CKD + rhabdo Flashcards
(33 cards)
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)
rhabdomyolysis
What are RF for rhabdomyolysis?
Coexisting kidney/liver disease
DM
Hypothyroidism
>80
Small body frame/frailty
Thyroid disorders
High triglycerides
Metabolic muscle disease
ICU
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
rhabdomyolysis
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)
rhabdomyolysis
how do you treat rhabdomyolysis?
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
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
CKD
what stage of CKD:
hyperphosphatemia, hypocalcemia, and hypovitaminosis D → secondary hyperparathyroidism → renal osteodystrophy
CKD stage 3
Anemia
Mineral bone disorder → hyperphosphatemia, hypocalcemia, hypovitaminosis D
stage 3-4 CKD
Coagulopathy
Hyperkalemia
stage 4-5 CKD
ESRD = GFR <–
15
What are RF for CKD?
Sub-saharan African ancestry (APOL-1)
Smoking
AAs, NAs, Asian, family/personal history, advancing age, structural kidney abnormalities, obesity
70% of ESKD is due to DM or HTN/vascular disease
Rest = glomerulonephritis, cystic diseases, chronic tubulointerstitial diseases, urological diseases, infections, toxins, meds
CKD
what is a measurement of added risk of CKD progression and CVD?
persistent albuminuria
Kidney damage or GFR <60 for 3+ months
→ damage = pathologic abnormalities or markers of damage (abnormalities in blood, urine, imaging)
CKD
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)
CKD
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)
CKD
What are complications of CKD that you must treat to prevent progression?
HTN
HF
bone disease
anemia
coaglopathy
hyperkalemia
acid base disorders
neuro
hypothyroidism
How do you treat CKD HTN?
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
how do you treat CKD HF?
Diuretics, fluid/salt restriction
AVOID DIGOXIN
MRAs with GFR>30
SGLT2 inhibitors
Atrial fibrillation
DOACs
Pericarditis
With pleuritic CP + rub → hospitalize and initiate hemodialysis
How do you treat CKD bone disease?
Controlling phosphorus levels (<4.5 in early CKD and <5.5 in ESRD)
Dietary restriction
Oral phosphorus binders
+ Vitamin D
How do you treat CKD anemia?
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
How do you treat CKD coagulopathy disorders?
Symptomatic only!
Raise Hgb to 9-10 → desmopressin for surgery or kidney biopsy (SE: hyponatremia)
Dialysis in uremic patients
How do you treat CKD hyperkalemia?
Treat acutely
Monitoring
EKG changes >6-6.5
Chronic = dietary restriction, minimize/eliminate meds that impair excretion, loop diuretics
How do you treat CKD acid-base disorders?
Reduction of dietary animal protein, increased fruit/veg intake
Oral sodium bicarbonate