renal

Question 1

CKD criteria

Answer 1

either of the following for >3 months

• markers of kidney damage (one or more)
• decreased GFR (<60)

Question 2

GFR calculation

Answer 2

serum creating or cystatin C with other components

Question 3

CGA staging

Answer 3

cause
GFR category
albuminuria category

Question 4

CGA A

Answer 4

A1 - normal to mildly increased albuminuria
A2 - moderately increased albuminuria
A3 - severely increased albuminuria

Question 5

CGA G

Answer 5

G1 - normal (>90) with evidence of kidney disease
G2 - mildly decreased (60-89)
G3a - mild to moderately decreased (45-59)
G3b - moderately to severely decreased (30-44)
G4 - severely decreased (15-29)
G5 - kidney failure (<15) - RRT

Question 6

clinical proteinurea

Answer 6

> 150-160 mg/24 level period

Question 7

proteinurea treatment

Answer 7

ACE/ARB
decrease risk factors - BP<130/80

Question 8

how to evaluate for structural renal conditions

Answer 8

renal US

look for renal asymmetry, hydronephrosis, cysts, scaring, arterial stenosis

small ethnogenic kidneys (<10 cm bilaterally) - CKD

Question 9

CKD complications

Answer 9

• HTN - keep <140/90 w ACE/ARB
• anemia - erythropoietin stimulating agents (R/O other causes)
• nutritional status - protein malnutrition
  abnormalities of bone, calcium, phosphorus (phosphate binders)
• neuro changes
• functioning and well being/mental health

Question 10

ACE/ARB monitoring

Answer 10

serum K/crt before starting
K/crt 1-2 weeks after initiation or dose increase
do not start in K>5

if crt rises >30% or GFR falls by >25%… repeat CMP & evaluate for other causes. if no other causes, consider renal artery stenosis

if crt rises <30% or GFR falls by <25%…. repeat CMP & evaluate for other causes. if no other causes, observe & remove cause if possible

if K>6, repeat CMP and stop contributing drugs (NSAIDs, diuretics, abx). if persists, then hold ACE/ARB

AKI risk may want to hold ACE/ARB (vomiting)

Question 11

when to refer to nephrology

Answer 11

• GFR <30
• 25% drop in GFR
• progression of CKD with a sustained GFR of more than 5 per year
• significant albuminuria
• persistent unexplained hematuria
• secondary hyperparathyroidism, persistent AGMA, non-iron deficiency anemia
• CKD and HTN refractory to treatment with 4 or more agent
• persistent K abnormalities
• recurrent or extensive nephrolithiasis
• hereditary kidney disease or unknown cause of CKD

Question 12

renal diet

Answer 12

low salt
low protein
low potassium
low phosphorus

Question 13

when will you see creatinine bump with contrast

Answer 13

24-72 hours later

Question 14

prevention of contrast associated AKI

Answer 14

prevent!

500 ml 0.9% before contrast

3 ml/kg 1 hour before, then 1 ml/kg/hour for 6 hours after

Question 15

when to initiate acute RRT

Answer 15

AEIOI

Acidosis unresponsive to medical therapy
Acute, severe, refractory electrolyte changes
Intoxication with dialyzable drug or toxin
Volume overload unresponsive to diuretic therapy
Uremia

educate pt with GFR <30

Question 16

complications of hemodialysis

Answer 16

common procedural complications

HYPOTENSION

dialysis disequilibrium - headache, N/V, fever/chills, back pain, chest pain, cramps, itching, dyspnea

arrhythmias, air embolism

long term - pneumonia, QOL

Question 17

vascular access complications

Answer 17

bleeding
thrombosis
infection
arterial steal syndrome - arterial graft diversion ->ischemia