SM_206a: CKD Clinical

Question 1

Stage 1 CKD is GFR ____

Answer 1

Stage 1 CKD is GFR ≥ 90

(kidney damage with normal or increased GFR)

Question 2

Stage 2 CKD is GFR ____

Answer 2

Stage 2 CKD is GFR 60-89

(kidney damage with mildly decreased GFR)

Question 3

Stage 3 CKD is GFR ____

Answer 3

Stage 3 CKD is GFR 30-59

(moderately decreased GFR)

Question 4

Stage 4 CKD is GFR ____

Answer 4

Stage 4 CKD is GFR 15-29

(severely decreased GFR)

Question 5

Stage 5 CKD is GFR ____

Answer 5

Stage 5 CKD is GFR < 15 (or ESRD)

(kidney failure)

Question 6

CKD is defined as _____ and classified based on _____

Answer 6

CKD is defined as abnormalities of kidney structure or function present for > 3 months with implications on health and is classified based on cause, GFR category, and albuminuria category

Question 7

Serum creatinine is not entirely accurate for measuring GFR because of _____, _____, and _____

Answer 7

Serum creatinine is not entirely accurate for measuring GFR because of variable creatinine production, variable creatinine secretion, and extra-renal secretion

Question 8

Relationship between GFR and creatinine is _____

Answer 8

Relationship between GFR and creatinine is non-linear

Question 9

Describe the systemic consequences of CKD

Answer 9

Question 10

Describe the reciprocal relationship between drugs and kidney function

Answer 10

Reciprocal relationship between drugs and kidney function

• Renal excretory capacity leads to drug accumulation
• Drug accumulation can accelerate kidney disease

Question 11

Greater sodium intake is associated with ____ proteinuria in CKD

Answer 11

Greater sodium intake is associated with greater proteinuria (induces hyperinflation)

(interaction with profibrotic effects of aldosterone, activate local RAAS in vessels and enhance conversion of Angiotensin I to Angiotensin II)

Question 12

Treatment with an ARB + thiazide _____ proteinuria in CKD

Answer 12

Treatment with an ARB + thiazide lowers proteinuria

Question 13

Giving bicarbonate _____ creatinine clearance in CKD

Answer 13

Giving bicarbonate raises creatinine clearance

Question 14

CKD can lead to _____ due to disorder iron balance

Answer 14

CKD can lead to iron deficiency anemia due to disorder iron balance

(chronic inflammation and reduced renal clearance in CKD -> increased hepcidin -> reduced duodenal iron uptake and enhanced iron release from cellular iron stores)

Question 15

Roxadustat is an _____ that is used to treat _____ in CKD patients

Answer 15

Roxadustat is an HIP inhibitor that is used to treat iron deficiency anemia in CKD patients

(blocks hepcidin -> allows formation of RBCs -> stops anemia)

Question 16

CKD leads to a _______ disorder due to abnormal Ca²⁺, P^3-, PTH, and Vitamin D metabolism

Answer 16

CKD leads to a mineral bone disorder due to abnormal Ca, P, PTH, and Vitamin D metabolism

Question 17

_____ fluctuates by the second to keep Ca²⁺ in a narrow range

Answer 17

PTH fluctuates by the second to keep Ca²⁺​ in a narrow range

Question 18

Hypoparathyroidism is ___ PTH and ___ Ca²⁺

Answer 18

Hypoparathyroidism is low PTH and low Ca²⁺

(hyperphosphatemia)

Question 19

Hyperparathyroidism is ___ PTH and ___ Ca²⁺

Answer 19

Hyperparathyroidism is high PTH and high Ca²⁺​

(hypophosphatemia)

Question 20

_____ is associated with low PTH and high Ca²⁺

Answer 20

Malignancy is associated with low PTH and high Ca²⁺​

Question 21

Increased PTH leads to _____ calcitriol, which leads to _____ reabsorption of Ca²⁺ and P^3-

Answer 21

Increased PTH leads to increased calcitriol, which leads to increased reabsorption of Ca²⁺ and P^3-

Question 22

____ inhibits calcitriol

Answer 22

Calcitriol inhibits calcitriol (is its own inhibitor)

Question 23

FGF23 secreted by osteocytes _____, _____, and _____

Answer 23

FGF23 secreted by osteocytes stimulates phosphaturia, decreases 1,25-D levels, and inhibits PTH

Question 24

The trade-off (Bricker) hypothesis states that PTH ____ so Ca²⁺ can fall as GFR decreases

Answer 24

The trade-off (Bricker) hypothesis states that PTH decreases so Ca²⁺​ can fall as GFR decreases

Question 25

\_\_\_\_ is the first molecule to increase in CKD

Answer 25

FGF23 is the first molecule to increase in CKD (inflammation, iron deficiency)

Question 26

Glomerular _____ occurs in diabetes mellitus

Answer 26

Glomerular hyperinflation occurs in diabetes mellitus (glucose load causes tubule to work harder and hypertrophy)

Question 27

ACE-inhibitors and ARBs _____ glomerular hyperfiltration in CKD

Answer 27

ACE-inhibitors and ARBs decrease glomerular hyperinflation in CKD

Question 28

Diabetes mellitus leads to glomerular \_\_\_\_\_

Answer 28

Diabetes mellitus leads to glomerular hypertension (less Na⁺ delivery to macula densa -\> less ATP converted to adenosine -\> glomerular afferent vasodilation -\> GFR increases)

Question 29

SGLT2 inhibitors _____ intra-glomerular pressure

Answer 29

SGLT2 inhibitors decreases intra-glomerular pressure (block hyperinflation)

Question 30

SGLT2 inhibition leads to afferent \_\_\_\_\_, while RAAS blockade leads to efferent \_\_\_\_\_

Answer 30

SGLT2 inhibition leads to afferent vasoconstriction, while RAAS blockade leads to efferent vasodilation

Question 31

SGLT2 slows progression of ____ and protects against \_\_\_\_\_

Answer 31

SGLT2 slows progression of CKD and protects against cardiovascular disease

Question 32

Describe the clinical action plan for management of CKD

Answer 32

* Early stages: slow progression, reduce CVD risk * Middle stage: reduce CVD risk, treat complications * End stage: work up for transplant (CKD progression defined based on drop in GFR category and/or decline of ≥ 25% in eGFR from baseline - rapid progression is sustained decline of eGFR of \> 5 mL/min/1.73 m²/yr)

Question 33

Once damaged, CKD progresses over time due to \_\_\_\_\_\_\_

Answer 33

Once damaged, CKD progresses over time due to increased work of the remaining nephron mass

Question 34

Describe indications for dialysis

Answer 34

Indications for dialysis * Acute: acidosis, electrolytes (hyperkalemia), ingestions (lithium, ASA), overload (volume overload causing hypoxia, decompensated HF), uremia, nutrition (pediatric) * Chronic: acute indication in setting of CKD (GFR \< 15 cc/min), general malaise or failure to thrive in patient with GFR \< 10-15 cc/min

Question 35

Azotemia is \_\_\_\_\_, while uremia is \_\_\_\_\_

Answer 35

Azotemia is high BUN level, while uremia is high BUN level with symptoms (confusion, encephalopathy, bleeding, asterixis)