Chronic Renal Failure

Question 1

Stage 1 of CKD

Answer 1

1. Kidney damage (protein in urine)
2. Normal GFR >/= to 90
3. Function: 50-60%
4. No symptoms
5. Tx comorbidities

Question 2

Stage 2 of CKD

Answer 2

1. Kidney damage (protein in urine)
2. Decreased GFR: 60-89
3. Function: 60-70%
4. No symptoms
5. Glucose control
6. BP <130/80 through use of ARB or ACE inhibitor

Question 3

Stage 3 of CKD

Answer 3

1. Moderate renal damage
2. GFR: 30-59
3. Refer to nephrologist
4. Manage anemia, malnutrition, bone disease as well as BP

Question 4

Stage 4 of CKD

Answer 4

1. Severe damage
2. GFR 15-29
   3, Symptoms: Fatigue, Insomnia
   Difficulty concentrating,
   Edema (face and feet)
   Itching (uremic pruritis)
   Dialysis education
   Dialysis access
   Transplant education

Question 5

Stage 5 of CKD

Answer 5

1. Kidney Failure
2. GFR < 15 mL/min or on dialysis
   More severe fluid retention
   Anorexic
   Declining mental function
   Peripheral neuropathy
   Treat with dialysis or transplant

Question 6

What % loss of glomerular filtration correlates to symptom development?

Answer 6

75% loss of glomerular filtration

Question 7

CKD Definition

Answer 7

1. Progressive, irreversible loss of nephrons and nephron function which takes place over months to years
2. GFR months

Question 8

What is the leading cause of morbidity and mortality for CKD?

Answer 8

1. Cardiovascular, including: CAD/PVD/Cerebral VD, HTN, CHF, LVH, pericarditis

Question 9

What are the skin symptoms seen with CKD?

Answer 9

Yellow-brown color, dry & scaly skin, brittle nails, severe itching

Question 10

What are the neurologic symptoms seen with CDK?

Answer 10

Altered mental status, muscle cramps and twitching, paresthesias, muscle wasting

Question 11

What are the endocrine symptoms seen with CKD?

Answer 11

Secondary hyperparathyroidism

Anemia (erythropoietin deficiency)

Question 12

What are the hematologic symptoms seen in CKD?

Answer 12

GI bleeding, easy ?bruising, bleeding from body orifices

Question 13

What are the MSK symptoms seen in CKD?

Answer 13

Fractures, bone & muscle pain, abnormal gait

Question 14

Why is calcitriol important in CKD?

Answer 14

Calcium in cells in dropping, so calcitriol is increased to cause increased absorption of ca in the intestine and increased release of Ca in ECF

Question 15

Diagnostic Studies in CKD: CBC results

Answer 15

1. Low Hgb/Hct

Question 16

Diagnostic Studies in CKD: Renal function

Answer 16

1. Increased BUN and Cr

Question 17

Diagnostic Studies in CKD: Electrolytes results

Answer 17

Hyperkalemia
Hypocalcemia
Hyperphosphatemia

Question 18

Diagnostic Studies in CKD: ABG results

Answer 18

Metabolic acidosis

Question 19

Diagnostic Studies in CKD: UA results

Answer 19

Specific gravity low

Proteinuria, glycosuria, RBC’s, casts, crystals, WBC’s

Question 20

Diagnostic Studies in CKD: Imaging studies results

Answer 20

Reduced kidney size (<9-10 cm)

Enlarged in PKD, Diabetic Neph., Mult. Myeloma, Amyloidosis, Obstructive Neph.

Question 21

Diagnostic Studies in CKD: renal biopsy results

Answer 21

Identify underlying disease

Question 22

Conservative Tx of CKD

Answer 22

1. Low protein diet to reduce end products of protein metabolism
2. High calorie diet to prevent ketoacidosis
   Na+ & K+ restrictions
3. Phosphorous restriction
   4 Fluid restriction to maintain fluid balance: esp. dialysis pts

Question 23

Drug therapies for CKD

Answer 23

1. Loop diuretics (furosemide/Lasix)
2. Anti-hypertensives
   ACE inhibitor or ARB
   Diuretic should be added
3. Anti-emetics prn
4. Stool softeners prn
5. Iron and folate supplements prn
6. Synthetic erythropoietin – Epogen/Procrit

Question 24

Procedural tx of CKD

Answer 24

1. Dialysis
   A. Hemodialysis
   Filters blood through dialysis machine via AV fistula
   B. Peritoneal dialysis
   Catheter is placed in peritoneal cavity for instillation of dialysate

Question 25

Tx of Hyperkalemia: Emergent

Answer 25

1. Emergency Measures (EKG changes) A. Hyperkalemia (>6.5 mEq/L) - Regular insulin 10 cc IV + 50% Dextrose 50 cc IV Facilitates uptake of glucose into the cell, which brings potassium with it. Give dextrose to replace the glucose that was taken up into the cells -HCO3 IV Give if acidotic ↑ pH, resulting in temporary potassium shift from the extracellular to intracellular. Use as adjunct to insulin B. Dialysis: if a dialysis pt C. Pericardiocentesis: Cardiac tamponade D. Thoracentesis: Relieve pulmonary edema and pleural effusion

Question 26

Tx of Hyperkalemia: non-emergent

Answer 26

1. Non-emergent measures (No EKG changes) 2. Loop Diuretics (Lasix/furosemide) Cause potassium loss through the kidney 2. Beta 2-adrenergic agonist (Albuterol) Promote cellular reuptake of potassium 3. Exchange Resin (Kayexalate) Exchanges Na+ for K+ (binds) and evacuates with BM

Question 27

What ethnic groups are more prone to CKD?

Answer 27

Hispanics, African-Americans, Asians, and Native Americans

Question 28

What age group is CKD most commonly seen in?

Answer 28

>60 yr

Question 29

What vascular diseases can lead to CKD?

Answer 29

HTN, Renal artery stenosis

Question 30

What primary chronic glomerular diseases can lead to CKD?

Answer 30

IgA nephropathy: common, many improve but some turn chronic

Question 31

What secondary chronic glomerular diseases can lead to CKD?

Answer 31

1. Collagen-vascular disease (SLE, Sarcoidosis, etc.) 2. Postinfectious glomerulonephritis 3. Diabetic nephropathy Most common cause in U.S. & other developed countries

Question 32

What tubulointestinal nephritic disorders can lead to CKD?

Answer 32

Drugs, heavy metals, chronic pyelonephritis

Question 33

What 2 misc disease can lead to CKD?

Answer 33

Polycystic kidney disease | Obstructive nephropathy: postrenal obstructions not taken care of

Question 34

Pathophys of CKD

Answer 34

Decreased renal function interferes with the kidneys' ability to maintain fluid and electrolyte homeostasis Decreased ability to excrete phosphate & K+ When renal failure is advanced (GFR ≤ 10 mL/min) the ability to concentrate urine is lost

Question 35

What 3 parameters is CrCl affected by?

Answer 35

Age Muscle mass High protein diet

Question 36

The amount of filtrate produced by the kidney depends on...

Answer 36

Amount of blood flow to kidney | Ability of glomeruli to filter

Question 37

Complications from CKD

Answer 37

1. Proteinuria: not immediately, but soon after disease starts 2. HTN Most common physical finding in CKD 3. CV disease: due to underlying HTN 4. Decreased renal function can lead to uremia Accumulation of nitrogenous wastes (urea) from protein metabolism (azotemia) Accompanies loss of fluid and electrolyte balance

Question 38

What are the systemic effects of uremia?

Answer 38

``` Extracellular fluid accumulation Low Caˉ, high K+ Acidosis (metabolic) Anemia/bleeding disorders Osteomalacia (soft bones): due to high phosphorus and low calcium, PTH also plays a role CAD/PVD/CVA Encephalopathy, seizures, peripheral neuropathy Pruritis/yellow skin Secondary to uremia ```