CKD, ESRD, and RRT

100-120 mL/min/1.73 m2 (drops 1 ml per year after 30)

Normal GFR levels

Abnormal kidney function for 3+ months OR structure 3+ months with/without abnormal renal function

Chronic kidney disease (CKD) is characterized by

Hematuria, proteinuria, PCDK, hydronephrosis

Examples of CKD with normal GFR (remember these gotta be present for 3+ months)

DM (then HTN)

What is the number 1 cause for CKD?

90+ (kidney damage with normal or high GFR)

GFR levels for stage 1 CKD

60-89 (Kidney damage with mildly decreased GFR)

GFR levels for stage 2 CKD

45-59 (mildly-moderately decreased GFR)

GFR levels for stage 3a CKD

30-44 (Moderately-severely decreased GFR)

GFR levels for stage 3b CKD

15-29 (severely decreased GFR)

GFR levels for stage 4 CKD

Under 15 (ESKD and its time to dialyze)

GFR levels for stage 5 CKD

glomerular disease, cystic diseases, vascular and systemic disease

Etiology for CKD

DM, HTN, CVD, HLD, smoking, salt intake, overweight, meds

Modifiable Risk factors for CKD

age, gender, race/ethnicity, FHx, chronic infections (HIV, Hep B/C), renal diseases

Non-modifiable Risk factors for CKD

loss of nephrons → hyperfiltration → fibrosis and sclerosis → lose functioning nephrons → toxins can’t be removed and urine cannot be made

Pathophysiology for CKD

HTN (most common 🥇), edema 🥈, uremic symptoms (metallic taste, frost skin, etc) at stage 5

What are the most common physical exam findings in CKD

urine dipstick, microscopy, Albumin-Creat ratio (ACR), Protein-creat ratio (PCR), GFR, BUN/SCr, CMP, CBC (normal then anemia), ABGs (monitor for acidosis)

Lab work up for CKD

bilateral small kidneys (under 10 cm on U/S) → except in PCKD, DM, HIV, Amyloidosis, obstructive uropathy

Imaging findings for CKD

GFR!!

CKD staging is based on

GFR and albuminuria/proteinuria (the more stuff you kidneys are throwing out the worse it is)

CKD risk is based on

Anemia, HTN, CVD, DM, osteodystrophy, malnutrition, metabolic acidosis, dyslipidemia, hypothyroidism

Complications associated with CKD

Stage 3b - V

When are we referring to nephrology for CKD?

CVD (worse with proteinuria)

What is the #1 cause of death for CKD and ESKD patients

Low salt diet, diuretic for edema (thiazide, loop/K+ sparing if severe), ACEI/ARB/Mineralocorticoid receptor antagonist

Gameplan for HTN associated with CKD

treat HTN aggressively, lifestyle changes

Gameplan for Coronary Artery Disease associated with CKD

loop diuretics, ACEI/ARB/Mineralocorticoid receptor antagonist, lifestyle

Gameplan for HF with CKD

low dose statins (we want it under 100 or 70 if they have proteinuria)

Gameplan for lipidemia with CKD (usually pops up in stage 3)

DOACs (eliquis, pradaxa, xarelto)

Gameplan for A.fib with CKD (there’s an increased risk with dialysis peeps)

prolactin elevated contributes to gynecomastia and sexual dysfunction, low T contributes to ED and osteoporosis

Mechanism behind male hypogonadism associated with CKD

Elevated LH → irregular cycles, amenorrhea, infertility (can carry baby to term if SCr is under 1.4 and CKD is not advanced)

Mechanism behind female hypogonadism associated with CKD

SGLT2s (NOT metformin especially if GFR is under 30)

What meds should be used in a diabetic patient with CKD?

Get a TFT, B12, retic count, ferritin, hepcidin → try oral iron → start erythropoiesis-stimulating agents (epoetin/darberpoetin when Hgb under 10, BP under 160/100, and everything else is ruled out)

Game plan for anemia associated with CKD

desmopressin, dialysis (uremia)

Game plan for coagulopathy associated with CKD (stage 4-5) - bleeding occurs due to platelet dysfunction or severe anemia

infection (get those vaccines)

What is the 2nd most common cause of death in patients with CKD?

We cannot get rid of phosphorus → bones release FGF-23; We cannot make vitamin D, so less calcium is absorbed, less calcium in the blood, more PTH is released

Describe the mechanism behind renal osteodystrophy (usually stage 3 to ESKD)

osteitis fibrosa cystica, adynamic bone disease, osteomalacia

Types of renal osteodystrophy

Osteitis fibrosa cystica

Which type of renal osteodystrophy is characterized by HIGH BONE TURNOVER with bones being broken too fast to release calcium (overactive parathyroid glands)

Adynamic bone disease

Which type of renal osteodystrophy is characterized by low bone turnover due to too little PTH, low osteoblast and clast activity so bones become brittle

Osteomalacia

Which type of renal osteodystrophy is characterized by soft bones due to the lack of bone mineralization (most commonly caused by vitamin D deficiency)

Phosphate binders (Calcium carbonate, acetate), Sevelamer, lanthanum, cinacalcet, aluminum hydroxide, vitamin D supplements (once phosphate is normal)

Treatment plan for renal osteodystrophy

Change medication dosing based on CrCl, low protein, salt and water restrictions, K and phosphorus restrictions, low cholesterol; exercise and weight loss, reduce EtOH, stop tobacco, Avoid NSAIDs/Contrast dyes; treat any anxiety and depression

Additional treatments for CKD

5-10 yrs (up to like 30 though)

What is the life expectancy on dialysis?

GFR under 10 (with or without uremic symptoms)

When should RRT be initiated

remove waste products and excess fluid, maintain electrolyte balance, regulate bp

What is the role of dialysis (usually done 3 days a week)?

Acid base issues, electrolyte problems, intoxications, fluid overload, uremic issues

What are the 5 signs that a patient need to be dialyzed in any CKD stage?

Hemodialysis

Which type of dialysis am I describing - a dialyzer is used to remove waste and extra fluid from the blood, and return the filtered blood back into the vascular system?

Subcutaneous arteriovenous fistula (AVF - most common and lowest complications), Polytetrafluoroethylene graft (PTFE - matures in 2 weeks, higher infection risk), Tunneled catheter (inserted into a large vein, high infection risk)

Types of Hemodialysis Vascular access

S. aureus

Most common infection associated with hemodialysis

Hypotension 🥇, disequilibrium, HA, febrile reaction, restlessness, tremor, fatigue, N/V, cramps, palpitations, dizziness, syncope, allergic reactions, clotting, bleedings

Complications of hemodialysis

Peritoneal dialysis

Which type of dialysis am I describing - the lining of your abdomen acts as a filter, dialysis fluid is put into the abdomen, waste products move into the solution (occurs at the capillary level), then the fluid is drained?

Continuous ambulatory peritoneal dialysis (self-exchange 4-6x a day for 30-40 min), Continuous cycler (assisted peritoneal dialysis - machine does it while you sleep)

Types of peritoneal dialysis

Peritonitis (presents with fever, chills, abd pain, N/V/D, cloudy dialysate)

Complications of peritoneal dialysis

Staph A, E.Coli

Most common infectious orgs in peritoneal dialysis complications

Vanc (gram +), AMG (gram -), replace the catheter

Treatment plan for peritoneal dialysis associated peritonitis

DM

What is the most common cause of a kidney transplant (makes up 25% in the US)

95% (1 yr - living donor), 89% (1 yr - cadaver), 80% (5 yr - living), 66% (5 yr - cadaver)

Prognosis for kidney transplant

Palliative care

For homies not a candidate of RRT, what are we doing?