U of U PA School CKD

What is CKD?

Chronic and permanent reduction in renal function

Irreversible path accompanied by few signs until advanced

What is the broad mechanism causing CKD?

Underlying disease of kidneys, blood vessels, or urinary pathway

Almost any renal disease can cause CKD

What is ESRD?

CKD that has advanced to the stage of becoming symptomatic

Needs treatment with dialysis or transplant

What are the stages of CKD? What eGFR and markers of kidney damage are needed for each stage?

Stage 1 - eGFR >90 + markers of kidney damage

Stage 2 - eGFR 60-89 + markers of kidney damage

Stage 3a - eGFR 45-59

Stage 3b - eGFR 30-44

Stage 4 - eGFR 15-29

Stage 5 - eGFR < 15

What affects serum creatinine? (4)

Excretion of creatinine (GFR)

Age

Muscle mass

Diet

What can the equation for GFR account for? What does it not consider?

Known variables such as age, weight, and sex

Does not consider unknown variables that do need to be considered

What should be done if eGFR from creatinine is thought to not reflect true GFR?

eGFR based on cystatin C

24 hour urine collection to eGFR based on urea and creatinine clearance

What causes CKD? (6)

Diabetic nephropathy

Hypertensive nephrosclerosis

Glomerulonephritis

Polycystic kidney disease

Obstruction

Monoclonal disease

What kidney pathology wont cause CKD?

Minimal change disease

What are the symptoms of CKD that appear later in course? (7)

Nocturia

Anemia

GI symptoms

Neurologic changes

Sleep inversion

Uremic pruritus

Pericarditis

What are the signs of CKD? (4)

Pallor from anemia

Terrys nails

Hypertension

Uremic frost

When should CKD be referred to nephrology? (6)

Stage 3

All of the following regardless of GFR:

All CKD with >1 g/day proteinuria

All patients with nephrotic syndrome

All patients with active urine findings

All patients with declining GFR

All patients with CKD and difficult control hypertension

What mechanisms lead to progression of CKD? (5)

Continuation of causative factors

Progression despite removal of causative factor

-Hyperinflation injury

-Proteinuria (can cause more rapid interstitial fibrosis)

AKI episodes in CKD

How does hyperinflation injuries progress CKD?

Primary renal disease -> partial nephron loss -> glomerular hypertension and hypertrophy -> glomerulosclerosis -> ESRD

What is the main goal of management of CKD? What medications are used at the front line of this? When should it be held?

Delay progression of CKD

Max tolerated ACE/ARB

-Can increase creatinine but do not discontinue

-Hold in pre-renal AKI

What should be prevented in CKD? How?

AKI

-Prevent volume depletion

-Relieve obstruction of collecting system

-Avoid nephrotoxic drugs especially NSAIDs

What BP is the goal for CKD? Why?

<130/80

Hypertension accelerates CKD by aggravating glomerular hypertension and vascular damage

How is proteinuria controlled in CKD?

Modest protein diet if significant proteinuria

-Reduce protein intake to 1g/kg/day focused on plant protein

RAAS inhibitors

SGLT2 inhibitors

What additional things need to be managed in CKD?

Manage metabolic acidosis

Stop smoking

Address obesity

How is anemia due to CKD managed?

First - rule out other causes first, especially iron deficiency

Treat with recombinant EPO targeting hemoglobin of 10-11

What characterizes CKD-mineral bone disease (MBD)?

Renal osteodystrophy

Soft tissue and vascular calcification

Due to elevated phosphorus and PTH - calciphylaxis

How should CKD-MBD be monitored?

Serum phosphorus, calcium, vitamin D, and PTH levels

How is CKD-MBD treated?

Phosphorus restricted diet

Phosphorus binders

-Calcium based binder - calcium carbonate/acetate

-Sevelamer - non calcium binder

Provide activated vitamin D if deficient

-Calcitrol/paracalcitrol

How does CKD lead to metabolic acidosis?

Impairs renal amniogenesis

Causes 2 types of acidosis

-Non anion in early/moderate CKD

-Anion in advanced CKD

What does metabolic acidosis in CKD cause?

Bone disease

Muscle wasting

Progression of CKD

How is metabolic acidosis treated?

Decrease acid intake

Sodium bicarb if <22

What is the most common cause of secondary hypertension? How (4)?

Main cause - CKD

Volume overload

RAAS activation

Endothelial dysfunction

Sympathetic activation

What is the treatment for secondary hypertension in CKD?

Volume control

Antihypertensives - usually require multiple agents

How should CKD causing cardiovascular disease be managed? (4)

Aggressive risk factor modification

Control hypertension

Manage CKD-MBD

Treat hyperlipidemia

What uremic complications can arise from CKD? (4)

Uremic platelet dysfunction

Uremic encephalopathy

Uremic pericarditis - indication to start dialysis

Uremic polyneuropathy - indication to start dialysis

What is stage of CKD is ESRD and what is required?

Stage 5 CKD requiring renal replacement therapy (RRT)

What is used for RRT?

Hemodialysis

Peritoneal dialysis

Kidney transplant

What symptoms arising at stage 5 CKD indicate a need to start RRT? (6)

Fatigue

GI symptoms

Pruritus

AMS

Refractory volume overload

Electrolyte imbalance

How is a renal transplant done? What treatment is needed after?

Allograft placed in iliac fossa to restore renal function, electrolyte balance, hematocrit, and vitamin D

Need lifelong immunosuppression

How is hemodialysis done? (4)

Based on diffusion of solutes across semipermeable membrane

Blood-barrier/dialyzer-dialysate

Solutes from blood (urea, creatinine, potassium, etc) flow into dialysate

Has to be done in a clinic

What is the order of vascular access preference for hemodialysis?

Arteriovenous fistula

Arteriovenous graft

Tunneled dialysis catheter (infection risk)

How is a fistula made?

Anastomosing a segment of radial artery to vein

Vein thickening (maturation) takes 6 weeks

How is peritoneal dialysis done?

Uses peritoneum as membrane

Abdomen filled with glucose solution (dialysate) that solutes and toxins diffuse from blood into dialysate that it is then drained and discarded

New dialysate is infused

What are the types of periotoneal dialysis?

Continusous via CCPD

Manually via CAPD

Has to be done daily but can be done at home