Chronic Kidney Disease Overview

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Questions and Answers

What is chronic renal failure defined as?

A condition that resolves with medical intervention

An acute and reversible loss of kidney function

An irreversible decrease of renal function over 3 months or years (correct)

A temporary, non-progressive decline in kidney filtration

What term has recently replaced chronic renal failure?

Acute kidney injury

Chronic kidney disease (CKD) (correct)

Reversible renal impairment

End-stage renal disease (ESRD)

Which option describes a characteristic of diabetic nephropathy?

Decreased urine output

Increased glomerular filtration rate (GFR)

Normal blood pressure levels

Persistent proteinuria greater than 300 mg/24 h (correct)

What occurs during the adaptive mechanism in chronic kidney disease?

Remnant nephron GFR rises despite overall decline Signup and view all the answers

What is a potential consequence of glomerular hypertension in CKD?

Further glomerular injury or damage Signup and view all the answers

How does high glucose levels contribute to kidney damage?

By stimulating free radical production Signup and view all the answers

What is a key diagnostic feature for CKD?

Kidney damage for more than 3 months Signup and view all the answers

In the context of CKD, what does the term 'hyper-filteration' refer to?

Increased filtration activity of remaining nephrons Signup and view all the answers

Which condition is commonly associated with postrenal obstructive nephropathy?

Prostatic disease Signup and view all the answers

Which of the following is a modifiable risk factor for kidney disease?

Obesity Signup and view all the answers

What is the target blood pressure goal for most people with diabetes?

140/90 mm Hg Signup and view all the answers

Which type of cholesterol is considered 'bad' and can lead to cardiovascular problems?

LDL Signup and view all the answers

Which of the following lifestyle modifications can help protect kidney health?

Maintaining a healthy weight Signup and view all the answers

What should be avoided to prevent kidney damage when using over-the-counter pain relievers?

Taking long-term without supervision Signup and view all the answers

Which of the following factors is a non-modifiable risk factor for kidney disease?

Older age Signup and view all the answers

What dietary change can contribute to kidney health?

Choosing whole grains Signup and view all the answers

What is a critical initial step in distinguishing between acute kidney injury (AKI) and chronic kidney disease (CKD)?

Repeat kidney function tests after 2 weeks Signup and view all the answers

Which of the following laboratory findings are indicative of chronic kidney disease (CKD)?

BUN greater than 140 mg/dl Signup and view all the answers

What lifestyle change is associated with retarding the progression of chronic kidney disease (CKD)?

Cessation of smoking Signup and view all the answers

Which condition should be identified and treated as a reversible cause of acute kidney injury?

Hypotension from shock Signup and view all the answers

What is one of the factors that can be addressed to help slow the progression of chronic kidney disease (CKD)?

Hypertension management Signup and view all the answers

Which marker may be used when eGFR based on serum creatinine is known to be less accurate?

Cystatin-C Signup and view all the answers

Which statement regarding metabolic acidosis in CKD is true?

Bicarbonate supplementation can delay progression Signup and view all the answers

What is a common laboratory finding in patients with CKD?

Microhematuria Signup and view all the answers

What is a common sign of calcium deficiency that may indicate osteoporosis?

Muscle spasms Signup and view all the answers

Which treatment options are effective for managing hypertension in chronic kidney disease (CKD) patients?

Thiazides and loop diuretics Signup and view all the answers

What can excessive sodium and fluid intake lead to, exacerbating hypertension?

Worsening kidney function Signup and view all the answers

Which of the following is considered a first-line agent for blood pressure control in patients with proteinuria?

ACE inhibitors Signup and view all the answers

Massive doses of loop diuretics are generally ineffective and may induce which of the following risks?

Ototoxicity Signup and view all the answers

Which condition may result from prolonged obstruction of the urinary tract?

Enlarged prostate Signup and view all the answers

What role does hypertension play in kidney function?

It creates a cycle of damage by increasing fluid in blood vessels. Signup and view all the answers

Which mechanism is primarily involved in diabetic kidney disease?

Hyperglycemia stimulating RAS Signup and view all the answers

Which type of disease causes inflammation of the kidney's filtering units?

Glomerulonephritis Signup and view all the answers

Which condition is characterized by genetic kidney cysts?

Polycystic kidney disease Signup and view all the answers

What is the primary effect of chronic prerenal disease?

Causes progressive renal dysfunction Signup and view all the answers

Which of the following is NOT a significant risk factor for ESRD?

Hyperlipidemia without diabetes Signup and view all the answers

Which of the following conditions is caused by recurrent kidney infections?

Pyelonephritis Signup and view all the answers

What is the primary benefit of renal transplantation for patients with end-stage renal disease (ESRD)?

It provides better long-term survival outcomes. Signup and view all the answers

What triggers anemia in patients with chronic kidney disease (CKD)?

Insufficient erythropoietin (EPO) production. Signup and view all the answers

When should Erythropoietin therapy be discontinued in patients with CKD?

When hemoglobin reaches 12 g/L. Signup and view all the answers

What condition is primarily caused by phosphorus retention in patients with CKD?

Reduced calcium absorption. Signup and view all the answers

What should be assessed prior to initiating Epoetin therapy in CKD patients?

Iron balance. Signup and view all the answers

What symptom is commonly associated with anemia in CKD patients?

Fatigue. Signup and view all the answers

At what estimated glomerular filtration rate (eGFR) are patients typically eligible for the renal transplant program?

Below 20 ml/min/1.73m2. Signup and view all the answers

What is the most common cause of suboptimal response to Erythropoietin therapy in CKD patients?

Iron deficiency. Signup and view all the answers

Signup and view all the answers

Study Notes

Chronic Renal Failure

Chronic renal failure (CRF) is a slow, irreversible decline in kidney function over 3 to 12 months or years. It may lead to end-stage renal failure (ESRD).
ESRD is when renal failure is severe, and the patient needs dialysis to survive.
The term CRF or Chronic kidney impairment has been replaced by the term Chronic Kidney Disease (CKD).
CKD is considered kidney damage for 3 or more months.
Damage can be detected functionally via tests like CrCL, proteinuria, or hematuria, or structurally (via kidney biopsy or radiology).

Adaptive Mechanism

Although total kidney glomerular filtration rate (GFR) falls, remnant nephrons increase their filtration rate.
This allows increased excretion proportionally.
This adaptation initially blunts the drop in whole kidney GFR.
However, it ultimately leads to glomerular hypertension and hypertrophy, and further damage.

Stages of CKD

Stage One: Normal kidney function, urine findings suggest kidney disease. eGFR = 90 mL/min or higher
Stage Two: Slightly reduced kidney function. eGFR = 60 to 89 mL/min
Stage Three: Moderately reduced kidney function. eGFR= 30 to 59 mL/min
Stage Four: Severely reduced kidney function. eGFR= 15 to 29 mL/min
Stage Five: Very severe or end-stage kidney failure. eGFR < 15 mL/min or on dialysis.

Etiology of Chronic Renal Failure

The most frequent causes of CRF/ESRD worldwide are diabetes and nephropathy.
Diabetic nephropathy is more common with IDDM than NIDDM.
Nephropathy Symptoms:
- Persistent albuminuria (> 300 mg/24 h)
- High blood pressure (HTN)
- Decreased GFR
All of these factors cause renal disease progression to ESRD.

Causes of Chronic Renal Failure/ESRD

Glucose build-up and blood vessel damage to the kidneys causes damage overtime, leading to poor kidney filtering of waste and excess fluid. This is called persistent albuminuria or proteinuria
High blood glucose levels create reactive oxygen species and cause oxidative stress, which results in nephropathy.
Hyperglycemia also promotes the renin-angiotensin-aldosterone system (RAS) in the blood, which contributes to microvascular disease, altering glomerular hemodynamics and supporting diabetic nephropathy development.

Hypertension

High blood pressure damages kidney blood vessels, affecting the ability to filter waste and fluid, causing a potential vicious cycle.
25-28% of ESRD patients are attributable to hypertension.

Other Causes of CKD

Hyperlipidemia: Alone is not a significant risk factor, but with DM, it can lead to ESRD. A mechanism involving glomerular sclerosis (hardening of glomeruli) is involved.
Primary or secondary glomerulonephritis. Inflammation of the kidney's filtering units (glomeruli).
Chronic Tubulointerstitial nephritis: Inflammation of kidney tubule and surrounding structures.
Polycystic kidney disease (genetic disease that causes kidney cysts to grow).
Prolonged urinary tract obstruction (e.g., enlarged prostate, kidney stones, cancer.)
Recurrent kidney infections (pyelonephritis).
Vesicoureteral reflux: Urine backs up into the kidneys.
Sickle cell nephropathy (rare).

Pre-renal Disease and CKD

Decreased renal perfusion pressure, as from chronic heart failure or liver cirrhosis, is a pre-renal cause of chronic renal failure, resulting in a progressive loss of kidney function over time.

Intrinsic Renal Vascular Disease

Nephrosclerosis: Chronic damage to blood vessels, glomeruli, and tubule
Renal artery stenosis: From atherosclerosis

Post-renal Disease

Chronic obstruction from prostatic disease, nephrolithiasis, or abdominal/pelvic tumors.
These cause a mass effect on the ureters.

Risk Factors

Modifiable: High blood pressure, family history of kidney disease, heart disease, abnormal kidney structure, smoking, obesity, and nephrotoxic drugs.
Non-modifiable: Older age, male gender, being black or native American/Asian.

Prevention of CKD

Manage existing medical conditions (diabetes, high blood pressure, heart conditions).
- Goal for blood glucose is close to individual goals
- Blood pressure goal is below 140/90 mmHg for people with diabetes.
Lifestyle modifications: Healthy weight, smoking cessation, alcohol moderation, and healthy eating habits.
Adhere to medical prescriptions.

Symptoms of CKD

Weight loss and poor appetite
Swelling (edema) of ankles, feet, or hands
Shortness of breath
Blood in the urine
Difficulty sleeping (insomnia)
Itchy skin
Feeling sick
Muscle cramps
Headaches

Tests and Diagnosis

Early kidney disease often lacks symptoms, so testing the kidneys function is critical.
Testing is needed to assess the health and function of the kidneys.
Blood tests (e.g., GFR):
- A GFR ≥ 60mL/min/1.73m² is normal.
- A GFR <60 may indicate kidney disease, <20 ESRD.
Kidney function tests should be repeated 2 weeks after initial diagnosis to determine if kidney disease is acute kidney injury (AKI) or chronic kidney disease (CKD); further testing may be required over three months.

Lipid Profile

Patients with CKD are at heightened risk for cardiovascular disease.

Renal Bone Disease

Evidence of renal bone disease can be determined by tests like serum calcium, phosphate, 25-hydroxyvitamin D, alkaline phosphatase, and intact parathyroid hormone (PTH) levels.

Urine Test for Albumin

Albuminuria may show some albumin in the urine. Less albuminuria is considered better.
Urine albumin-to-creatinine ratio (UACR): 30 mg/g or less is normal; >30 may be a sign of kidney disease.

Evaluation of Chronicity

When eGFR < 60 mL/min, pay attention to prior blood and urine testing results and clinical history to check for AKI or asymptomatic CKD.
Clinical factors relevant to evaluation include a history of chronic hypertension, proteinuria, microhematuria, and potential for prostate disease.

Other Considerations

Factors such as low calcium, high phosphate, or normal PTH may help differentiate acute kidney injury (AKI) from chronic kidney disease (CKD).
BUN >140 mg/dL or creatinine >1.5 mg/dL who are relatively healthy and have normal urine flow are likely to have CKD over AKI.
If the distinction is unclear, the kidney function tests should be repeated to determine if the decreased GFR is chronic. If so, CKD may be confirmed.

Treatment

General Management: Adjust doses of medications for the estimated glomerular filtration rate (GFR). This is needed for proper preparation for eventual renal replacement therapy.
Treat Reversible Causes: Identify and treat acute kidney injury causes from infection, drugs that reduce GFR, hypotension, or dehydration (vomiting, diarrhea). Avoid nephrotoxic agents such as aminoglycoside antibiotics and NSAIDS. Avoid nephrotoxic medications
Retarding CKD Progression: Manage factors like hypertension, proteinuria, metabolic acidosis, and hyperlipidemia.
- Smoking cessation can reduce nephrosclerosis and slow CKD progression and is an important lifestyle change.

Treating Chronic Kidney Disease

Bicarbonate supplementation: For treating metabolic acidosis, this can help delay CKD progression.
Intensive glucose control: In patients with diabetes, this helps delay the development of albuminuria and prevent progression to proteinuria.

Renal Replacement Therapy

After confirming CKD progression, the patient should be offered options for renal replacement therapy (e.g., hemodialysis, peritoneal dialysis, or kidney transplantation).

Renal Transplantation

Kidney transplantation is the best treatment option for end-stage renal disease (ESRD) and offers better long-term outcomes compared to dialysis.
Patients are typically listed for a transplant when their eGFR is below 20 ml/min/1.73m².

Complications

Anemia: Reduced EPO production can lead to anemia (low red blood cell count). It may result from low iron, vitamin B12, or folic acid. - Signs/symptoms include fatigue, exertion dyspnea, dizziness, headache, pallor, and decreased hematocrit -Treatment may include erythropoietin (EPO) therapy, iron supplements, or blood transfusions.
Renal osteodystrophy and soft tissue calcification: Can result from phosphate retention affecting calcium levels.
- Signs/symptoms include muscle spasms, mouth numbness and tingling, or itchy skin
- Treatment options may include phosphate-binding agents, calcium supplementation, vitamin D therapy, or parathyroidectomy.
Cardiovascular disease: Increased sodium and fluid can lead to edema, hypertension, and cardiovascular disease.
- Signs/symptoms may include swelling of limbs (edema), high blood pressure, and fluid in the lungs.
- These impacts need medication like diuretics (thiazides or loop diuretics).

Therapeutic Management

Hypertension :
- ACE inhibitors and angiotensin receptor blockers are first-line medications in patients with proteinuria.
- Blood pressure (BP) goals in CKD patients, using KDIGO guidelines: BP <130/85 mmHg but may be lower in patients with proteinuria or diabetes.
- Other medications, like calcium channel blockers (dihydropyridines), may be used to lower systemic vascular resistance.
Dyslipidemia:
- Lifestyle changes can be helpful in patients with low-to-moderate LDL cholesterol, particularly those between 100 and 129 mg/dL.
- Statins may be a needed treatment for higher LDL values (≥130 mg/dL.
- Treatment with lifestyle changes plus a low dose of statin may be used when triglycerides are very high (>200 mg/dL).
Metabolic acidosis:
- Sodium bicarbonate can be beneficial in treating metabolic acidosis to help replenish bicarbonate stores found within the body. This also helps to prevent complications.

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Description

This quiz explores essential concepts related to chronic kidney disease (CKD), including its definition, causes, and diagnostic features. Test your knowledge on the changes and challenges that arise from CKD, particularly in the context of diabetic nephropathy and renal function. Enhance your understanding of the adaptive mechanisms and potential complications associated with kidney health.