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Flashcards in CKD Deck (36):
1

CKD is defined as? 

  • Presence of kidney damage or decrease in kidney function for 3 months or longer 
    • Seen by markers of damage or pathological abnormalities
    • eGFR <60 
    • CKD is classified by: cause, GFR, albuminuria 

2

Glomerulonephritis (GN) 

Specific diseses effect glomular filtration 

 

  • Lupes nephritis
  • Post-infectous GN 
  • Congenital malformations 
  • Polycystic kidney disease
  • Acute renal failure 

3

Risk factors for CKD chart 

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4

Presentation 

Stages 

  • 1/2 usually asymptomatic 
  • 3-4 minial symptoms
    • Fatigue, edema, changes in urination (amount, color, frequency) 
  • 5
    • Pruritus
    • N/V/constipation
    • Muscle pain
    • Fatigue
    • Bleeding abnormalities 

5

Systems affected by CKD

  • Carbia/pulmonary
    • Na retention: volume expansion edema
    • Uremia: pericarditis, decreased contractility 
    • Anemia: high CO state, decreased oxygen delivery, left ventricle hypertophy
  • GI
    • Alt tastes, anorexia, N/V, hiccups 

6

CKD stages 

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7

Cockcroft-Gault equations for calculating GFR?

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8

Markers of kindey damage?

  • Albuminuria 
  • Urine sediment abnormalities
  • Imaging abnormalities
  • Assess these through: Urinalysis, SCr, Blood pressure, serum electrolytes and imaging studies. 

9

What will cause an increase or decrease in SCr?

Increase

  • CKD
  • AA
  • Drugs that inhibit tubular secretion
  • Ingestion of meat or creatine supplements 

Decrease

  • Reduced muscle mass (elderly, females)
  • Malnutrition
  • Amputation
  • Vegan 

10

Albuminuria catagories and ACR values 

  • A1 <30 
  • A2 30-300
  • A3 >300

11

Nephrotoxic medications

  • NSAIDs, Amphotericin B, Aminoglycosides, Cyclosporine, vancomycin, ACEs, ARBs

12

Goals of CKD treatment

  • Delay progression of CKD to ESRD
  • Appropriate manage risk factors associated with CKD (Albuminuria, DM, HTN, HLD)
  • Prevent and minimize complications associated with CKD (MBD and Anemia)
  • Reduced mobidity and mortality associated with CKD

13

Albuminuria indication?

Treatment?

Effectiveness?

  • ACR >= 30 mg/g or AER >= 30 mg/24 hrs
  • Treatment
    • ACE
    • ARBs
    • CCBs if cant tolerate others
  • Effectiveness
    • With HTN: titrate dose until BP goal lower if tolerated
    • Normotensive: titrate dose as tolerated and proteinuria reduced

14

Albuminuria check what for when?

SCr, BUN, K+ 2-4 weeks after initiation of ACE/ARB

SCr increase

<30% no dose change

30-50 reduce dose and recheck in 1 week

>50% discontinue agent and recheck after 1 week 

15

Control related conditions

DM

HTN

DM

  • A1c < 7% 
  • if >65 yo or significant comorbidities (stroke, MI, PVD, liver disease), consider goal A1c 7-8%

HTN

  • <140/90 if ACR < 30 
  • <130/90 IF ACR > 30
  • TREAT WITH ACE OR ARB

16

Preventative therapy for CKD

  • Aspirin 81 mg daily
  • Vaccines 
    • Influenza
    • Pneumococcal
    • Elevated Uric Acid (>6), Start allopurinol 

17

Vit D deficiency 

Indication 

Safety 

Monitoring

  • 25OHD < 30 ng/mL
  • Ca < 9.5, Phos <5.5 but iPTH remains elevated (use Vit D analog) 

 

Safety

  • Discontnue if Ca > 10.2, Ca x Phos >55, Phos > 4.6 
  • Monitor: Check iPTH every 3 months, Ca/Phos monthly for 6 months, Vit D monthly until stable, then every 3 months 

18

Nutritiional Vit D use in stage?

Analog?

  • 3-4 
  • Ergocalciferol
  • Cholecalciferol

Analog

  • Calciferiol
  • Paricalciferol
  • Doxercalciferol

19

CKD-MBD lab goals 

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20

Treat hyperphosphatemia if?

>4.6 

21

hyperphosphatemia

Initiate treatment when?

 

When elevated phosphorus and/or iPTH levels remain after 2-4 mo of treatment 

22

hyperphosphatemia drugs 

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23

CKD-MBD monitoring

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24

Phosphate binders

  • Calcium PB, Sevelamer, Lanthanum 
  • separted these med by 1 hour before or 3 hours after PB 

25

Cinacalcet (calcimimetic) 

Only approved for?

  • Only approved for ESRD

26

Diagnosing Anemia

  • Lab tests 
    • CBC + Diff
      • Look at hemoglobin
    • Ferritin
    • Percent transferrin saturation (TSAT)
    • Absolute reticulocyte count
    • Total iron binding capacity (TIBC)

27

Treat anemia if?

  • Hgb <12 in females
  • <13 in males 
  • Ferritin
    • <= 500 ng/mL
  • TSAT
    • <= 30%

28

Evaluation of Anemia 

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29

Anemia tx goals

  • Increase oxygen carrying capacity 
    • Hgb > 11 dont want to be higher than this
    • TSAT >20% same
    • Ferritin > 100 (non-HD) or >200 HD
  • Decrease signs and symptoms of anemia
  • Decrease need for blood transfusion 

30

Anemia therapy

  • IV/Oral iron
  • Erythropoiesis- stimulating agents (ESAs)
  • Blood transfusion 

31

Dont give IV iron if?

Pt has infection 

32

When do you choose IV Iron?

  • TSAT <12
  • Hgb <7 
  • Risk of ongoing blood loss
  • Cannot tolerate oral Fe
  • Dont respond to oral 
  • Not compliant 
  • Hemodialysis 

33

Initiate ESAs when?

Hgb<10 

34

What should you make sure to tell patients when taking Oral Iron?

Interact with?

  • Dark stools, urine discoloration 
  • Antacids, PPIs, H2RA, levothyroxine

35

Hemodialysis access types

  • AV fistula most preferred but must be planned in advance 
  • AV graft quicker

36

Peritoneal Dialysis 

  • Preserves residual kidney function
  • Similar to HD but uses peritoneal membrane and dialysate is instilled into peritoneal cavity 
  • Physiologic removal of waste products, mimics, endogenous kidney function
  • Complications: peritonitis and catheter-related infections