C K D

what does CKD 5d mean? how related to ESRD?

• end stage renal disease

• means have to go on dialysis — abt 10 years if on dialysis

major cuases of dialysis in our region?

t2dm

number 2 is HTN

which popos more liley to have ESRD

AA pts

what are some signalling molecules the kidney controls

renin

erythroposiesis (make red blood cells)

vitamin D

where does most secretion take place

proximial tubules

what does glomerular filtration rate represent

combined rates of all the nephrons

• best indicator of kidney function

what are some reasons protein could get through the glomerulus

inflammed kidney

damage from DM— sugar has damaged glomerulus so the sugar and proteins get through

medications— RENALLY elminated

normal GFR for men

127 ± 20 mL/min/1.73 m²

normal GFR for women

118 ± 20 mL/min/1.73 m²

what med hits GLUT1/2 in prox tub

sglt-1 and -2 inhibitors!

• recall that glucose FREELY goes into urine, these cause REABSORPTION

RECALL what is serum creatinine

product of creatine from muscle metabolism

• filtered and not reabsorbed, but a smalll bit is secreted

what is cystatin C normally

protease inhibitor produced by all nucleated cells, all of it should be filtered by golmerulus

so what in cystatin measurement would represent decrease in kidney function

increased in the blood plasma bc the kidneys usually completely get rid of it

why can creatinine be falsely elevated in the elderly?

bc they could have poor renal function but as muscles are breaking down with age so it looks like kidneys are doing ok

when eGFR based on creatinine might be thrown off what equation do you use (extremes of body size, near decision like of renal function)

CKD-EPI creatineine-cystatin C equation

what are some nephrotox agents?

NSAIDs, vanc, aminoglycosides

what does evaluation of albuminuria (the protein of albumin in the urine) used to see

how severe the CKD is— monitor progress/regression

• pref morning urine

what suggests abnormal renal function in regard to urine albumin to creatinine ratio

> 30 mg/g (or > 3 mg/mmol)

top three reasons for CKD

• diabetes

• hypertension (more pressure pushing stuff through the glo)

• glomerulonephritis — inflamed nephron— red blood cells and proteins flow through the glo

what are Susceptibility factors and where come from

associated with kidney disease but not proven to directly cause. mostly NOT modifiable factors

• obesity

• fam history of ckd

• low birth wt

• advanced age

• reduced kidney mass

• racial/ethnic group

• low income/education

what does INITIATION factors mean and what include

• diabetes

• hypertension

• autoimmune disease

• polycystic kidney diseases

• nephrotoxic drugs

what does diagnosis for CKD from KDIGO (note emphasis on CHRONIC, not ACUTE kidney disease)

abnormalities of kidney structure or function, presnet for more than 3 months, with implications for health

• so like either decreased eGFR or markers of damage like high albumin, persistent hematuria

what is schwartz

pedes kidney equation

rank kidney equations by accuracy (out of the three CKD-EPIs

creatinine-cystatin C> cystatin C> just creatinine

• 
  

for frail pt what need

cystatin C! but still used Cr-cys equation

what is DEFAULT eGFR equation now

2021 ckd-epi

what are some markers of kidney damage

Albuminuria (AER >30 mg/24 hours; uACR > 30 mg/g)

•Urine sediment abnormalities

•Persistent hematuria

• Electrolyte and other abnormalities due to tubular disorders

•Abnormalities detected by histology

• Structural abnormalities detected by imaging

•History of kidney transplantation

how is CKD staged

CGA staging— cause, GFR, albuminuria

what is related to MORTALITY , cv outcomes, and more

what does g1 stage mean

eGFR over 90

what does G2 stage mean

• eGFR between 60-89

• mildly decreased

what does G3a mean

• eGFR between 45-59

• mildly to moderately decreased

what does G3b mean

• eGFR between 30-44

• mod to severely decreased

what does g4 mean

eGFR between 15-29

sevrely decreased

what does g5 mean

• <15 eGFR

• kdiney failure

what GA classifications mean CKD per KDIGO

• G3a, G3b, G4, G5

• anything under 60 for eGFR

what categories of albuminura mean CKD

• A2 and A3

  • that mg/g is above 30 mg/g

what is A1 albumin mg/g

<30

what is a2 mg/g

30-300

what is a3 mg/g

>300

what are risk factors that can cause progression

• smoking

• consequences of disease (HTN, proteinuria)

• persistance of underlying initiation (DM, HTN, glomueronephoritis)

what meds CHANGE gfr

loops, aceis, arbswh

why does ANG2 get activated in nephron damage

• bc trying to bring GFR bcak up by constricting the efferent artieroles

• however this ends up scarring the glo more

symptoms for ckd? complications?

not rly any for CKD but complciations present— fluid overload, anemia, uremia, electrolyte/pH abnormalities

• Cold intolerance

  • Fatigue

  • Palpitations, shortness of breath

  • Cramping, muscle/back pain

  • Edema

  • Itching— uric acid build up (uriema)

  • Changes in urination

  • Loss of appetite

  • Ammonia breath or ammonia/metal taste in the mouth

what are some SIGNS of ocmplicaations

• less active vitamin D

• secondary hyperparathryoid

• worsning HTN and dyslid

• anemia

• electrolyate abnormalites

non pharm treatment for CKD

• lifestyle— diet, wt, activity, tobacco— plant dominate if possible

• protein (CKD 3-5 not no dialysis)— maintain protein intake 0.8 g/kg/bw/day == AVOID high protien in adutls at risk of progression

when is HIGHER protein categories actually better for CKD patients

olderly adults with frailty, sarcopenia, underlying conditions

what are the rec vac for CKD

• flu

• pneumococcal (rec for adults with CKD at lower age, which is 19-49)

• hep B

• live vax— CKD alone not a CI

• recombinant zoster— 2 doses for adults 50+ or 19+ who are immunosuppressed

• RSV— one dose for all adults over 75, pr ages 50-74 with rsik facotrs

not super necessary here

HTN. what is goal? what drugs are pref in presence of albuminuira (categories A2-A3)

• goal: <120 mmHg systolic

• drug: ACEi or ARB pref

for heart failure potential, what drug you add? what GFR do you have to be at?

• add SGLT2 i

• if GFR above 20 (G4 and above)

when should acei and arb be given even, even if BP is ok?

• give if A3 (>300 mg/g) for sure

• could give A2

so in DIABETIC ckd what is BP goal and what do you give

• <120 mmHg

• Acei/arb in presence of albuminuria (a2-a3)

when would you give FINERENONE

in diabetic CKD

• nonsteroidial MRA

what are the three big drug classes

• sglt-2 i

• raas inhibitors

• statins

what do sglt2-i’s reduce? what do they increase?

• decrease weight, BP, uric acid, intraglomerular pressure

• increase LDL, HDL, potassium, SCr

what are qualifications for getting sglt29

• have diabetes

• have album. (a2-a3)

  • if a1 you could maybe still use it

NOTE THAT you ahve to have GFR above 20

when is it ok to use slgt2i when gfr is under 20

if you have already been taking it and started when GFR was above 

if you have already been taking it and started when GFR was above 

why we take ppl off sglt2i if surgery, sick, fasting

hypovolemia, ketosis

• bc DKA risk

when did credence trial show

• canaglifozin (invokana) vs placebo

• showed reduction in composite outcome of ESRD, increased creatinine, renal mortality, CV mortality

which three slgt2-I have proven benefit for CKD

• canaglif

• dapaglif (farxiga)

• empag (jardiance)

why give statins

primary prevention

• give if over 50 years durp

• OR 18-49 years with ASCVD, DM, prior storke, and 10 year risk above 10%

when would you NOT give statins

stage 5 ckd— means you are on dialysis

when in CKD with DM recommended RAAS i

• A2 or A3 albuminuria

when are aceis/arbs most strongly rec for CKD withotu t2dm

strongly rec in a3

• suggested in a2 as well

what is foundational therpay for albuminuria

acei/arbs

what do acei/arbs effect

• eGFR—-decreasing perfusion bc you are vasodilating the efferent arteriole—- DECREASES

• potassium— can cause hyperkalemia (bc more is being reabsorbed)

what eGFR decrease means acei/arb has to be stopped

>30% in creatinine

when do younger folks get statin (18-49 years)

with coronary artery disease, DM, stroke, 10 yr risk >10%

when should statins NOT be used

stage 5 CKD on dialysis

• can continue therapy if already on it

when are antiplt used

LD aspirin for PRVEVENTION of recurrent ischemic CV events

what are the three risk-based pharmacotherapies

• nsMRA

• GLP-1ag

• antiplts

when rec add nsMRA (finererone only)

in T2DM

• if persistent albuminuria is present

when fineronone ok but less strong rec

• t1DM if albuminuria present despite max tolerared RAASi

• pts without DM if uACR> 200 mg/g while taking ras and slgt2

do you have to wait to start fineronone with t2dm if also starting raasi for album.

no can start together

what are criteria for starting finereone (contraind)

• eGFR over 25

• normal K

what lab monitor on fineronoone

potassium

when can you use steriodal MRAs in ckd

if also in heart failure

what are the three main factors that may contribute to CKD progression

1. overactivity of RAAS— inflammation in kidneys

2. elevated BP— hemodynamic

3. elevated A1c— metabolic

Finerenone (Kerendia®) moa

selectively blocks aldosterone receptors in kidneys and blood vessels à increased sodium and water excretion and PROPSED TO reduced fibrosis and inflammation

GLP ag what are requirements in t2dm to qualify

• unmet a1c goals

• persistnet album depsite max RAASi, SGLT2, nsMRA

• documented ASCVD or obesity

can you use glp in dialysis? stages 4-5?

yeah glo

when can you use glp in NON diabetic ckd

if you have documented ASCVD and overweight

• particularly helpful in trying to get weight down for kidney transplant

is HTN cause or result of kidney disease

BOTH lolll

what LAB monitor when on GLP

eGFR bc creatinine can change with wt loss f

how can CKD cause HTN?

fluid retention

what is the trial that shaped KDIGO guidelines

s p r i n t

what do KDIGO guidelines rec for what target blood pressure ? what about if you get kidney transplant?

<120 mmHg systolic as tolerated

• using office measurement

• <130/80

what can you use in kidney transplant for HTN

DHP ccb or ARB

which diueretic loses efficacy at gfr <30 ml/min

HCTZ

• chlorthalidone might be more efficacious

what is pref in HTN with albuminuira (cmon now!)

ace or arb

recalll what was sprint about

• pts over 50

• increased BP

• CKD up to 3a to 4

• no change in renal outcome if better BP goal; BUT decreased risk of CV events and mortality

NO metformin at what gfr

30 or under

at GFRs 45-59 what do you do with metformin dosing

half max rec dose

what IS a secondary complication

Secondary complication: condition or disease that arises as a result of and during the course of the primary disease

what is the big toxin that causes toruble

uriecmic toxin

where is most potassium elminated

kidneyyyys

main complications of CKD

Fluid and electrolyte abnormalities • Uremia • Metabolic acidosis • Cardiovascular disease • Anemia • CKD-related mineral and bone disorder (CKD-MBD) and renal osteodystrophy • Secondary hyperparathyroidism

what IS urecmic syndrime

the constellation of s/s associated with the later stages of CKD or acute kidney injury caused by an accumulation of nitrogenous waste products normally removed by the kidneys

what induce HYPERkal

acei/arb, MRA, K sparing diueretics

• bactrim

• nsaids

• heparin

how can you take care of hyperkalemia

• potassium binders (hospital

• veltassa

• lokelma