spectrum of pathophysiologic processes associated with abnormal kidney function and a progressive decline in glomerular filtration rate (GFR)

Answer 1

Chronic Kidney Disease

Question 2

2 Broad Sets of Mechanisms of Damage in CKD

Answer 2

1. initiating mechanisms specific to the underlying etiology

2. hyperfiltration and hypertrophy of the remaining viable nephrons

Question 3

Risk Factors of CKD

Answer 3

• small for gestation birth weight
• childhood obesity
• hypertension
• diabetes mellitus
• autoimmune disease
• advanced age
• African ancestry
• a family history of kidney disease
• a previous episode of acute kidney injury and presence of proteinuria
• abnormal urinary sediment
• structural abnormalities of the urinary tract

Question 4

Normal annual mean decline in GFR with age from the peak GFR (~120 mL/min per 1.73 m2) attained during the 3rd decade of life

Answer 4

~1 mL/min per year per 1.73 m2

Question 5

Refers to the excretion of amounts of albumin too small to detect by urinary dipstick or conventional measures of urine protein

Answer 5

Microalbuminuria

Question 6

Serves as a marker not only for early detection of primary kidney disease, but for systemic microvascular disease as well

Answer 6

urinary albumin to creatinine ratio (UACR)

MEN - > 17 mg albumin/g creatinine
WOMEN - > 25 mg albumin/g creatinine

Question 7

Devised to predict the risk of progression to stage 5 dialysis-dependent kidney disease

Answer 7

Kidney Failure Risk (KFR) equation

Question 8

Factors affecting the likelihood and rate of CKD progression

Answer 8

baseline eGFR and degree of albuminuria
primary renal disease
ongoing exposure to nephrotoxic agents
others: obesity, hypertension, age, ethnicity and laboratory parameters

Question 9

Stage of CKD where the accumulation of toxins, fluid, electrolytes normally excreted by the kidney –> uremic syndrome

Answer 9

ESRD

Question 10

Etiologies of CKD

Answer 10

Diabetic nephropathy
Glomerulonephritis
HPN associated CKD
ADPKD
Other cystic and tubulointerstitial nephropathy

Question 11

Major risk factor for cardiovascular disease

Answer 11

Minor decrement in GFR or the presence of albuminuria

Question 12

PATHOPHYSIOLOGY OF UREMIC SYNDROME (3 Spheres Of Dysfunction)

Answer 12

1. accumulation of toxins that normally undergo renal excretion
2. loss of other kidney functions such as fluid and electrolyte homeostasis and hormone regulation
3. progressive systemic inflammation and its vascular and nutritional consequences

Question 13

May serve as an indication to initiate dialysis in advanced CKD

Answer 13

diuretic resistance with intractable edema and hypertension

Question 14

Common disturbance in advanced CKD – metabolic acidosis

Answer 14

NAGMA – early stage

HAGMA – later stage

Question 15

Used to maintain euvolemia in CKD

Answer 15

dietary salt restriction and loop diuretics + metolazone

Question 16

Treatment of hyperkalemia in CKD

Answer 16

dietary restriction of potassium
Kaliuretic diuretics
potassium-binding resins – calcium resonium, sodium polystyrene or patiromer

Question 17

Considered a uremic toxin and high levels are associated with muscle weakness, fibrosis of cardiac muscle, and nonspecific constitutional symptoms

Answer 17

parathyroid hormone

Question 18

Leading cause of morbidity and mortality in patients at every stage of CKD

Answer 18

cardiovascular abnormalities

Question 19

Cardiovascular abnormalities

Answer 19

Ischemic Vascular Disease
Heart Failure
Hypertension and Left Ventricular Hypertrophy
Pericardial Disease

Question 20

For the CKD patient not yet on dialysis or the patient treated with peritoneal dialysis

Answer 20

oral iron supplementation

Question 21

Subtle clinical manifestations of uremic NEUROMUSCULAR disease usually become evident at

Answer 21

stage 3 CKD

Question 22

PERIPHERAL NEUROPATHY becomes clinically evident after the patient reaches

Answer 22

stage 4 CKD

Question 23

EARLY MANIFESTATIONS OF CNS COMPLICATIONS:

Answer 23

mild disturbances in memory and concentration and sleep disturbance

Question 24

LATER STAGES:

Answer 24

neuromuscular irritability – hiccups, cramps, and twitching

Question 25

ADVANCED UNTREATED KIDNEY FAILURE

Answer 25

asterixis myoclonus seizures coma

Question 26

Characterized by ill-defined sensations of sometimes debilitating discomfort in the legs and feet relieved by frequent leg movement

Answer 26

“restless leg syndrome”

Question 27

Urine-like odor on the breath, derives from the breakdown of urea to ammonia in saliva and is often associated with an unpleasant metallic taste (dysgeusia)

Answer 27

uremic fetor

Question 28

Quite common and one of the most vexing manifestations of the uremic state

Answer 28

pruritus

Question 29

Skin condition unique to CKD patients which consists of progressive subcutaneous induration, especially on the arms and legs

Answer 29

nephrogenic fibrosing dermopathy

Question 30

Diagnosis of CKD of long-standing duration

Answer 30

bilaterally small kidneys ``` EXCEPTION: diabetic nephropathy amyloidosis HIV nephropathy polycystic kidney disease ```

Question 31

COMMONLY ACCEPTED CRITERIA FOR INITIATING PATIENTS ON MAINTENANCE DIALYSIS

Answer 31

• presence of uremic symptoms nausea, vomiting, anorexia altered mental status – lethargy, somnolence, malaise, stupor, coma, delirium pericarditis friction rub chest pain dyspnea bleeding diathesis uremic encephalopathy – asterixis (flapping tremor of the hand), tremor multifocal myoclonus, seizures uremic fetor (breath smells like urine) sallow skin (slightly yellow and/or slightly pale) * presence of hyperkalemia unresponsive to conservative measures * persistent extracellular volume expansion despite diuretic therapy * acidosis refractory to medical therapy * bleeding diathesis * creatinine clearance or estimated glomerular filtration rate (GFR) <10 mL/min per 1.73 m2)

Question 32

Relies on the principles of solute diffusion across a semipermeable membrane, movement of metabolic waste products takes place down a concentration gradient from the circulation into the dialysate

Answer 32

Hemodialysis

Question 33

3 essential components to hemodialysis

Answer 33

dialyzer composition and delivery of the dialysate blood delivery system

Question 34

Have the highest long-term patency rate of all hemodialysis access options

Answer 34

Fistula

Question 35

The most common additives to peritoneal dialysis solutions

Answer 35

heparin

Question 36

dialysis access is the preferred option if your veins are too small

Answer 36

AV graft

Question 37

Absolute Indications for Renal Replacement Therapy

Answer 37

Pericarditis or Pleuritis Progressive Uremic Encephalopathy or neuropathy w/ signs such as confusion, asterixis, myoclonus, wrist or foot drop, seizures Bleeding diathesis attributable to uremia Persistent metabolic disturbances that are refractory to medical therapy - hyperkalemia, metabolic acidosis, hypercalcemia, hypocalcemia and hyperphosphatemia Fluid overload refractory to diuretics HPN poorly responsive to antiHPN medications Persistent nausea and vomiting Evidence of malnutrition

Question 38

Relative Indications for Renal Replacement Therapy

Answer 38

anorexia and nausea impaired nutritional status increased sleepiness decreased energy levels, attentiveness and cognitive tasking

Question 39

Indication for Maintenance Dialysis

Answer 39

Uremic Symptoms - N/V, loss of consciousness, uremic pericarditis Intractable HYPERKALEMIA Persistent Volume Expansion despite Diuretics Refractory ACIDOSIS Bleeding Diasthesis eGFR < 1.73 mL