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Flashcards in CKD Deck (68)
1

KDIGO AKI criteria

↑ creat 0.3+ within 48 hoursOR↑ creat greater than 1.5x baseline within last 7 daysORurine vol less than 0.5 mL/kg/h FOR 6 HOURS

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nephrotic v nephritic

Otic = damage to podocytes = holesItic = inflammation = bloody time

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focal segmental glomerulosclerosis

#1 seen clinicallyhypertension (always)nephrotic syndromeasymptomatic or microscopic proteinuriarenal insufficiency↑ risk progress to ESRD

4

FSGS dx

RENAL BIOPSY

5

FSGS tx

corticosteroids + immunosuppressant

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IgA nephropathy

#2 seen clinicallyaka Berger's - IgA settles in kidneys = glomerulonephritisoften only manifestation is hematuriagood BP w/o large proteinuria often doesn't progress to ESRD

7

IgA nephropathy tx

BP control w ACE-I or ARBproteinurialt 1g - typically no txgt 1g - 6 mo steroid trial, maybe immunosuppressants

8

IgA s/s

often only manifestation is hematuria

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IgA nephropathy and proteinuria relationship

lt 1g - typically no txgt 1g - 6 mo steroid trial, maybe immunosuppressants

10

primary glomerular disease x2

FSGSIgA nephropathyAcute GN, MCD, FSGS, MN, MPGN, IgA Nephropathy, Post Infectious GN, Anti‐GBM Nephritis

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secondary glomerular disease example

SLESLE, Wegner’s Granulomatosis, Vasculitis, Goodpasture’s Syndrome, Hepatitis C, Hepatitis B, HIV

12

SLE + kidney relationship

nephropathy! secondary glomerular diseasemore females, and younger

13

SLE glomerular disease s/s

often present, not always: proteinurianephrotic syndromehematuria

14

SLE glomerular disease dx

renal biopsycomplement (see depression), anti-dsDNA, anti-nuclear ab (positive)

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IgA nephropathy dx

RENAL BIOPSY

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** renal biopsy as dx **

FSGSIgA nephropathySLEnephritic syndrome

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nephrotic vs nephritic setting

OTIC: chronicITIC: acute (biopsy to dx/tx STAT)

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nephrotic vs nephritic mechanism

OTIC: podocyte injury, changed architecture (scar, matrix deposition)ITIC: inflammation, GBM break, crescent formation

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nephrotic vs nephritic onset

OTIC: insidiousITIC: abrupt

20

nephrotic vs nephritic edema

OTIC: largeITIC: small - mod

21

nephrotic vs nephritic BP

OTIC: normal - lowITIC: HIGH

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nephrotic vs nephritic proteinuria

OTIC: LARGEITIC: small - mod

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nephrotic vs nephritic hematuria

OTIC: eh maybe, maybe notITIC: MOD - LARGE

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nephrotic vs nephritic RBC casts

OTIC: absentITIC: present

25

leading cause of CKD in US

DIABETIC KIDNEY DISEASE! (diabetic nephropathy)

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** diabetic kidney disease dx **

CLINICAL PRESENTATION! often r/t poorly controlled DMACR- macro OR - micro + diab retinopathy or T1DM x10 years

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** ACR is... **

albumin:creatinine ratiomacro: greater than 300 mg/gmicro: 30 - 300 mg/g

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consider differentials for diabetic kidney disease if what are seen...

- absence of diabetic retino/neuro pathy- urine sediment- DM less than 5 years- little to no proteinuria

29

proteinuria and diabetic kidney disease

YES - think albumin!!!!ACR: micro or macroalbuminuria??

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** diabetic kidney disease treatment for proteinuria **

ACE or ARB- low dose 2.5 mg lisinopril- check BMP 1 week (hyper K, AKI)DONT START / DO DC... IF LATE STAGE 4 good for normotensive albuminuric DM pts if BP can tolerate

31

late stage 4 diabetic kidney disease tx nota bene

do not start ACE/ARBdc ACE/ARB if taking

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** metformin + CKD mgmt **

creatinine: 1.5 (f) 1.4 ()AVOID METFORMIN. (lactic acid increase believed) change to glipizide.

33

hypertensive nephrosclerosis

2nd leading cause of CKD in USkidney damage d/t htn

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hypertensive nephrosclerosis risk factors for ESRD progression

african americanadvancing agemalesmokerlipid abnormalitiesinsulin resistance

35

** hypertensive nephrosclerosis dx **

clinical - systemic signs of chronic, uncontrolled htn

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hypertension goals - diabetic v non-diabetic

diab: less than 130/80non-diab 120/70

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stage 4 CKD med nota bene

thiazides do not work!dc ACE/ARB (or don't start)

38

AE procardia, hydralazine

LE swelling

39

** clonidine + CKD **

NO NO NO. missed dose = rebound hypertension- difficult to wean off

40

CKD stages mnemonic

90 / 60 / 30 / 15 / less(GFR)

41

CKD: refer to nephrology

proteinuriaGFR declinehematuriamultiple renal cysts (incidental or purposeful imaging)resistant hypertensionrecurrent renal stones → urology & nephrology!electrolyte abnormalities (ex: hypercalcemia, hypernatremia)

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UA dipstick proteinuria equivalencies

mg/dL1+ 302+ 1003+ 300 - 5004+ 1000+

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nephrotic range proteinuria

3g +

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glucose usually not present in urine until...

serum glucose over 160-180

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normal 24 hour urine protein content

less than 150

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UA: leukocyte esterase and nitrite tell you

about pyuriareduction product from nitrites: E Coli, enterobacter, citrobacter, klebsiella, proteus

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urine pH typically

6between 4.5 - 7

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how much renal fxn lost before elevations of creat noted

60%

49

CKD + anemia

NORMALLYlow blood volume = erythropoetin to increase RBC creationCKD - depressed kidney fxn = no epo = anemia

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anemia w CKD tx

iron PO if tolerated- give with vitamin CESA (epo stimulating agent)

51

increases absorption of PO Fe

Vit C

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renal osteodystrophy/mineral bone disease

NORMALLY kidney works with parathyroid gland to manage Ca & PO4CKD- can't secrete = hyperphosphatemia = less calcium- 2ndary hyperparathyroidism (gland keeps secreting PTH trying to fix)

53

CKD + chronic metabolic acidosis tx

bicarb supplement - NaBicarb, NOT baking soda

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CKD + hyperuricemia tx

tx only if uric acid greater than 12REFER IF GOUT

55

** absolute indications for dialysis (ESRD) **

Uremic pericarditis/effusionUremicencephalopathyGI BleedingAnorexia/N/VProgressive Malnutrition

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** relative indications for dialysis (ESRD)

↑ serum CrGFR under 10‐15 ml/minRefractory lyte abnormalities (remember K can be managed without dialysis!!)Volume Overload not otherwise manageable

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ESRD referrals

dialysis centersocial workRD

58

PD complications

- peritonitis- fluid/vol mgmt- hypoalbuminemia- glucose management (dialysate has lots of glucose)- non-compliance

59

acute tubular necrosis: general definition

d/t ischemia r/t poor perfusion OR nephrotoxic drugs; if sufficient to cause tubular ischemia, will result in loss of tubular fxn

nephrotoxic drugs - include contrast, also cause vasoconstriction leading to ischemia/loss function (pre-tx with fluids, may add bicarb)

60

acute tubular necrosis: 3 phases of injury

oliguric
diuretic
recovery (post-oliguric)

61

ATN: oliguric phase

- UOP lt 400 ml/day
- increased BUN & creat
- electrolyte disturbances, acidosis, fluid overload (d/t kidney inability to excrete water)

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ATN: diuretic phase

occurs when cause of AKI corrected
- renal tubule scarring/edema
- increased GFR
- daily UOP 400+ ml
- possible electrolyte depletion from excretion of more H2O & osmotic effects of high BUN

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ATN: recovery phase

- decreased edema
- normalization of fluid & electrolyte balance
- return of GFR to 70% or 80% of normal

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ATN: treatment

- loop diuretics (Lasix)
- dialysis (until functional again)
- dopamine (increase perfusion, but no longer recommended)

65

chronic kidney disease definition

GFR under 60 for 3+ mos
+ "kidney damage": pathologic abnormalities or markers of damage including abn blood/urine tests, imaging

66

CKD: stages 1-5

GFR
1 - 90+
2 - 60 - 89
3 - 30 - 59
4 - 15 - 29
5 - under 15 (ESRD)

67

end stage renal disease definition

- renal fxn under 85%
- Stage V CKD: GFR under 15 OR dialysis
- uremia/CVD

68

pharm tx of choice for anemia s/t CKD

ESA erythropoesis stimulating agent