Lecture 7: CKD and Kidney Transplant

Question 1

Acute renal injury/disease is defined by and staged according to what value?

Answer 1

Rate of rise in serum creatinine

Question 2

CKD is defined by and staged using what value?

Answer 2

GFR

Question 3

What GFR is associated with G1 (normal or high)?

Answer 3

≥90

Question 4

What GFR is associated with G2 (mildly decreased)?

Answer 4

GFR = 60-89

Question 5

What GFR is associated with G3a (mildly to moderately decreased)?

Answer 5

GFR = 45-59

Question 6

What GFR is associated with G3b (moderately to severly decreased)?

Answer 6

GFR = 30-44

Question 7

What GFR is associated with G4 (severely decreased)?

Answer 7

GFR = 15-29

Question 8

What GFR is associated with G5 (kidney failure)?

Answer 8

GFR <15

Question 9

What is the first systemic sign of CKD seen in stage 2?

Answer 9

HTN

Question 10

Why are there fictitious “normal” sodium levels on serum labs in someone with CKD?

Leads to worsening?

Answer 10

• Due to extracellular volume expansion as excretion decreases
• Increased H₂O dilutes serum, making Na⁺ levels appear normal
• This worsens HTN and edema

Question 11

What type of acidosis is initially present in CKD and what does it progress to?

Answer 11

• Initially = hyperchlorermic metabolic acidsosis
• Progresses to anion-gap acidosis because of retained organic acids

Question 12

Presence of acidosis in CDK can induce what type of state?

Answer 12

Protein catabolic state

Question 13

Potassium homeostasis is relatively unaffected in CKD, UNLESS what?

Answer 13

• Increase in dietary intake
• Use of loop or K+-sparing diuretics
• Other meds that interfere w/ RAAS (spironolactone, ACE, ARBs)

Question 14

What happens to levels of vitamin D, calcium, and phosphate levels during uremia seen in CKD?

Answer 14

• HYPO-vitamin D
• HYPOcalcemia
• HYPER-phosphatemia

Question 15

Sx’s of hyperparathyroid include?

Answer 15

• Muscle weakness
• Nonspecific constitiutional sx’s

Question 16

What are 3 bone diseases which may develop as a result of uremia?

Answer 16

1. Osteitis fibrosa cystica = high-turnover bone dz
2. Osteomalacia = defective mineralization
3. Adynamic bone disease= decreased rate of bone turn-over

Question 17

Adynamic bone disease associated with CKD is worse in which patients?

Answer 17

Diabetes

Question 18

Phosphorus complexes with what causing a further increase in PTH during CKD?

Answer 18

Complexes with calcium and deposits in soft tissues

Question 19

What are the toxic cardiovascular effects of PTH seen in CKD?

Answer 19

• Cause cardiac muscle fibrosis
• Elevated phosphorus/calcium complex increase vascular calcification and atherosclerosis

Question 20

What is the treatment for the toxic cardiovascular effects due to PTH seen in CKD?

Answer 20

Supplemental calcitriol (vitamin D analog) to depress PTH

Question 21

What is the #1 cause of mortality in pt with CKD?

Answer 21

Cardiovascular disease

Question 22

Decreased erythropoietin production in uremia associated w/ CKD causes what?

Answer 22

Normochromic, normocytic anemia

Question 23

What is a cardiovascular effect of the anemia seen in CKD?

Answer 23

Left ventricular hypertrophy

Question 24

Elevated PTH, anemia,elevated phosphorus, and acidosis/hyperkalemia are apparent during what stage of CKD?

Answer 24

Stage 3

Question 25

Neuromuscular effects of CKD are evident by what stage?

Answer 25

Stage 3

Question 26

What are the neuromuscular sx's seen in stage 3 of CKD?

Answer 26

- Neuromuscular **irritability** - **Twitches, cramps, and hiccups**

Question 27

Which stage of CKD does peripheral neuropathy become evident? What type of neuropathy is it initially (sensory/motor) and in which body regions?

Answer 27

- Stage **4** - **Sensory** \> motor until later stages - **Lower extremities** \> upper extremities

Question 28

What are the GI effects of uremia in CKD? These pts have what characteristic smell to breath?

Answer 28

- **Uremic fetor** = **urine-like** odor on **breath**; unpleasant **metallic taste** - Gastritis, peptic disease and mucosal ulcerations - Anorexia, N/V, constipation

Question 29

What are the plasma levels of insulin, estrogen (women), and testosterone (men) like in uremia associated with CKD?

Answer 29

- **Insulin** levels are **increased** (usually cleared by kidney) - **Estrogen** and **Testosterone** is **decreased**

Question 30

What are effects on the skin associated with uremia in CKD?

Answer 30

- **HYPER**pigmentation - **Pruritus** = worse w/ **hyper**phosphatemia

Question 31

What is the first line of treatment for controlling BP in CKD?

Answer 31

**Control BP** ---\> ACE-I and ARBs

Question 32

What are 2 dietary changes used for TX in someone with CKD?

Answer 32

1. Na⁺ restriction 2. Protein restriction - but monitor for malnutrition

Question 33

Medication adjustments in CKD are based off of what?

Answer 33

Renal function (**GFR**)

Question 34

Nephrology referral for CKD should be made when GFR =?

Answer 34

GFR **\<30**

Question 35

By what stage should their be a discussion of replacement therapies (i.e., dialysis amd renal transplant) in pt with CKD?

Answer 35

No later than **stage 4**

Question 36

What are 4 nephrotoxic drugs/agents which can worsen CKD?

Answer 36

- NSAIDs - Antibiotics - Antiarrhythmics - **Radiocontrast agents** and **G****adolinium**

Question 37

Metabolic acidosis in CKD is related to reduced production of?

Answer 37

Ammonia (NH₃)

Question 38

What is a long-term and serious complication of peritoneal dialysis involving the bowels?

Answer 38

**Sclerosing encapsulating peritonitis** --\> entraps loops of bowel --\> sx's of **bowl obstruction**

Question 39

What type of dialysis creates an arterial-venous fistula by joining a high pressure vessel to low pressure vessel that becomes an access port?

Answer 39

Hemodialysis

Question 40

3 contraindications for renal transplant include?

Answer 40

1. Malignancy 2. Active infection 3. Significant cardiopulmonary disease

Question 41

At what GFR should a transplant start being considered?

Answer 41

GFR \<15