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Y4R3 - Medicine II 🩺 > L4: CKD > Flashcards

L4: CKD Flashcards

(179 cards)

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1
Q

Start

A

…

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2
Q

Introduction to CKD

A
  • Chronic kidney disease (CKD) is a significant health threat that can progress to End-Stage Kidney Disease (ESKD)
  • Leading to early death, diminished quality of life, and placing a heavy burden on healthcare systems.
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3
Q

Def of ESKD

A

Irreversible kidney dysfunction with…

▪ eGFR < 15 mL/min/1.73 m2

▪ Manifestations of uremia requiring chronic renal replacement therapy

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4
Q

Def of CKD

A
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5
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Criteria of CKD

A
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6
Q

Criteria of CKD

  • General
A
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7
Q

Criteria of CKD

  • Markers for Kidney Damage
A
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8
Q

Markers for Kidney Damage

  • Lab Abnormalities
A
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9
Q

Criteria of CKD

  • Markers of Decresed Function
A

Decreased GFR: < 60 mL/min per 1.73 m2

(i.e.GFR categories G3a–G5)

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10
Q

Criteria of CKD

  • Duration
A
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11
Q

Staging of CKD

A
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12
Q

Staging of CKD

  • Acc to Cause
A
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13
Q

Staging of CKD

  • Acc to GFR
A
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14
Q

GFR in Staging of CKD

  • G1
A
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15
Q

GFR in Staging of CKD

  • G2
A
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16
Q

GFR in Staging of CKD

  • G3
A
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17
Q

GFR in Staging of CKD

  • G4
A
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18
Q

GFR in Staging of CKD

  • G5
A
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19
Q

In the absence of evidence of kidney damage, neither GFR category ….. fulfill the criteria for CKD

A

G1 nor G2

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20
Q

Staging of CKD by Albuminuria

A
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21
Q

Staging of CKD by Albuminuria

  • A1
A
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22
Q

Staging of CKD by Albuminuria

  • A2
A
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23
Q

Staging of CKD by Albuminuria

  • A3
A
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24
Q

CP & Complicaions of CKD

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25
Etiology of **CKD**
① Diabetic nephropathy ② Hypertensive nephropathy ③ Glomerulonephritis ④ Other causes (e.g., polycystic kidney disease – analgesic misuse – amyloidosis) ⑤ Unknown causes.
26
Def of **Uremia**
Accumulation of uremic toxins due to decreased Renal excretion
27
Naming of **Uremia**
Historically, the first solute recognized to be retained in persons with kidney failure was urea, hence the terms; uremia.
28
Examples of Potential Uremic Toxins
Over 100 substances identified as potential uremic toxins, e.g., ① Urea. ② Creatinine. ③ β2 microglobulin.
29
Significance of **Uremia**
- Most of CKD manifestations are due to uremic toxins. - Examples for uremic symptoms: nausea, vomiting, hiccough, pruritis.. etc.
30
Uremia Symptoms Timeframe
- Patients are often asymptomatic until later stages due to the exceptional compensatory mechanisms of the kidneys.
31
Volume Status in **CKD**
Hypervolemia resulting from impairments of sodium and water handling
31
Def of **CKD-MBD**
A systemic disorder manifested by either one or a combination of the following three components: ① Abnormalities in the metabolism ② Abnormalities in bone turnover, mineralization, volume linear growth, or strength ③ Extra-skeletal calcification
32
**CKD-MBD** - Abnormalities in the Metabolism
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Po4 in CKD
34
Vit D in CKD
34
FGF23 in CKD
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Ca in CKD
36
PTH in CKD
37
**CKD-MBD** - Abnormalities in Bone Turnover, Mineralization, Volume Linear Growth, Strength
38
Renal Osteodystrophy Classified acc to Bx into:
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Renal Osteodystrophy - Low Bone Turnover
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Renal Osteodystrophy - High Bone turnover (Osteitis fibrosa cystica)
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Renal Osteodystrophy - Mixed Uremic Osteodystrophy
...
41
Gold Standard in Dx of Renal Osteodystrophy & Its Classification
Bone biopsy
42
- The term "renal osteodystrophy" should be used exclusively to define alterations in bone morphology associated with CKD based upon bone biopsy, and it is only one component of the bone abnormalities of CKD-MBD
...
43
Extra-Skeletal Manifestations of **CKD MBD**
44
Extra-Skeletal Manifestations of **CKD MBD** - Vascular Calcification
For example: 1. Coronary artery calcification → Increased cardiovascular risk. 2. Arterioles & capillaries in the dermis & subcutaneous adipose tissue → Calciphylaxis
45
CVS Abnormalities in **CKD**
45
Extra-Skeletal Manifestations of **CKD MBD** - Other Calcifications
Soft tissue, valvular, etc..
46
CVS Abnormalities in **CKD** - HTN
▪ Salt & water retention. ▪ Note that: Hypertension is a cause and precipitating factor of CKD.
47
CVS Abnormalities in **CKD** - LVH
① Volume overload ② Systolic hypertension
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CVS Abnormalities in **CKD** - IVD
49
CVS Abnormalities in **CKD** - HF
① Myocardial ischemia ② Left ventricular hypertrophy ③ Frank cardiomyopathy ④ Salt and water retention
50
CVS Abnormalities in **CKD** - Arrhythmia
① Electrolyte disturbances. ② Volume overload. ③ Sympathetic overactivity. ④ Acidosis.
51
CVS Abnormalities in **CKD** - Pericardial Diseases
Uremic pericarditis & Pericardial effusion
52
What is the Leading Cause of Morbidity & Mortality in patients at every stage of CKD?
53
Hematological Disorders in CKD
54
Hematological Disorders in CKD - Hb in Anemia
55
Hematological Disorders in CKD - type of Anemia
56
Hematological Disorders in CKD - Etiology of Anemia
57
Hematological Disorders in CKD - WBCs
58
Hematological Disorders in CKD - Platlets
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Dermatologic Abnormalitis in CKD
60
Dermatologic Abnormalitis in CKD - Pigmentations
- d2 failure of kidneys to excrete beta-melanocyte stimulating hormone.
61
Dermatologic Abnormalitis in CKD - Pallor
d2 anemia
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Dermatologic Abnormalitis in CKD - Uremic Pruritis
...
63
Dermatologic Abnormalitis in CKD - Bullous Dermatosis
...
64
Dermatologic Abnormalitis in CKD - Calcific uremic arteriolopathy
calciphylaxis
65
Dermatologic Abnormalitis in CKD - Nephrogenic systemic fibrosis
- formerly known as nephrogenic fibrosing dermopathy) - The condition is seen in patients with CKD who have been exposed to the magnetic resonance contrast agent gadolinium
66
Respiratory Problems in CKD
67
Respiratory Problems in CKD - Pleurisy
Due to uremia.
68
Respiratory Problems in CKD - Pulmonary Edema
Multifactorial due to Hypoalbuminemia, Hypervolemia, Heart failure (LVF)
69
Respiratory Problems in CKD - Pneumonia & TB
Due to impaired immunity.
70
Neuromuscular Abnormalities in CKD
71
Neuromuscular Abnormalities in CKD - CNS
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Neuromuscular Abnormalities in CKD - PNS
73
Neuromuscular Abnormalities in CKD - Muscles
Uremic Myopathy
74
Infections in CKD
75
2nd Leading Cause of Death in CKD
Infections
76
Infections in CKD - Etiology
Partially due to immune dysfunction, although multiple other factors are involved.
77
Infections in CKD - Types
Bacterial or viral infection
78
Infections in CKD - Which type is more susceptible?
There is an increased susceptibility to bacterial infection (particularly staphylococcal)
79
Infections in CKD - TB
There is an increased risk of reactivation of tuberculosis (with a negative tuberculin skin test response)
80
Infections in CKD - HBV & HCV
Failure to eliminate HBV and HCV after infection may occur.
81
GIT Abnormalities in CKD
82
GIT Abnormalities in CKD - Mouth Odour
83
GIT Abnormalities in CKD - Tongue
84
GIT Abnormalities in CKD - Esophagus
A. Gerd: d2 delayed gastric emptying. B. Esophagitis.
85
GIT Abnormalities in CKD - Stomach
A. Gastritis. B. Delayed gastric emptying. C. Peptic ulcer.
86
GIT Abnormalities in CKD - Intestinal
Constipation
87
Nutritional Abnormalities in CKD
88
Nutritional Abnormalities in CKD - Incidence
Very common problem among patients with advanced CKD and those undergoing maintenance dialysis (MD) therapy.
89
Nutritional Abnormalities in CKD - Morbidity & Mortality
Associated with high morbidity & mortality.
90
Nutritional Abnormalities in CKD - Contributing Factors
91
Glucose Metabolism in CKD
92
ACKD
Refers to an acute, often reversible decline in kidney function that occurs in a patient with pre-existing chronic kidney disease (CKD).
93
Done
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94
Screening & detection of **CKD** - Rationale
The rationale for screening at-risk individuals for CKD is to: ① Permit earlier detection of CKD, and allowing interventions aimed at slowing CKD progression. ② Identify people who are at risk of CKD associated cardiovascular disease (CVD), morbidity and mortality.
95
Screening & detection of **CKD** - Candidates
96
Screening & detection of **CKD** - Methods
Screening should consist of: ① Urinalysis. ② Urine albumin or protein estimation (such as PER or ACR). ③ Measurement of serum creatinine and estimation of GFR.
97
Predictors of Progression of **CKD** - Non-Modifiable RF
98
Predictors of Progression of **CKD** - Modifiable RF
99
The most significant predictors of CKD progression are
① The degree of impaired kidney function at presentation. ② Hypertension and its control. ③ The severity of proteinuria and albuminuria
100
No single biomarker can identify those at risk of progression with high sensitivity and specificity.
...
101
Investigation for **CKD**
- Investigations to detect functional decline - Investigations to detect structural renal damage - Investigations to identify underlying causes - Other Investigations
102
Serum Markers Used in **CKD**
103
Creatinine & Bun in **CKD**
- Increased Creatinine & BUN ▪ Patients with BUN > 140 mg/dl, serum creatinine > 13.5 mg/dl, or blood urea > 300 mg/dl **who appear relatively well & are still passing normal volumes of urine are much more likely to have chronic than acute kidney disease.**
104
Cystatin C in **CKD**
Increased
105
GFR in **CKD**
Decreased
106
Methods of Estimation of GFR in **CKD**
107
Na in **CKD**
Na+ retention: Occurs once GFR is severely reduced, and sodium intake is unchanged.
108
K in **CKD**
109
Ca in **CKD**
Decreased
110
PO4 in **CKD**
Increased
111
ABG in **CKD**
112
Urinary Albumin in **CKD**
▪ AER ≥ 30 mg/24h ▪ ACR ≥ 30 mg/g
113
Urine Dipsticks in **CKD**
May show hematuria or proteinuria
114
Urine MIcroscopy in **CKD**
May show abnormal urine sediments (e.g., waxy casts)
115
Imaging in **CKD**
Renal US: (1st line imaging technique for the assessment of kidney structure)
116
Imaging in **CKD** - Findings Suggestive of CKD
117
Imaging in **CKD** - Findings Suggestive of Other Etiologies
① Ureteral or renal pelvic dilation suggests obstructive nephropathy. ② Bilaterally enlarged kidneys with multiple cysts suggest polycystic kidney disease.
118
In CKD, Kidneys are bilaterally shrunken EXCEPT IN ......
(DM – Polycystic kidney disease – Amyloidosis – Hydronephrosis)
119
Bx in **CKD**
Not routinely indicated - consider in either of the following: ① Rapid & unexplained decline in eGFR. ② Need for diagnostic confirmation of the underlying etiology (e.g., glomerulonephritis) prior to initiating disease-specific therapy.
120
Investigations for Underlying Causes of **CKD** - DM
▪ Fasting plasma glucose ▪ HbA1c
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Investigations for Underlying Causes of **CKD** - GN
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Investigations for Underlying Causes of **CKD** - PCKD
APKD ( genetic testing)
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Other Investigations for CKD
124
Managment of **CKD**
125
Managment of **CKD** - TTT of Cause
E.g., Diabetes Mellites & Hypertension.
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Managment of **CKD** - Supportive Care
127
How to Manage Medications in **CKD**?
128
Managment of **Volume Status** in CKD
① Dietary salt restriction. ② Use of diuretics (loop diuretics, occasionally in combination with metolazone)
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Managment of **Electrolyte Status** in CKD
130
Managmnet of Na in CKD
Na restriction.
131
Managmnet of K in CKD
- Dietary restriction of potassium. - Use of kaliuretic diuretics. **+ Refer to “Potassium disorders” Lecture**
132
- Some patients with renal dysfunction develop renal wasting of Na+ (Salt wasting nephropathy) and they are usually hypotensive and may benefit from liberalization of salt in their diet.
...
133
Managment of **Acid-Base Disturbance** in CKD
134
Managment of **Acid-Base Disturbance** in CKD - Alkali Suppmentation
135
Managment of **Acid-Base Disturbance** in CKD - Diet
- A low-protein diet can decreased acid production. - Base-inducing fruits & vegetables ⇢ Increase Serum [HCO3−] **Fruits & Vegetables increase risk of Hyperkalemia**
136
Managment of **MBD** in CKD
137
Managment of **MBD** in CKD - Goal
goal is to normalize phosphate, calcium, and PTH levels
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Managment of **MBD** in CKD - Hyperphosphatemia
139
Managment of **MBD** in CKD - Vit D
140
Managment of **MBD** in CKD - Avoid Hypocalcemia
① Correcting hyperphosphatemia & treating vitamin D deficiency. ② Dietary calcium should be increased to 1500 mg of elemental calcium daily.
141
Managment of **MBD** in CKD - Avoid Hyperparathyroidism
- Correction of Ca++, P & Vit D. - Parathyroidectomy (last-line therapy if medical ttt is failed)
141
Managment of **HTN** in CKD
142
Managment of **HTN** in CKD - Target BP
- Target blood pressure in patients with CKD: < 130/80 “Acc. to (ACC/AHA) Recommendation”
143
Managment of **HTN** in CKD - Aspects
- Non-pharmacological Treatment - Pharmacological Treatment
144
Managment of **HTN** in CKD - Non-Pharmacological TTT
① Maintaining healthy weight ② Lower salt intake (<5 gm of NaCl) ③ Regular exercise if not contraindicated ④ Stop smoking and alcohol.
145
Managment of **HTN** in CKD - Pharmacological TTT
146
U-shaped curve of SBP has been reported in which very low, and very high SBP is associated with faster rates of decline in eGFR.
...
147
Managment of **Anemia** in **CKD**
148
Managment of **Anemia** in **CKD** - Rationale of TTT
149
Managment of **Anemia** in **CKD** - Options of TTT
① Iron therapy. ② Check for & Treat Vit B12 & Folate deficiency. ③ Erythropoiesis-stimulating agent (The Best) ④ Blood transfusion
150
Managment of **Anemia** in **CKD** - Best Option of TTT
Erythropoiesis-stimulating agent
151
Managment of **Anemia** in **CKD** - Blood Transfusion
152
Managment of **Pruritis** in **CKD**
153
Managment of **Glycemic Control** in **CKD**
154
Managment of **Glycemic Control** in **CKD** - Target
▪ For diabetic patient with CKD → is to keep HbA1c not exceed 7 % ▪ If the patient has limited life expectancy comorbidities or risk of hypoglycemia → It may be > 7%
155
Managment of **Glycemic Control** in **CKD** - TTT Options
156
Managment of **Glycemic Control** in **CKD** - Use Insulin?
- Insulin treatment should be used with caution in patients with reduced eGFR due to the increased risk of hypoglycemia.
157
Managment of **Lifestyle** in **CKD** - PTN
Low protein diet 0.8 g/kg/day (unless the patients start dialysis)
158
Managment of **Lifestyle** in **CKD** - Cal
High (25 – 35 Kcal/Kg IBW/day)
159
Managment of **Lifestyle** in **CKD** - Salt
- Restricted (< 5 gm/day) → To correct hypervolemia & Hypertension
160
Managment of **Lifestyle** in **CKD** - Fluids
Fluid balance → To avoid volume overload
161
Managment of **Lifestyle** in **CKD** - K
Restricted → To correct hyperkalemia.
162
Managment of **Lifestyle** in **CKD** - PO4
Restricted → To correct hyperphosphatemia.
163
Managment of **Lifestyle** in **CKD** - Ca
Allowed within the dietary recommendations.
164
Managment of **Lifestyle** in **CKD** - Smoking
165
Managment of **Lifestyle** in **CKD** - Obesity
166
Managment of **Lifestyle** in **CKD** - Dyslipidemia
167
Managment of **CKD** - Retarding CKD Progression
168
Retarding CKD Progression - Goals
① To reduce proteinuria as much as possible, ideally to less than 500 mg/day. ② Slow GFR decline as much as possible, ideally to about 1 ml/min/yr, which is the rate of GFR decline attributable to the nephropathy of aging.
169
Retarding CKD Progression - Methods
By managing modifiable risk factors
170
RRT in **CKD**
171
RRT in **CKD** - Options of Non-Operative TTT
- Hemodialysis - Peritoneal dialysis
172
RRT in **CKD** - Indications of Non-Operative TTT
173
RRT in **CKD** - Operative TTT
174
Done
Doneeeeeee

Y4R3 - Medicine II 🩺 (35 decks)

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