Chronic Renal Failure

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  1. 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
  2. What is ESRD?
    Stage 5 CKD where accumulation of toxins fluids, and electrolytes normally secreted by the kidney result in uremic syndrome
  3. What is the mc cause of ESRD?
  4. What are clinical features of ESRD?
    • HTN (70% of pts)
    • Glomerulonephritis
    • PCKD
    • Interstitial nephritis
    • Obstruction
  5. At waht point of CKD does electrolyte and acid-base regulation become deranged?
    When GFR<15mL/min
  6. 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)
  7. What are clinical manifestations of CKD?
    • N/V/Anorexia/Weight loss
    • HA
    • Pruritus
    • Neuropathy
    • If extremely uremic: seizures, coma, pericarditis
    • Pts appear chronically ill
    • Sensorimotor polyneuropathy (glove and stocking)
    • Decreased vibratory sensation
    • Muscle weakness
    • Uremic fetor (fish breath)
    • Rales
    • Peripheral edema
    • Asterixis
    • Myoclonus
    • Pericardial friction rub
  8. What do labs show in a person with CKD?
    • Increased BUN/Cr
    • Hyperphosphatemia
    • Hypermagnesemia
    • Metabolic acidosis
    • Anemia
    • HL
    • High PTH level
  9. What does a U/A show in someone with CKD?
    • Could be positive for isothenuria
    • Sediment (+) for broad, waxy casts
  10. What does a renal US show in a CKD pt?
    Small, atrophic kidneys
  11. In what cases might you see nl sized or large kidneys in CKD pts?
    • HIV,
    • multiple myeloma,
    • amyloidosis,
    • PCKD,
    • diabetic nephropathy,
    • HIV associated nephropathy
  12. What does an EKG show in with a person with CKD?
    • LVH
    • Signs indicative of electrolyte abnl
  13. What might a CXR show in a CKD pt?
    • Noncardiogenic pulmonary edema
    • Pleural effusions
    • Cardiomegaly
  14. 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
  15. 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
  16. 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
  17. What is the m/c cause of death at every state of CKD?
    CV complications
  18. List common CV complications in CKD
    • HTN
    • LVH with diastolic and usually systolic dysfunction
    • CAD
    • Uremic pericarditis
    • Dyslipidemia (<HDL, >TG and LDL)
  19. What are GI complications of CKD?
    • Gastritis, peptic dz
    • GI bleeding
    • Protein catabolism and malnutrition
  20. 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)
  21. 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)
  22. 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
  23. 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
  24. How do you tx CKD overall?
    • Protein restriction
    • Reduction HTN and BP control
    • Reducing proteinuria
    • Glucose control
    • Control microalbuminuria and proteinuria
    • Tx complications
  25. 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
  26. What is the goal BP for proteinuric CKDers?
  27. 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
  28. 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
  29. What is optimal glucose control for pts with CKD?
    • Preprandial glucose 90-130
    • Post prandial <180
    • A1c<7%
  30. Which glucose control drugs are contraindicated?
  31. How do you control microalbuminuria?
    • Test all diabetics yearly for uless they already have established proteinuria
    • Tx HTN
    • ACE-Is and ARBs
  32. 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)
    • ACE-ARB
    • Use digoxin with caution
  33. 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
  34. How do you tx coagulopathy?
    • Dialysis
    • DDAVP
    • Correct anemia
  35. 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
  36. 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
  37. 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)
  38. When does phosphate excretion remain intact?
    until GFR 20-30
  39. When does K excretion remain intact?
    Until GFR <10-20
  40. How do you manage hyperkalemia in the CKD pt?
    Usually dialysis
  41. What contributes to hyperkalemia in the CKD pt?
    • Increased exogenous intake
    • Increased cellular destruction
    • Acidemia
    • Drugs that < K excretion (ie spirinolactone)
  42. 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
  43. When are Vit D analgogs contraindicated?
    In the presence of hyperphosphatemia and hypercalcemia
  44. 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
  45. What drugs should you avoid in CKD pts?
    Metformin, meperidine, NSAIDs
  46. When should a pt be put on dialysis?
    • AEIOU
    • Intractable sx not attributable to any other reversible cause
    • Persistent ECV despite diuretics
    • Bleeding diathesis
    • Estimated GFR or CrCl<10 mL/min
  47. What is the best access route for dialysis?
    • Fistula: longest long-term patency rate
    • Needs 2-3 mos to mature
  48. When is a graft indicated for dialysis access?
    Pts with small or wornout veins
  49. What are complications from a graft being used as dialysis access?
    • Thrombosis, graft failure, infection
    • Tx with angioplasty and removal of graft
  50. What vessels are used in catheter access in dialysis?
    IJ, subclavian, femoral
  51. What are complications of using a catheter as access in CKD pts?
    Stenosis, infection "death catheter"
  52. 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
  53. When do you refer a CKD pt to a nephrologist?
    • CKD stage 3-5
    • Cr >1.2 in women and 1.5 in men
Card Set:
Chronic Renal Failure
2011-05-09 13:11:07

For my upcoming nephrology exam
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