Chronic Kidney Disease

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when is world kidney day

08 March 2012

Progressive azotemia over months to years
Symptoms and signs of uremia when nearing end-stage disease
Hypertension in majority
Isosthenuria and broad, waxy casts in urinary sediment are common
Bilateral small kidneys on US (unless PKD)

Essentials of Diagnosis of Chronic Kidney Disease

`National Kidney Foundation (NKF) defines CKD as

Evidence of renal damage
Based on abnormal urinalysis [proteinuria, hematuria] or structural abnormalities found with US
or

GFR < 60 mL/min for 3 or more months!!!

if you don't look for kidney failure...

you aren't going to find it

GFR < ___ will exhibit clinical signs & symptoms

< 30 some can be as low as 15 before they present clinically

what is the normal (adult) GFR

100 - 120 ml/min

how os GFR controlled

control of blood flow by changing the diameter of the afferent and efferent arterioles
control of glomerular surface area via contraction or relaxtion of mesangial cells

How many stages of chronic kidney disease

5
1 GFR >90
2 GFR 60-89
3 GFR 30-59
4 GFR 15-29
5 GFR <15 or dialysis

what kidney situation is NOT associated with HTN

nephrotic syndrome

waxy casts in urinary sediment are common when there is

a problem in the DCT

what is the creatinine clearance formula

Ccr= (140-age) X weight (kg)/Pcr X 72

kidney damage w/normal GFR is seen at what GFR

>90 (Stage 1)
Dx & treat
treat comorbid conditions, slow progression, CVD risk reduction

Kidney damage w/mild decrease in GFR

60-89 (Stage 2)
estimaTE PROGRESSION

moderate decrease in GFR

30-59 (stage 3)
evaluate and treat complications

severe decrease in GFR

15-29 (stage 4)
perparation for kidney replacement therapy

kidney failure

GFR < 15 or dialysis (Stage 5)
replacement if uremia present

diabetes mellitus, hypertension, coronary vascular disease, FHx of CKD, and age > 60 yrs

Most common risk factors for CKD

Major outcomes of CKD include

coronary vascular disease, progression to renal failure, and development of complications of impaired renal function, such as anemia, disorders of mineral metabolism, and secondary hyperparathyroidism

In CKD:
reduced clearance of certain solutes principally excreted by the kidney results in

their retention in the body fluids.
The solutes are end products of the metabolism of substances of exogenous origin (food) or endogenous origin (catabolism of tissue)

is CKD revesrible?

no
the only exception is getting a kidney transplant

Reduction in renal mass leads to hypertrophy of the remaining nephrons with hyperfiltration, and the glomerular filtration rate in these nephrons is transiently at ________ levels

supranormal

placing a burden on remaining nephrons, leads to

progressive glomerular sclerosis and interstitial fibrosis, suggesting that hyperfiltration may worsen renal function

symptoms of CKD

develop slowly and are nonspecific

Patients may remain asymptomatic until renal failure is far-advanced:

(GFR < 10-15 ml/min)

Manifestations of CKD can include

include fatigue, malaise, weakness, pruritis
GI c/o anorexia, nausea & vomiting, metallic taste and hiccups are common

Neurologic problems of CKD include

irritability, difficulty concentrating, insomnia, and forgetfulness

other symptoms associated with CKD progression

Menstrual irregularities, infertility, and loss of libido are also common as condition progresses

Exam reveals

chronically ill-appearing patient
Look for possible underlying cause (DM, SLE)
Hypertension is common

Skin may be

yellow, with evidence of easy bruising. May have nail changes (Mee's lines)
Uremic fetor (fishy breath) may be present

Cardiopulmonary and mental status changes are

also frequently noted...CMDT

Dx made by

documenting elevations of BUN and serum creatinine concentrations

GFR...once < 60

refer to Nephrologist

Persistent proteinuria is suggestive of

CKD, regardless of GFR level

Urinalysis:

broad, waxy casts (evidence of LOSS of tubular concentrating ability)

Labs
May see

see anemia, metabolic acidosis, hyperphosphatemia, hypocalcemia, and hyperkalemia...with both acute and chronic renal failur

evaluation needed to differentiate between acute and chronic renal failure

Evidence of previously elevated BUN and creatinine, abnormal prior urinalysis, and stable but abnormal serum creatinine on successive days is most consistent with a chronic process

Finding of small echogenic kidneys ______ by US supports diagnosis of CKD/irreversible disease

Finding of small echogenic kidneys (<9 cm)

Radiological evidence of renal osteodystrophy is another helpful finding

Check phalanges of hands
Also check clavicles

Complications (of uremia)

Cardiovascular (over 50% of deaths in pts with ESRD)
Hyperkalemia
Acid-base disorders (tendency to retain hydrogen ions)
Hematologic
Neurologic
Disorders of mineral metabolism
Endocrine disorders

________is most common complication of ESRD

HTN

HTN control with

weight loss and tobacco cessation
Salt intake reduced to 2g/day

Initial RX to control HTN include

ACE inhibitor or angiotensin II receptor blocker (ARB)
If serum potassium and GFR permit (recheck 1 week)

Goal blood pressure is

Goal blood pressure is <130/80 mm Hg; for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg

BP Goal if pt has proteinuria

for those with proteinuria > 1-2 g/d, goal is < 125/75 mm Hg

Pericarditis may develop with

uremia
Cause believed to be retention of metabolic toxins
Symptoms include chest pain and fever. May have pulsus paradoxus and friction rub on exam
Pericarditis is an absolute indication for initiation of hemodialysis

_____ is an absolute indication for hemodialysis

pericarditis

Patients with ESRD tend toward a ___ cardiac output

high

CKD patients, especially those with DM, are more likely to die from

cardiovascular disease than to progress to ESRD/dialysis!
Do not focus only on the CKD...if you do, you are missing the boat
Screen for and treat the C/V Dz and other risk factors present

Potassium balance usually remains intact until

GFR < 10-20 mL/min

Tx of acute hyperkalemia involves

cardiac monitoring, IV calcium chloride or gluconate, insulin with glucose, bicarbonate, and sodium polystyrene sulfonate

Chronic hyperkalemia treated with

dietary potassium restriction/sodium polystyrene PRN

The resultant metabolic acidosis is primarily due to

loss of renal mass

Damaged kidneys are unable to excrete the ________of acid generated by metabolism of dietary proteins

1 mEq/kg/d

treatment for acid base d/o

Maintain serum bicarb level at > 20 mEq/L
Alkali supplements include sodium bicarb, calcium bicarb, sodium citrate
Keep pH > 7.20

anemia

Normochromic, normocytic
Due to decreased erythropoiesis and RBC survival
Many patients are also iron deficient

Recombinant erythropoietin (epoetin alfa) used in

patients whose hematocrits are < 33%
Some recommend start with iron supplement and then possibly add ESA (erythroproeitin stimulating agents..Procrit/Epogen)

main cause of coagulopathy

platelet dysfunction
Platelet counts only mildly decreased, but bleeding time is prolonged
Platelets show abnormal adhesiveness and aggregation

Patients may present with petechiae, purpura, and increased bleeding during surgery

CKD coagulopathy

Tx goal of pt w/coagulopathy

= Hematocrit increased to 30%
Dialysis improves bleeding time but doesn't normalize it

Uremic encephalopathy does not occur until GFR falls below

10-15 mL/min
Symptoms begin with difficulty concentrating and can progress to lethargy, confusion, and coma

Earlier initiation of dialysis may prevent peripheral neuropathies

Neuropathy found in 65% of patients on or nearing dialysis but not until GFR is 10% of normal

Disorders of calcium, phosphorus, and bone are referred to as

renal osteodystrophy

Most common disorder of mineral metabolism

is osteitis fibrosa cystica - the bony changes of secondary hyperparathyroidism...affecting 50% of patients nearing ESRD

Radiographically, lesions most prominent in phalanges and lateral ends of clavicles
Look for

subperiostial erosions

may cause bony pain, proximal muscle weakness, and spontaneous bone fractures

osteomalacia or adynamic bone disease

Tx of Disorders of mineral metabolism

may consist of dietary phosphorus restriction, oral phosphorus-binding agents such as calcium carbonate or Renogel, and vitamin D
Hyperparathyroidism treated with calcitriol or Sensipar

Circulating insulin levels are higher because

of decreased renal insulin clearance

Glucose intolerance can occur in chronic renal failure when GFR is

< 10-20 mL/min. This is mainly due to peripheral insulin resistance...

Decreased libido and erectile dysfunction are common

Men have decreased testosterone; women are often anovulatory

ACE/ARB to slow progression of

proteinuria and CVD
Potentiates hyperkalemia...repeat serum creatinine & potassium in one week!!!!

Maintain excellent diabetes control...keep HgA1C ___

<7

Lower cholesterol...consider

statin agent

Avoid fluid overload. Use diuretics such as

Lasix PRN

Refer patients to CKD clinics for management.... Goal of CKD clinics is to

keep the patient OFF dialysis!

Tx (Consult early) to

Nephrology, Vascular/Gen Surgery

Malnutrition very common secondary to

anorexia, decreased intestinal absorption/digestion...
Every patient should be evaluated by dietician

Protein restriction...

In general, protein intake should not exceed 1 g/kg/d!

salt and water restriction

For the nondialysis patient approaching ESRD, 2 g/d of sodium is an initial recommendation

Once GFR has fallen below 10-20 mL/min, potassium intake should be limited to

< 60-70 mEq/d

Magnesium restriction
No magnesium-containing .....

laxatives or antacids

Dialysis should be started when patient has GFR of

10 mL/min or serum creatinine of 8 mg/dL

when should diabetics start dialysis

Diabetics should start when GFR reaches 15 mL/min or serum creatinine is 6 mg/dL

indications for dialysis include

Uremic symptoms such as pericarditis, encephalopathy, or coagulopathy
Fluid overload unresponsive to diuresis
Refractory hyperkalemia...>7
Severe metabolic acidosis (pH < 7.20)
Neurologic symptoms such as seizures or neuropathy
BUN > 100

what dialysis method is the main choice for US pts

Hemodialysis (choice for 90% of patients in US)
Vascular access accomplished by an a/v fistula (preferred) or prosthetic graft

Patients typically require hemodialysis ___ times per week...sessions

Patients typically require hemodialysis 3 times per week...sessions last 3-5 hrs each

Ensure patient undergoing hemodialysis getting regular labs to include

PTH and ALK PHOS

Peritoneal dialysis

The peritoneal membrane is the "dialyzer"
Semi-permeable membrane...waste products pass through, blood cells do not

most common type of peritoneaLl dialysis is

continuous ambulatory peritoneal dialysis (CAPD)
Patients exchange dialysate 4-6 times per day
Put fluid in...drain in 3-4 hrs...repeat...

Continuous cyclic peritoneal dialysis (CCPD) utilizes

a cycler machine to automatically perform exchanges at night

Most common PD complication

= peritonitis
Most common pathogen = S aureus

PD is used more commonly

outside the US
Many nephrologists believe 25-35% of pts should be on PD

when is someone placed on a kidney transplant list

not placed on list until GFR <15
Living donor is best option!

One year survival rate is approximately 98% and five year survival rate is ____

70-80%

Expected remaining lifetime for the age group 55-64 is 22 years, whereas that of ESRD population is

5 years

CKD pts most common cause of death is

cardiac

For those who require dialysis to sustain life, but decide against it, death ensues within

days to weeks

dialysis numbers

10% Dxed with ESRD
3-4 dialysis txs/week (4 is best)
150 dialysis txs/year

Two-thirds of kidney transplants come from

deceased donors

Overall...medical care of CKD focuses on delaying or halting progression of CKD

Tx underlying cause(s)
Tx hypertension and diabetes
Avoid nephrotoxins
Tx complications
Lastly...watch out for meds that are renally excreted. You will need to adjust dose in patients with renal failure!!!

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