CKD + rhabdo

Question 1

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)

Answer 1

rhabdomyolysis

Question 2

What are RF for rhabdomyolysis?

Answer 2

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

Question 3

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

Answer 3

rhabdomyolysis

Question 4

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)

Answer 4

rhabdomyolysis

Question 5

how do you treat rhabdomyolysis?

Answer 5

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

Question 6

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

Answer 6

CKD

Question 7

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

Answer 7

CKD stage 3

Question 8

Anemia
Mineral bone disorder → hyperphosphatemia, hypocalcemia, hypovitaminosis D

Answer 8

stage 3-4 CKD

Question 9

Coagulopathy
Hyperkalemia

Answer 9

stage 4-5 CKD

Question 10

ESRD = GFR <–

Answer 10

15

Question 11

What are RF for CKD?

Answer 11

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

Question 12

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

Answer 12

CKD

Question 13

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

Answer 13

persistent albuminuria

Question 14

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

Answer 14

CKD

Question 15

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)

Answer 15

CKD

Question 16

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)

Answer 16

CKD

Question 17

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

Answer 17

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

Question 18

How do you treat CKD HTN?

Answer 18

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

Question 19

how do you treat CKD HF?

Answer 19

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

Question 20

How do you treat CKD bone disease?

Answer 20

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

Question 21

How do you treat CKD anemia?

Answer 21

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

Question 22

How do you treat CKD coagulopathy disorders?

Answer 22

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

Question 23

How do you treat CKD hyperkalemia?

Answer 23

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

Question 24

How do you treat CKD acid-base disorders?

Answer 24

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

Question 25

How do you treat CKD neuro issues?

Answer 25

Dialysis Peripheral neuropathies, ED, autonomic dysfunction, restless leg syndrome DO NOT improv

Question 26

How do you treat CKD hypothyroidism?

Answer 26

Disturbances in hormones Renal transplant for best change of successful pregnancy

Question 27

the development of uremia in CKD means

Answer 27

Uremia = IMMEDIATE hospital admission + consultation for initiation of dialysis

Question 28

how can you slow CKD progression?

Answer 28

– 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

Question 29

what is dietary management for CKD?

Answer 29

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

Question 30

What is CKD medication management?

Answer 30

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

Question 31

What is EKSD GFR <5-10 treatment?

Answer 31

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

Question 32

Refer for CKD if

Answer 32

Decompensation of problems related to CKD Worsening acid-base Electrolyte abnormalities Volume overload

Question 33

What are the two main causes of CKD?

Answer 33

HTN and diabetes