Chronic Renal Failure
Card Set Information
Chronic Renal Failure
For my upcoming nephrology exam
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)
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?
If extremely uremic
: seizures, coma, pericarditis
Pts appear chronically ill
Sensorimotor polyneuropathy (glove and stocking)
Uremic fetor (fish breath)
Pericardial friction rub
What do labs show in a person with CKD?
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?
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
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
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
Dyslipidemia (<HDL, >TG and LDL)
What are GI complications of CKD?
Gastritis, peptic dz
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
Prolonged bleeding time
How do you tx CKD overall?
Reduction HTN and BP control
Control microalbuminuria and proteinuria
What are protein intake recommendations for CKD pts?
0.6-0.75g/kg/day depending on proteinuria and nutritional status
What is the goal BP for proteinuric CKDers?
What drugs do we use for proteinuria and intraglomerular HTN control? (first and second line)
: ACE-Is and ARBs
Both slow progression in non-diabetic and diabetic pts that have proteinuria
: Verapamil, diltiazem
What drugs do we use for systemic BP control?
: ACE/ARBs in those with proteinuria
: CCB, BB, or diuretics
: 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
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?
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?
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
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
: 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:
: 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
Estimated GFR or CrCl<10 mL/min
What is the best access route for dialysis?
: 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?
: dialysis solution is infused into the peritoneal cavity during the day and exchanged 3-5xs
: 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