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CKD Flashcards

1
Q

CKD

A

broad range of disease severity and significant heterogeneity in risk of profession to end-stage renal disease, morbidity, mortality

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2
Q

CKD definded

A

based on 3 or more months of either kidney damage (albuminuria, kidney biopsy finding, imaging abmn) or GFR ,60

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3
Q

CKD- epidemiology

A

low GFR increases risk of systemic complications-CV disease, HTN, mineral/bone disorders, anemia- mortality and progression to end stage renal disease.

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4
Q

Dominant Risk factors for CKD

A

DM and HTN

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5
Q

Testing, risk stratification, treatment plan

A

differ based on eGFR and UACR

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6
Q

Detection of CKD- Recommendation

A

Test for CKD among high risk populations with DM and HTN

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7
Q

early detection

A

allows for complication management before symptoms occur and slows loss of kidney function over time

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8
Q

Detection by PCP

A

likely to avoid NSAIDs, use ACE/ARB when indicated and receive proper nephro care

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9
Q

Estimated Glomerular Filtration rate

A

most accurate assessment of kidney function, inaccurate in setting of AKI

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10
Q

Urine studies- Elevated albuminuria or protenunuria

A

Albuminuria- critical to evaluate prognosis
Albumin-CR- Ratio- more sensitive and specific marker of CKD than spot urine protein/creatinine ratio

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11
Q

CKD progression and complications- treatment aims to

A

delay progressive loss of kidney function, prevent/manage complications

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12
Q

Interventions fo Delay CKD Progression

A

manage HTN, Statin Use, Control DM, Correct Metabolic acidosis

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13
Q

Manage HTN

A

BP target is <130/80, sodium controlled diet, <2000mg of NA per day

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14
Q

Use of RAAS bloackers (ACE/ARB) for albuminuria and HTN

A

use in CKD with/out DM + A2/A3 levels of albuminuria, hyperkalemia ensues then look into ways to lower K, D/C RAAS blocker only of other methods to lower K fail. NEVER use ace and ARB in combo
Thiazides- stage G1-3b, loop diuretics second line with stage 4- BID

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15
Q

Statin Control

A

statin based therapies reduce vascular even in CKD

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16
Q

Control DM-

A

target A1c 7%, Higher target with limited life expectancy, reduces progression of albuminuria and loss of kidney function over time

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17
Q

CKD Anemia

A

measure hgb annually, start in G3a CKD- erythropoietin production decrease with low GFR

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18
Q

CKD+ mineral/bone disorder

A

secondary hyperparthyroidsm, hypocalcemia, hyperphosphatemia, decreased Vitd, vascular calcification- Begins in stage G3b- Measure at least once for baseline levels- Ca, phosphorus, intact parathyroid hormone, total 25-hydroxy VitD

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19
Q

Correct Metabolic acidosis

A

tx with oral alkali- achieve normal serum bicarb- slows kidney disease progression, Bicarb <22 prescribe sodium bicarb (650 TID), alternative- Sodium Citrate 30ml daily, if these fail- refer to nephro

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20
Q

Patient safety in CKD

A

Meds and metabolites are excreted by kidneys- dose adjustments on eGFR need to occur to reduce complications

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21
Q

D/c or briefly hold

A

RAAS blockers, NSAIDs, diuretics, metformin- r/t lactic acidosis- A patient safety approach to CKD considers the level of eGFR in prescription practice

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22
Q

NSAIDs

A

inhibit vasodilatory prostaglandins- esp with dehydration and HF- acute kidney injury; long term use increase rate of progression of CKD; Inquire about use of these OTC meds-educate potiental harm and SE- allergic interstitial nephritis, ^K, HTN, edema. Avoid with GFR less than 30. Limit these meds with GFR <60
EXTREME caution with CKD+ RAAS And/or diuretic therapy

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23
Q

Metformin:

A

Discontinue use with GFR <30, use with caugiton for pt with GFR <30-45, not reccomended with pt with Cr men >1.5 woman >1.4 r/t to risk of lactic acidosis

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24
Q

iodinated Contrast

A

major risk of nephropathy in CKD, prevention strategies include- Minimize dose, volume expansion with IV isotonic saline/bicarb, consider holding med that increase risk fo AKI, IV fluids 1ml/kg start 1 hour prior to procedure cont for 3-6hr post, measure kidney function 48-96h after

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25
CKD & CV disease
all patients with CKD are at increase risk for CV disease
26
Framingham Risk Factors for CV
Low eGFR and albuminuria
27
CKD risk factors for CV-
anemia, mineral/bone disorder, vascular clacification
28
Anti-platelet agents in CKD
advise to take low-dose aspirin for secondary prevention of CV disease- unless bleeding risk
29
referral to nephrologists
PCP are central to referring to specialists- associated with improved outcomes
30
Timely referral
improves preparation for kidney replacement therapy, lower use of hemodialysis/emergent dialysis, and increase use of kidney transplants/selfcare dialysis
31
Severe Albuminuria + DM
Don't need referral- can be managed by PCP
32
Stage G4-G5 CKD + limited life expectancy + adv dementia
Manage conservatively
33
common complications for PCPs
pt age over 65 with eGFR 45-60 but NO albuminuria or urinalysis Abmn- manage conservatively, avoid use of RAAS blockers, limit NSAIDs and IV contrast procedures
34
Elderly+ lab evidence of stage G3a CKD
Monitor closely for AKI after major surgeries.
35
When to referr
GFR <30, >25% drop in GFR, progression of CKD with sustain decline in eGFR of more than 5 per year, consistent finding of significant albuminuria, persistent and unexplained hematuria, secondary hyperparathyroidism, persistent anion gap acidosis, non-iron deficiency anemia, CKD and HTN in refractory, persistent abn in K, recurrent Nephrolithisais, hereditary kidney disease, or unkwn cause
36
early recognition of CKD
Enhances Kidney Protective Care by improving modifiable RF, Improves prediction of CV, events beyond RF, encourages timely nephro referral, limits patient safety risks with CKD
37
Improved CKD diagnosis
increased urinary albumin testing, Increased appropriate use of ACE/ARBs, Avoids NSAIDs with lower eGFR,
38
Modifiable Risk Factors
DM, HTN, NSAID use, hx of AKI
39
Non-Modifiable
fHx of kidney dx, >60 year old, ethnicity- AA, hispanic, Asian/Pacific islander, American Indian
40
eGFR-
Provides insight regarding overall kidney function
41
ACR- Albumin-Creatinine ratio
provides insight regarding extent of kidney damage
42
Albuminuria categories- A1
normal to mildly increased- <30 mg/g <3 mg/mmol
43
Albuminuria categories- A2
moderately increased 30-200 mg/g, 3-29 mg/mmol
44
Albuminuria categories- A3
Severely Increased >300 mg/g >30 mg/mmol
45
eGFR Categories- G1
Normal or high <90
46
eGFR Categories - G2
mildly decreased 60-89
47
eGFR Categories G3a
mildly to moderately decreased 45-59
48
eGFR Categories G3b
moderately to severely decreased 30-44
49
eGFR Categories G4
severely decreased 15-29
50
eGFR Categories G5
Kidney failure <15
51
Diagnostic Criteria
eGFR <60, ACR >30, Markers of kidney damage- 1+ glomerular hematuria, kidney biopsy abnm, polycystic kidney dx on imaging
52
CKD-EPI creatinine equation
Most accurate and least biased method to estimate eGFR
53
Urine Albumin creatinine ratio
calculated by dividing albumin concentration/creatinine concentration Assist in adjusting levels of varying urine concentrations- more accurate than albumin alone
54
Spot UACR
qualifies proteinuria, 3 levels exist, normal/mild/moderate/severe
55
Patient safety- Electroyletes
HyperK, magnesemia, phosphatemia, Hypoglycemia
56
AKI RISK
Avoid NSAIDs, Dual RAAS blockade, Med >30% clearance in kidney- requires dose adjustment, No bisphophonares of eGFR <30, avoid gadolinium-based contrast fo egFR <30
57
indications for Referal
eGFR <30, persistent albuminuria, atypical progression of CKD, AKI, urinary red cell cast, RBC >20, refractory HTN, abnm K persistent, nephrolithiasis, hereditary kidney disease,
58
Which vitamin D is perferred form to achieve normal serum levels
Vit D3,
59
Which stage does the complications normally start?
Stage 3
60
What can a PCP do for CKD?
recognizing and test at-risk patients, educate, manage blood pressure and DM
61
How to address othe risks?
Vaccinations, malnutrition, depression, refer to dietitian for nutritional guidance,
62
Stage 1- 90-100 function
no symptoms, other health issues, DM, HTN, obesity
63
Stage 2- 60-89
no symptoms, protein leaking in urine <200mg
64
Stage 3 30-59
edema, fatigue, back pain, foamy-darker urine, microalbumin >200, food restrictions, sodium/phosphorous
65
Stage 4 15-29%
Stage 3 symptoms + n/v, difficulty concentration, tingling in toes/fingers, loss of appetite, sleep issues, kidney dialysis, renal dietitian required, most food restrictions, less K
66
Stage 5 <15%
Stage 4 symptoms, fatigue, easy bruising, thirst, cramps, skin color changes, making little to no urine, kidney dialysis/ transplant
67
Anemia + CKD+ ESA
Not required until Stage 4-5
68
Anemia Treatment
Iron supplements needed for ESA to be effective,
69
Initiate Iron therapy
if TSAT is <30 and ferritin <500- IV for dialysis and oral for non
70
Individualized ESA therapy
start at Hb <10, and maintain Hb <11.5, Ensure good iron stores
71
Avoid transfusion in who?
transplant patients- if needed use leukocyte filter to reduce HLA sensitization
72
Testing in Stage 3
Calcium+ phos Q6-12 months, PTH- Once, 25-D- once/annually
73
Testing in stage 4
Calcium + Phos Q3-6 months, PTH- Q6-12M, Vit D- Based on treatment levels
74
Testing in stage 5
Calcium + Phos Q 1-3m, PTH- Q3-6M, Vit D- based on treatment levels
75
Vit D treatment
D3- 2000 IU by mouth is cheaper and better absorbed than 50000- IM monthly,
76
Diet-
Limit phosphorus, emphasis on decreasing packaged products, refer to renal RD
77
Fracture risks
Dexa scan wont predict fx risk in CKD 3-5, PTH goals and use of Calcutriol
78
Lipid management- >50 and CKD 1-2
Statin alone
79
Lipid Management- >50 and CKD 3a- 5
use statin alone or statin/zetia combo
80
Lipid Management- adults <50 + CKD+ hx of CAF, MI, DM, Stroke
use statin alone
81
Lipid Management- Dialysis and transplant pt
cont but do not start a statin after dialysis initiation
82
Lipid management- all transplant patients
statin generally recommended
83
Risk factors of infection
Advanced age, high burden of coexisting illness, HYPOalbuminemia, Immunosuprrive therapy, Nephrotic syndrome, uremia, anemia and malnutrition, high prevalence of functional disabilities.
84
mental health conseling
depression is associated with chronic dx, patient with eGFR < 60 requires constant assessment of impairment of function and well-being
85
Vaccinations
Annual Flu recommended Polyvalent when eGFR < 30, both vaccines COIVD- mRNA booster, HepB immunization when GFR < 30- confirm with response sero testing Use of live vaccine- most consider Pt, immune system status first
86
malnutrtion
common with protein energy wasting Beings at stage 3-4, Prevent- assess nutritional status, individualize prevention/tx patient education, promote patient adherence
87
Common meds requiring reduction of dose
Allopurinol, gabapentin, reglan, narcotics, BB, Digoxin, Statins, antimicrobials, lovenox, methotrexate, colchicine
88
Hyperkalemia
1st line- stop diet K intake, stop NSAIDs, Cox 2 inhibitors, stop K sparing diuretics, avoid salt substitutes New binding agent- Patiromer
89
Conditions that increase risk for CKD
DM, HTN, CV, >60 y/o, ethic/racial minority, obesity, fam hx, AKI history
90
eGF < 60 Safety risk
drug dose consider, reduce risk of AKI volume depletion, contrast induced AKI,
91
eGFR 45-60 Safety risk
avoid prolong NSAIDs, cont metformin
92
eGFR 30-45 safety risk
avoid prolong NSAIDs, use metformin with close monitoring at 50% dose
93
eGFR <30 safety risk
avoid NSAIDs, AVOID bisphophonates, avoid metformin, Avid PICC lines, Monitor PT INR, closely given increased risk of warfarin anticoagulation bleeding
94
CKD progression and Complications- HTN
Blood pressure goals, <140/90, Consider BP goal <130/80 only if ACR >300, ACE/ACR for HTN of ACR >30, avoid ACE/ARB use together, diuretic is normally required, Dietary sodium <2000mg/day
95
CKD progression and Complications- DM
Target A1C- 7%
96
CKD progression and Complications-- testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10 Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
97
CKD progression and Complications-- testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10 Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
97
CKD progression and Complications-- testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10 Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
98
CKD progression and Complications-- testing
anemia- CKD stg 3 + evaluation if Hb <13 for men and < 12 in woman, treat iron deficiency first, refer to nephrology for ESA to treat Hb <10 Acidosis- Bicarbonate goal > 22-26 use sodium bicarbonate 650mg thrice daily CKD-MBO- CKD 3b- calcium, phos, 25D, PTH,
99
CKD- Prevalence
10% of Americans- most are asymptomatic untill end stage
100
70% of cases of late stage are due to what
DM or HTN/Vascular disease
101
APOL-1 Gene
increase risk of CKD in African Decent
102
Most Stg 3
die from CVD prior to progression to ESRD
103
Patho
Destruction of nephrons- compensatory hypertrophy and supernormal GFR of remaining nephrons- ACE/ARB can help with hyperfiltration
104
Clinical signs
Early stg- saymptomatic- accumulation of metabolic waste products-uremic syndrome- any signs of uremia=hospital admit
105
Reversible causes of kidney injury
Infection, obstruction, extracellular fluid volume, HypoK, Hypercalemia, hyperuricemia, nephrotoxic agents, severe/urgent HTN, heart failure
106
CKD- Dx imaging
US- small echogenic kidneys b/l-chronic parenchymal scarring of advanced CKD, Large kidneys- adult polycystic kidney disease, DM neuropathy, HOV, plasma cell myeloma, amyoidosis, obstructive ureopathy

Mod 4 (4 decks)

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