Chronic Renal Failure
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What is the definition of chronic renal failure?
- Progressive and irreversible loss of renal function
- GFR<60mL/min for >30 months or evidence of pathologic abnormalities or makers of damage on radiology and lab studies
What is ESRD?
Stage 5 CKD where accumulation of toxins fluids, and electrolytes normally secreted by the kidney result in uremic syndrome
What is the mc cause of ESRD?
What are clinical features of ESRD?
- HTN (70% of pts)
- Interstitial nephritis
At waht point of CKD does electrolyte and acid-base regulation become deranged?
What are the three dysfunctional pathways in uremia?
- Accumulation of toxins that nl undergo renal excretion
- Systemic inflammatory response causing nutritional and vascular consequences (CRP, acute phase reactants; accelerates vascular dz)
- Deranged metabolic and endocrine functions (abnl hormone levels, abnl metabolism of proteins/carbs)
What are clinical manifestations of CKD?
- N/V/Anorexia/Weight loss
- If extremely uremic: seizures, coma, pericarditis
- Pts appear chronically ill
- Sensorimotor polyneuropathy (glove and stocking)
- Decreased vibratory sensation
- Muscle weakness
- Uremic fetor (fish breath)
- Peripheral edema
- Pericardial friction rub
What do labs show in a person with CKD?
- Increased BUN/Cr
- Metabolic acidosis
- High PTH level
What does a U/A show in someone with CKD?
- Could be positive for isothenuria
- Sediment (+) for broad, waxy casts
What does a renal US show in a CKD pt?
Small, atrophic kidneys
In what cases might you see nl sized or large kidneys in CKD pts?
- multiple myeloma,
- diabetic nephropathy,
- HIV associated nephropathy
What does an EKG show in with a person with CKD?
- Signs indicative of electrolyte abnl
What might a CXR show in a CKD pt?
- Noncardiogenic pulmonary edema
- Pleural effusions
What might an xray show in a CKD pt?
- Evidence of metabolic bone dz (subperiosteal lesions)
- Most prominent in phalanges and lateral ends of the clavicle
Which labs/imaging are most important in establishing the CKD dx?
- Serial Cr (persistent elevation without much variation)
- High phos, low Ca, elevated PTH with evidence of bone dz
- Normocytic anemia
- U/S with B/L small kidneys
When is a renal bx indicated?
- Long-standing HTN with cerebrovascular, CV complications with mild proteinuria
- History of DM x 10-15 years with proteinuria, no hematuria
- UA results not consistent with primary dz process
What is the m/c cause of death at every state of CKD?
List common CV complications in CKD
- LVH with diastolic and usually systolic dysfunction
- Uremic pericarditis
- Dyslipidemia (<HDL, >TG and LDL)
What are GI complications of CKD?
- Gastritis, peptic dz
- GI bleeding
- Protein catabolism and malnutrition
What are common endocrine complications of CKD?
- Decreased estrogen, progesterone (->sterility, amenorrhea)
- Decreased testosterone and oligospermia (->decr libido, impotence, sterility)
- Glucose metabolism (plasma levels of insulin increase)
What are common neuromuscular complications of CKD?
- Muscular weakness, bone pain, fx
- Renal osteodystrophy (m/c is osteitis fibrosa cystica)
- Peripheral neuropathy (sensory before motor, LEs before UE, distal before proximal)
When neurologic complications are associated with CKD? When are they evident?
- Evident at Stage 3
- Disturbances in memory, sleep, concentration
- Hiccups, cramps, fasiculations, twitching
- In uremic states: coma, seizures, myoclonus
What type of hemotologic complications are associated with CKD?
- Normochromic, normocytic anemia (usually stage 3)
- Due to insufficient production of EPO, also insufficient iron stores, chronic inflammatory state
- Bleeding diathesis
- Prolonged bleeding time
How do you tx CKD overall?
- Protein restriction
- Reduction HTN and BP control
- Reducing proteinuria
- Glucose control
- Control microalbuminuria and proteinuria
- Tx complications
What are protein intake recommendations for CKD pts?
- 0.6-0.75g/kg/day depending on proteinuria and nutritional status
- Stage 5: 0.9g/kg/day
What is the goal BP for proteinuric CKDers?
What drugs do we use for proteinuria and intraglomerular HTN control? (first and second line)
- First line: ACE-Is and ARBs
- Both slow progression in non-diabetic and diabetic pts that have proteinuria
- Second line: Verapamil, diltiazem
What drugs do we use for systemic BP control?
- First line: ACE/ARBs in those with proteinuria
- Without proteinuria: CCB, BB, or diuretics
- Second line/adjunct: vasodilators, alpha blockers
What is optimal glucose control for pts with CKD?
- Preprandial glucose 90-130
- Post prandial <180
Which glucose control drugs are contraindicated?
How do you control microalbuminuria?
- Test all diabetics yearly for uless they already have established proteinuria
- Tx HTN
- ACE-Is and ARBs
How do you tx CHF in CKD pts?
- Restrict H2O and salt
- Diuretics (thiazides ineffective GFR<20, so use loop and incre dose as GFR declines)
- Use digoxin with caution
How do you tx anemia in CKD pts?
What is HGB goal?
- Replete iron
- Start recombinant EPO-stimulatin agents with HGB <9 and other causes are ruled out
- Pts on HD will get iron IV onthly
- HGB should rise no more than 1g/dl q 3-4 weeks to max 12g/dl
How do you tx coagulopathy?
- Correct anemia
How do you tx metabolic acidosis in a CKD pt?
- Use sodium bicarb or sodium citrate to increase albumin and lean body mass
- Goal HCO3 > 21 mEq/L
How do you tx hyperphosphatemia in the CKD pt?
- Low phosphate diet 1gm/day
- Phosphate binders:
- calcium carb or calcium acetate (avoid aluminum containing binders)
- Renagel is the newest med
- Goal phosphorus is ~4
How do you manage hypocalcemia in CKD pts?
- Maintain serum Ca at high end of nl (<10)
- If taking supplemental Ca, take in between meals or it will act as a phosphate binder)
When does phosphate excretion remain intact?
until GFR 20-30
When does K excretion remain intact?
Until GFR <10-20
How do you manage hyperkalemia in the CKD pt?
What contributes to hyperkalemia in the CKD pt?
- Increased exogenous intake
- Increased cellular destruction
- Drugs that < K excretion (ie spirinolactone)
How do you tx secondary hyperparathyroidism in the CKD pt?
- Vit D analogs or Vit D to suppress PTH and raise serum phosphorus and Ca levels
- Options: calcitriol, Vit D, cinacalcet
- Do NOT use VIt D analog in presnce of hyperphosphatemia and hypercalcemia
When are Vit D analgogs contraindicated?
In the presence of hyperphosphatemia and hypercalcemia
Name the daily intake goals for the following nutrients:
- K: <60mEq/day
- Na: <2gm/day
- Phosphorus: <1gm/day
- Low magnesium: rare to see high levels unless from meds
What drugs should you avoid in CKD pts?
Metformin, meperidine, NSAIDs
When should a pt be put on dialysis?
- Intractable sx not attributable to any other reversible cause
- Persistent ECV despite diuretics
- Bleeding diathesis
- Estimated GFR or CrCl<10 mL/min
What is the best access route for dialysis?
- Fistula: longest long-term patency rate
- Needs 2-3 mos to mature
When is a graft indicated for dialysis access?
Pts with small or wornout veins
What are complications from a graft being used as dialysis access?
- Thrombosis, graft failure, infection
- Tx with angioplasty and removal of graft
What vessels are used in catheter access in dialysis?
IJ, subclavian, femoral
What are complications of using a catheter as access in CKD pts?
Stenosis, infection "death catheter"
What are the two forms of peritoneal dialysis?
- CAPD: dialysis solution is infused into the peritoneal cavity during the day and exchanged 3-5xs
- CCPD: exchanges are automated, occur at night
When do you refer a CKD pt to a nephrologist?
- CKD stage 3-5
- Cr >1.2 in women and 1.5 in men
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