Lecture 2: CKD & Nephrotic Syndrome

Question 1

Diagnostic Criteria for Nephrotic Syndrome

Answer 1

1. Spot urine showing a protein-to-creatinine ratio of > 3 to 3.5 mg protein/mg creatinine, or 24-hour urine collection showing > 3 to 3.5 g protein
2. Serum albumin < 3 g/dL
3. Clinical evidence of peripheral edema (d/t loss of oncotic pressure)

Question 2

Common causes of Nephrotic Syndrome

Answer 2

Type II DM 
Systemic Lupus Erythematosus
Membranous Nephropathy
Amyloidosis
Preeclampsia

Question 3

Other lab findings/features in Nephrotic Syndrome

Answer 3

• Severe hyperlipidemia (decreased plasma oncotic pressure stimulate hepatic lipoprotein synthesis
• Oval fat bodies (pathognomonic)
• Hypercoagulable (Loss of protein C & S, antithrombin II through damaged basement membrane)
• Prone to infection (Loss of immunoglobulin through damaged basement membrane)

Question 4

Management of nephrotic syndrome

Answer 4

1. Fluid restrictions (<1500 ml/day)
2. Loop Diuretics
3. Ace-Inhibitor
4. Monitor for s/s PE, DVT, renal vein thrombosis (flank pain)
5. Treat underlying cause

Question 5

Definition of chronic kidney disease

Answer 5

CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for
health.

Question 6

Criteria of CKD

Markers of kidney damage & GFR

Answer 6

Markers of kidney damage:
1. Albuminuria (AER 30 mg/24 hours; ACR 30 mg/g)
2. Urine sediment abnormalities
3. Electrolyte and other abnormalities due to tubular disorders
4. Abnormalities detected by histology
5. Structural abnormalities detected by imaging
6. History of kidney transplantation
OR
GFR <60 ml/min/1.73 m2

Question 7

Staging: What are the GFR categories of CKD?

Answer 7

G1 >90 Normal or high
G2 60–89 Mildly decreased
G3a 45–59 Mildly to moderately decreased
G3b 30–44 Moderately to severely decreased
G4 15–29 Severely decreased
G5 <15 Kidney Failure

Question 8

Staging: What are the albuminuria categories of CKD?

Answer 8

(AER or ACR)
A1 <30 Normal to mildly increased
A2 30-300 Moderately increased
A3 >300 Severely increased

Question 9

Which GFR equation is most accurate in GFR >60 & subgroups (DM, transplant status, elderly, & at higher BMIs)?

Answer 9

CKD-EPI creatinine equation

Question 10

Increased protein in the urine correlate with what complications of CKD?

Answer 10

1. Faster progression to ESRD
2. Increase risk of CV events
3. Increased risk of mortality

Question 11

What are other proteinuria etiologies?

Answer 11

• Fever
• Vigorous exercise
• Dehydration
• Acute illness
• Glomerulonephritis
• Congestive Heart Failure
• Seizures
• Drugs
• Interstitial nephritis

Question 12

Orthostatic Proteinuria epidemiology & etiology

Answer 12

Epidemiology
• 60% of all childhood cases & 75% of adolescent cases
• Rare in those > 30 years of age
• Does not appear to be a predictor of CKD
Etiology
• Exaggerated hemodynamic response to upright position
• Normal variant; Not well understood
• Subtle glomerular abnormalities

Question 13

American Society of Nephrology recommends screening in which 2 populations?

Answer 13

1. Family history of CKD

2. Person history of Diabetes Mellitus, HTN, or CV Disease

Question 14

Presentation of patient with GFR <30

Answer 14

o Fatigue
o Worsening edema
o Increased blood pressure
o Pruritus

Question 15

Presentation of patient with GFR <15

Answer 15

o	Uremia: Nausea, vomiting
o	Fatigue
o	Seizures 
o	Altered mental status: Confusion 
o	Uremic pericarditis, cardiac tamponade

Question 16

What are the predictors of progression of CKD?

Answer 16

• Level of GFR & Albuminuria
• Elevated BP
• Hyperglycemia
• Age/Sex/Race/ethnicity
• Dyslipidemia
• Smoking
• Obesity
• H/o CV Disease
• Ongoing exposure to nephrotoxins

Question 17

What are some recommendations for disease prevention?

Answer 17

• Exercise
• Weight loss
• Smoking cessation
• Managing CV Dz
• ASA, Statins
• Optimize glucose & BP control
• D/c nephrotoxins when possible

Question 18

What are the 7 main complications associated with CKD?

Answer 18

• Diabetes
• Hypertension —> B/P Goal: <130/80, Avoid hypotension (AKI), ACE/ARB
• Dyslipidemia —> Statin
• Coronary Artery Disease —> CV MC cause of death in CKD; treat ALL CKD patients with statin
• Mineral & Bone Disorders —> Osteoporosis & Osteopenia
• Uremia & Acidosis —> Excess build up of urea & H+
• Anemia —> Decrease erythropoietin, decreased erythrocyte life span and blood loss

Question 19

How does CKD cause mineral and bone disorders?

Answer 19

o Decreased GFR causes ↑ in phosphorus in the blood
o Hyperphosphatemia causes ↓ Ca absorption in the gut
o Hypocalcemia causes ↑ in PTH
o Hyperparathyroidism causes Ca released from bone & reabsorbed in proximal tubules
o Tubular damage causes ↓ Vitamin D activation causing ↓ reabsorption of Ca in tubules
o ↑ H+ (metabolic acidosis) cause move into bone cells which causes ↑ Ca++ release

Question 20

How do you monitor & manage bone disease in eGFR < 30ml/min/1.73m2?

Answer 20

Monitor labs:
• Ca, Ph, PTH, Alkaline phosphatase
Manage with:
o Calcium 1200 mg/day & 800 IU Vitamin D daily
o Bisphosphonates: Denosomab or bisphosphonates (Not on dialysis & by specialist)

Question 21

What are the 6 CKD management components?

Answer 21

• Optimize management of glucose, blood pressure, dyslipidemia, bone health
o ACE-I or ARB
o Statin & ASA when indicated
o Meds to be renally dosed
o Avoid NSAIDS, nephrotoxins
• Nutrition consult
o Low protein, phosphate, potassium, +/-supplementation
• Vaccines
o Flu, hep B, PCV
• Monitor disease progression & complications
o Electrolyte abnormalities (potassium, calcium, phosphorus)
o Anemia, PTH, uremia
• Refer to specialist for co-management when indicated
o Nephrologist & cardiologist
• Extensive patient education & empowerment
o Exercise, smoking cessation, limit EtOH, dietary health, avoid obesity