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 thatâ€™s influencing flow to the kidney (the person whoâ€™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 thereâ€™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

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