CKD + rhabdo Flashcards

(33 cards)

1
Q

Wide variation from mild muscle pain to severe AKI

Muscle pain, weakness

May be asymptomatic with dark urine

Classic triad: muscle pain + weakness/swelling of injured muscles + tea colored urine (rare to have all three, but generally)

A

rhabdomyolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are RF for rhabdomyolysis?

A

Coexisting kidney/liver disease
DM
Hypothyroidism
>80
Small body frame/frailty
Thyroid disorders
High triglycerides
Metabolic muscle disease
ICU

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Skeletal muscle injury → acute tubular necrosis
Necrotic muscle cells release myoglobin + CK into bloodstream at extremely high levels (also aldolase, LDH, electrolytes) → tubular obstruction from casts + vasoconstriction
FROM: trauma (crush injury), immobilization, alcohol/drug/exposure to other toxins, meds (statins + fibrates), metabolic disorders, viral infections, physical exertion
→ AKI, cardiac arrest, DIC

A

rhabdomyolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

LABS: elevated CK (5x normal limit), ~16000
AKI → check BUN/Cr

Elevated = AST, ALT, LD, uric acid
Electrolyte abnormalities (K, Ca, phosphate)

UA: protein, brown pigmented casts, uric acid crystals

Normal CK: 40-320 (men) and 25-200 (women)

A

rhabdomyolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

how do you treat rhabdomyolysis?

A

With uncomplicated + normal Cr + can hydrate themselves = discharge from ER after correction of volume deficits (IV fluids)
Stop any contributing meds

Admit if:
- CK > 15-20k
- AKI
- Electrolyte abnormalities

Cardiac monitoring and ICU if:
- K>6
- EKG abnormalities
- Rising potassium levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Asymptomatic until advanced - often not manifesting until GFR <10 → uremic syndrome:
fatigue, weakness, pruritus, easily bruising, metallic taste, epistaxis, SOB, anorexia, N/V, hiccups, nocturia, restless/numbing/cramping in legs, irritability, HTN, pleural effusion, pale

A

CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what stage of CKD:
hyperphosphatemia, hypocalcemia, and hypovitaminosis D → secondary hyperparathyroidism → renal osteodystrophy

A

CKD stage 3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Anemia
Mineral bone disorder → hyperphosphatemia, hypocalcemia, hypovitaminosis D

A

stage 3-4 CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Coagulopathy
Hyperkalemia

A

stage 4-5 CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

ESRD = GFR <–

A

15

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are RF for CKD?

A

Sub-saharan African ancestry (APOL-1)
Smoking
AAs, NAs, Asian, family/personal history, advancing age, structural kidney abnormalities, obesity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

70% of ESKD is due to DM or HTN/vascular disease
Rest = glomerulonephritis, cystic diseases, chronic tubulointerstitial diseases, urological diseases, infections, toxins, meds

A

CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what is a measurement of added risk of CKD progression and CVD?

A

persistent albuminuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Kidney damage or GFR <60 for 3+ months
→ damage = pathologic abnormalities or markers of damage (abnormalities in blood, urine, imaging)

A

CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

PE: MCC = HTN
Progression → fluid overload, edema, weight gain, ascites

GFR <10 = ill appearance, halitosis, neurological changes

Identify + correct all possible reversible insults/exacerbating factors

LABS: persistent proteinuria, abnormalities on imaging (polycystic, single)

A

CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Acute decline = evaluation for reversibility
Anemia, hyperphosphatemia, hypocalcemia, hyperkalemia, metabolic acidosis
Urinary sediment = broad, waxy casts, protein generally >1g/day

IMAGING: US → small, echogenic kidneys bilaterally (<9-10cm)

17
Q

What are complications of CKD that you must treat to prevent progression?

A

HTN
HF
bone disease
anemia
coaglopathy
hyperkalemia
acid base disorders
neuro
hypothyroidism

18
Q

How do you treat CKD HTN?

A

Diet, exercise, weight loss, OSA, low salt diet
Thiazides (through stage 4), loop diuretics (GFR<30), ACEI/ARB with proteinuria (monitor Cr and K)
Often need multiple classes due to resistance

19
Q

how do you treat CKD HF?

A

Diuretics, fluid/salt restriction
AVOID DIGOXIN
MRAs with GFR>30
SGLT2 inhibitors
Atrial fibrillation
DOACs
Pericarditis
With pleuritic CP + rub → hospitalize and initiate hemodialysis

20
Q

How do you treat CKD bone disease?

A

Controlling phosphorus levels (<4.5 in early CKD and <5.5 in ESRD)
Dietary restriction
Oral phosphorus binders
+ Vitamin D

21
Q

How do you treat CKD anemia?

A

Iron supplementation if serum ferritin <200 or iron saturation <20%
Withhold if ferritin >700
ESAs if other treatable causes are excluded (Hbg = 9-10) → 10-11

22
Q

How do you treat CKD coagulopathy disorders?

A

Symptomatic only!
Raise Hgb to 9-10 → desmopressin for surgery or kidney biopsy (SE: hyponatremia)
Dialysis in uremic patients

23
Q

How do you treat CKD hyperkalemia?

A

Treat acutely
Monitoring
EKG changes >6-6.5
Chronic = dietary restriction, minimize/eliminate meds that impair excretion, loop diuretics

24
Q

How do you treat CKD acid-base disorders?

A

Reduction of dietary animal protein, increased fruit/veg intake
Oral sodium bicarbonate

25
How do you treat CKD neuro issues?
Dialysis Peripheral neuropathies, ED, autonomic dysfunction, restless leg syndrome DO NOT improv
26
How do you treat CKD hypothyroidism?
Disturbances in hormones Renal transplant for best change of successful pregnancy
27
the development of uremia in CKD means
Uremia = IMMEDIATE hospital admission + consultation for initiation of dialysis
28
how can you slow CKD progression?
– treat underlying cause (DM → A1C <7%) – BP control – antiproteinuric agents (ACEI, ARB, MRA, SGLT-2, or combo) – weight loss – avoidance of nephrotoxins (contrast, NSAIDs, PPIs) – managing other risk factors
29
what is dietary management for CKD?
Refer to renal nutritionist Protein restriction Plant based diet Animal protein to .6-.8/kg/day (NOT advisable with cachexia or low serum albumin w/o nephrotic syndrome) Salt and water restriction 2g/day Restrict to 2L if volume overload is present Potassium restriction - GFR <10-20 <2g/day Aggressive bowel regimen to excrete Phosphorus restriction Restrict cola, processed foods When GFR <20-30, need phosphorus binder
30
What is CKD medication management?
Dosage adjustment for renal Consider insulin changes d/c metformin with GFR <30 Avoid magnesium-containing meds (laxatives, antacids, phosphorous) Avoid morphine metabolites Avoid NSAIDs/IV contrast PPIs only when necessary
31
What is EKSD GFR <5-10 treatment?
Referral to a nephrologist!!!! (should occur with stage 3 CKD or with rapid GFR decline, >5mL/year) Discuss options Evaluate for kidney transplant Dialysis - GFR ~10 and Cr >/= 8 Palliative care
32
Refer for CKD if
Decompensation of problems related to CKD Worsening acid-base Electrolyte abnormalities Volume overload
33
What are the two main causes of CKD?
HTN and diabetes