CKD

Question 1

CKD is defined as?

Answer 1

• 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

Question 2

Glomerulonephritis (GN)

Specific diseses effect glomular filtration

Answer 2

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

Question 3

Risk factors for CKD chart

Answer 3

Question 4

Presentation

Stages

Answer 4

• 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

Question 5

Systems affected by CKD

Answer 5

• 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

Question 6

CKD stages

Answer 6

Question 7

Cockcroft-Gault equations for calculating GFR?

Answer 7

Question 8

Markers of kindey damage?

Answer 8

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

Question 9

What will cause an increase or decrease in SCr?

Answer 9

Increase

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

Decrease

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

Question 10

Albuminuria catagories and ACR values

Answer 10

• A1 <30
• A2 30-300
• A3 >300

Question 11

Nephrotoxic medications

Answer 11

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

Question 12

Goals of CKD treatment

Answer 12

• 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

Question 13

Albuminuria indication?

Treatment?

Effectiveness?

Answer 13

• 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

Question 14

Albuminuria check what for when?

Answer 14

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

Question 15

Control related conditions

DM

HTN

Answer 15

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

Question 16

Preventative therapy for CKD

Answer 16

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

Question 17

Vit D deficiency

Indication

Safety

Monitoring

Answer 17

• 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

Question 18

Nutritiional Vit D use in stage?

Analog?

Answer 18

• 3-4
• Ergocalciferol
• Cholecalciferol

Analog

• Calciferiol
• Paricalciferol
• Doxercalciferol

Question 19

CKD-MBD lab goals

Answer 19

Question 20

Treat hyperphosphatemia if?

Answer 20

>4.6

Question 21

hyperphosphatemia

Initiate treatment when?

Answer 21

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

Question 22

hyperphosphatemia drugs

Answer 22

Question 23

CKD-MBD monitoring

Answer 23

Question 24

Phosphate binders

Answer 24

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

Question 25

Cinacalcet (calcimimetic) Only approved for?

Answer 25

* Only approved for ESRD

Question 26

Diagnosing Anemia

Answer 26

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

Question 27

Treat anemia if?

Answer 27

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

Question 28

Evaluation of Anemia

Answer 28

Question 29

Anemia tx goals

Answer 29

* 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

Question 30

Anemia therapy

Answer 30

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

Question 31

Dont give IV iron if?

Answer 31

Pt has infection

Question 32

When do you choose IV Iron?

Answer 32

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

Question 33

Initiate ESAs when?

Answer 33

Hgb\<10

Question 34

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

Answer 34

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

Question 35

Hemodialysis access types

Answer 35

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

Question 36

Peritoneal Dialysis

Answer 36

* 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