Chronic Kidney disease
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- Among all ethnic groups the number of pts who develop kidney failure is from what?
- Diabetes
- What is the #1 cause of Renal Failure?
- Diabetes
- What is the best overall measure of kidney function?
- GFR
- Normal GFR
- about 120
- Normal Serum Creatinine levels?
-
Male < 1.5
Female < 1.2 - Is serum Creatinine reliable to measure kidney function?
-
No.
very unrealiable esp in elderly females. Usually decreased with decreased muscle mass - What critical Creatinine value can indicate serious impairment in renal fxn?
- >4mg/dl
- What is Creatinine?
- Catabolic byproduct of creatinine phosphate, which is used in skeletal muscle contraction.
-
Why is Creatinine not considered
reliable? - The elderly and young normally have lower Creatinine levels as a result of reduced muscle mass. This may potentially mask renal disease in pts of these age groups.
- Correlation (reason why it can't be reliable) between SCr and GFR?
-
-SCr can be int he normal range even with GFR close to 60cc/min/
-In early renal disease, the initial drop in GFR will be missed if only the SCr is considered* - What is the Gold Standard for GFR calculation?
-
Inulin Clearance,
not done much though, requires a big lab...Creatinine is the easiest predictor of GFR - What else is used to measure fxn of the kidney?
-
Creatinine Clearance.
requires a 24 hour urine collection and is a hassle, not done much. - What 2 equations are used in assesing GFR?
-
Cockroft-Gault Equation
MDRD Equation
(MDRD may be more helpful in with African American Pts.) - What do you do if you suspect low GFR?
-
Watch BP
Watch for infxn
May have to be dialized - Creatine does not go up until you have lost a lot of----
- Kidney function
- Pt with slightly high creatinine calls c/o of stomach flu, diahrrea, what do you do?
-
Make sure they are hydrated, can't have more nephrons die.
May need IV fluids in hospital. - Almost 85% of pts with CKD will have....
- Hypertension
- What is the single most important factor in slowing the progression of renal disease?
- BP!
- What should BP control tx include?
-
Asides from lifestyle change
It should include:
1) ACEI or ARB
2) a diuretic also - What is the goal BP in all pts with kidney disease?
- <130/80
- What is a major cause of morbidity in pts with chronic kidney disease?
- Anemia-it is a major cause of morbidity with pts with CKD
- What is anemia in CKD defined as?
-
<11 in females
< 12 in males - Anemia is primarily a deficiency in?
- Erythropoietin, made in the kidney
- Anemia increases as what goes down?
- GFR
- If GFR<60, Hgb<12 in males and <11 in females requires a...
- Initial workup
- What should be evaluated with initial workup?
-
-Hgb or Hct
-Fe studies
-Reticulocyte count
- Stool Guaiac
- Erythropoietin is not useful and not recommended* - What is the target Hgb with pts with CKD?
- 11-12
- What needs to be done to get vascular access when the GFR<25?
- Preserve the Non-Dominant Hand
- What else with a GFR<25?
- Refer to a vascular surgeon!
- What is the vascular access of choice?
-
Fistulas:
1) Radiocephalic fistula
2) Brachiocephalic fustula - What is the concern with vascular access via grafts?
- Higher infxn and clotting rates compared with fistula, but far superior to a hemodialysis catheter.
- What is the most common cause of mortality in CKD and dialysis pts?
- Cardiovascular disease
- Anemial of renal failure and hypertension can lead to what?
- LVH
- Hyperlipidemia should be treated....
-
Aggressively.
All CKD pts should have a goal LDL<100 - Diet?
-
Appropriate protein intake
Restriction of dietary Na, K, and Phosporous. - CKD causes hypo....
- hypocalcemia and hyperphosphatemia
- Should intact PTH levels be checked for CKD pts?
- Yes!
- What kind of binder be avoided with CKD pts...
-
Aluminum based binders.
due to chronic aluminum toxicity in CKD pts. - What kind of acidosis happens when the kidney's can't excrete the daily adic load?
- Metabolic Acidosis
- When should you refer to a Nephrologist?
-
1) GFR<30
2) Stage III CKD
3) CKD pts with difficult to control htn
4) pts with nephrotic proteinuria regardless of renal fxn. - Specific Gravity?
-
weight of urine vs wt. of distilled water
1.010=equivalent to plasma - <= 1.005?
- Dilute
- 1.015-1.030
- Increasing osmolarity
- RBC in Urine?
- acute glomerular nephritis
- WBC in urine?
- UTI, pyelonepthiris
- Casts in Urine?
- Pathology in the KIDNEY
- What is Renal Failure?
- -reduction of GFR that is expressed as retention of nitrogenous wastes (BUN, CR)
- What is Azotemia?
- Increased BUN/Creatinine
- What are the lab abnormalities in RF?
-
-Azotemia
-Hyperkalemis
-Hyperphosphatemia
-Acidemia - Clinical abnorm of RF?
-
-Uremia
-Volume overload with loss of UOP - Pre-renal failure?
- Prerenal: Anything that’s influencing flow to the kidney (the person who’s terribly dehydrated or in CHF with low C.O., or renal artery stenosis
- Intrinsic Renal failure?
- Intrinsic: Post streptococcal glomerulnephritis (antibodies that attack renal), lupus, acute tubular necrosis
- Post Renal falilure?
- Postrenal: Obstruction some place after the kidney. The guy with BPH. Bladder fills up and there’s back pressure up to the kidney. Can also be a woman post radiation for cervical cancer. The radiation down the road can cause scar tissue that obstructs ureter. Back pressure on the kidney.
- Thiazide diuretic?
- 25mg to 50mg only a little improvement in BP but side effects go way up. Stay 25 mg and below.
- Glomerular Nephropathies?
-
Abnormalities of glomerular fxn.
Damage to glomerulus and its - Nephritic Syndrome?
-
-Proteinuria
-hematuria
-reduced GFR
-Edema
-Hypertension
-Hematuria (with or without casts) - Nephrotic Syndrome?
-
-Significant Proteinuria (>3.5/24 hours)**
-hypoalbuminemia(<3)
- hyperlipidemia
-peripheral edema - What is the hallmark of Nephrotic syndrome?
- Peripheral Edema!
- Acute tubular necrosis?
-
-Acute Renal insufficiency
-Urine segment or pigmented granualr casts and renal tubular epithelial cells. - What are the two major causes of ATN?
-
1) Ischemia: shock/sepsis
2) Toxin Exposure: NSAIDS/Iodinated IV contrast/ACEI/ARB
Aminoglycosides/Ampho B, etc... - Non-anion gap metabolic acidosis?
-
-loss of HC03 from body
Renal losses(Renal tubular acidosis)
GI losses: Diarrhea, vomitting, pancreatic or biliary secretions - If anion gap is elevated a ? is present?
- metabolic anion-gap acidosis is prestent
- Anion gap metabolic acidosis=think?
- Acute renal failure
- Causes of Metabolic Alkalosis?
-
-Acid loss from stomach
-Diuretics
-Mineralocorticoid excess
-Congenital Syndromes - Calculate Anion Gap?
-
NA - CL + HC03
Example:
140-104+(-15) = 21 - Things that will give an anion gap?
-
-ASA overdose will have an anion gap.
-Diabetic ketoacidosis: Metabolic byproduct of fat/protein digestion. These will have an increased anion gap. - What is the single most important factor in slowing the progression of renal dz?
- BP control!!
- What is the goal BP with kidney dz pts?
- <130/80
- Kidney failure tx should include ?
- ACE1 or an ARB as long as is tolerated. A diuretic is needed
- Anemia with CKD?
-
-deficiency in EPO
-slowly** give EPO - which renal disease can have Eosinophils in the urine?
-
Interstitial Nephritis
Triad: Eosinophilia,Fever, Rash! - Which renal disease has hematuria and proteinuria?
- Nephrotic Syndrome
- Pts that present with heavy proteinuria but few formed elements(casts, cells, etc..) in their urine?
- Nephrotic syndrome
- What is the most common form of glomerulonephritis Worldide?
- IgA Neuropathy
- Once again, Nephrotic Syndrome?
-
-Heavy Proteinuria > 3.5
-peripheral edema
-hypoalbuminemia
-hyperlipidemia
-hypercoaguable state(maybe) -
Which of the following is the most common cause of Intrinsic Renal Failure?
A. Prerenal Azotemia
B. Glomerulonephritis
C. Interstitial Nephritis
D. Acute Tubular Necrosis
E. Obstructive Neuropathy - D. Acute Tubular Necrosis**
- The leading cause of chronic renal failure is?
- Diabetes mellitus!!!!
- What are the common fluid or electrolyte abnormalities seen in chronic renal failure?
-
-metabolic acidosis
-hyperkalemia
-hyperphosphatemia
-hypocalcemia
M.H.H.H. - What are findings that may indicate the chronicity of renal failure?
-
-Azotemia for 3-6 months
-bilaterally small kidneys by sonogram
-broad casts in urinary sediment
-anemia - Urine output of <400ml/day is defined as?
- -Oliguria
- The most common electrolyte imbalance in a hospitalized population is?
- Hyponatremia
- What is the most important complication of peritoneal dialysis?
-
Peritonitis
-Organism responsible=Staphylococcus - Calculation of anion gap is helpful in determining the cause of?
- Metabolic acidosis
- Normal Anion Gap?
- 8-16
- Increased anion gap in these?
-
-Ketoacidosis
-lactic acidosis
-renal failure
-Salicylate overdose - Pt with Abrupt onset of edema, proteinuria, and Cola colored urine has?
- Acute Glomerulonephritis
-
Methicillin hypersensitivity
Fever
Rash**
Eosinophilia
Pyuria
WBC casts
Hematuria - Think Interstitial Nephritis
-
All of the following renal stones are radiopaque except?
A. Calcium Oxylate
B. Uric Acid
C. Cystine
D. Stuvite
E. Calcium Phosphate -
B. Uric Acid
They are Radioluscent - The most serious consequence of rapid correction of hyponatremia is?
- Severe Brain Damage
- factors associated with adverse prognosis in HTN?
-
-Black Males
-Diabetes Mellitus
-Cardiomegaly - Single dose antibiotic therapy in acute uncomplicated cystitis is not good for?
- Male pts with urinary tract infections, males UTI are considered complicated and require more than a single dose abx.
- Hypertonic saline is indicated for the tx of?
-
Fever, symptomatic Hyponatremia
ex: Na of 115
Normals are 135-145 - What can cause hypercalcemia?
-
-Primary hyperthyroidism
-Thyroxicosis
-Malignancy
-Thiazide diuretics - Clinical signs of hypoclacemia?
-
-positive Chovstek's sign
-Cramps and tingling
-Tetany
-Siezures - What may suggest that the pt does not have non-glomerular source of bleeding?
- -Hematuria and PYURIA(usu urinary tract stuff)
- What is the tx for RCIN?
-
-Acetylcsteine
-Hydration with D5W
-3 ambs bicarb
Stop diuretics/NSAIDs/ACE1/ARB - Vasculature Atheroembolic dz?
- Renal failure 2ndary to occlusion of renal arteries, arterioles, and glomerular capillaries.
-
AED see notes many symptoms,
The Great Masquerader, many problems -
-course is usu progressive over weeks to months
-prognosis is very poor
-unlikely to recover renal fxn
-affects multiple organs
-can be recurrant or intermittant. -
Hyperkalemia
Acidemia
Hyponatremia
Azotemia
Reduced GFR
Anuria
Oligura?? - All sxms of Acute renal failure...
- Three primary mechanisms by which a nephritic state can be induced?
-
-Cirlculating antibodies directed against the glomerular basement membrane
-immune complex formation
-circulation antibodies directed against neutrophil cytoplasmic agents - Secondary hyperparathyroidism with CKD?
-
CKD causes:
-hypocalcemia
-hyperphosphatemia
-decreased Vit D synthesis by kidney
-Secondary hyperparathyroidism occurs
Check PTH levels** -
Causes of AG Metabolic Acidosis
MUDPALES -
Causes of an AG Metabolic Acidosis (MUDPALES)
Methanol (Wood alcohol)
Uremia
Diabetic Ketoacidosis
Paraldehyde
Alcoholic Ketoacidosis
Lactic Acidosis
Ethylene Glycol (anti-freeze)
Salicylates (Aspirin overdose) - Prerenal Azotemia?
- Prerenal Azotemia: is the most common cause of acute renal failure
-
True or False:
The MDRD equation used to predict GFR is more accurate for advanced dz and for African Americans? -
True
*results debatable though - Signs of Azotemia in ARF are?
-
-Nausea
-Vomitting
-Malaise
-Altered sensorium - What accounts for 85% of acute renal failure?
- Acute Tubular Necrosis
- Azotemia over months to years is known as?
- Chronic Renal Failure
- The highest anion gap acidoses are seen with?
-
-Lactic Acidosis
-Ketoacidosis
-Toxins - Non-anion gap acidosis
-
-HCO3 loss -GI (diarrhea, pancreatic)
-Renal/tubular(renal tubular acidosis) - Causes of metabolic acidosis
-
Acid loss from stomach
Cong. syndromes
Diuretics
Mineralocorticoid excess