Chronic Kidney Disease Overview
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Questions and Answers

What does CKD stand for?

Chronic Kidney Disease

Most deaths in patients with CKD are caused by kidney failure.

False

Early diagnosis of CKD is important because it can help delay the progression of the disease and prevent complications.

True

Which of these organizations defines CKD as abnormalities of kidney structure or function greater than 3 months with implication for health?

<p>All of the above</p> Signup and view all the answers

What are the two main phases of CKD pathophysiology?

<p>The path of CKD can be understood through two phases: the Initiating Mechanism, where the initial damage occurs, and the Progressive Mechanism, where the damage worsens over time.</p> Signup and view all the answers

Which of the following is NOT a factor that can initiate CKD?

<p>High blood pressure</p> Signup and view all the answers

Which of the following is NOT a short-term adaptation in the progressive phase of CKD?

<p>Sclerosis</p> Signup and view all the answers

What are the main steps in the systematic approach to CKD?

<p>History taking, physical examination, clinical evaluation, and investigations.</p> Signup and view all the answers

What is the best overall index of kidney function?

<p>Glomerular filtration rate (GFR)</p> Signup and view all the answers

A GFR of less than 60 mL/min per 1.73 m2 suggests a high risk of complications related to CKD.

<p>True</p> Signup and view all the answers

What is NOT a complication associated with a GFR less than 60 mL/min?

<p>Gastrointestinal bleeding</p> Signup and view all the answers

What is the normal GFR range in young adults?

<p>120 to 130 mL/min per 1.73 m2</p> Signup and view all the answers

GFR declines with age but is constant throughout life.

<p>False</p> Signup and view all the answers

GFR varies based on sex and body size.

<p>True</p> Signup and view all the answers

What is the approximate annual mean decline in GFR with age?

<p>1 mL/min per year per 1.73 m2</p> Signup and view all the answers

The mean GFR is lower in women than men.

<p>True</p> Signup and view all the answers

What is albuminuria a marker of?

<p>Chronic kidney damage</p> Signup and view all the answers

Albuminuria can be used to predict the progression of CKD.

<p>True</p> Signup and view all the answers

Albuminuria is an independent risk factor for cardiovascular disease.

<p>True</p> Signup and view all the answers

Which of the following is NOT a test used for initial testing of proteinuria?

<p>Urine culture</p> Signup and view all the answers

Which test is often preferred for initial proteinuria testing, especially for CKD assessment?

<p>Urine albumin to creatinine ratio (ACR)</p> Signup and view all the answers

Which of the following is NOT a reason to refer a patient with CKD to a nephrologist?

<p>Treatment of heart failure</p> Signup and view all the answers

Which of the following is NOT a possible consequence of untreated CKD?

<p>Diabetes</p> Signup and view all the answers

CKD can be effectively managed with consistent monitoring and proper treatment, but it is not curable.

<p>True</p> Signup and view all the answers

What is the most common complication of CKD?

<p>Hypertension</p> Signup and view all the answers

The absence of hypertension in a patient with CKD can indicate a poor prognosis.

<p>True</p> Signup and view all the answers

Low blood pressure is less concerning than high blood pressure in a patient with CKD.

<p>False</p> Signup and view all the answers

Which blood pressure value is recommended as the primary target in managing CKD?

<p>Systolic blood pressure</p> Signup and view all the answers

Metformin should typically be discontinued when GFR is less than 30 mL/min per 1.73 m2.

<p>True</p> Signup and view all the answers

Dialysis is the only treatment option for patients with CKD.

<p>False</p> Signup and view all the answers

What are the main indications for dialysis?

<p>All of the above</p> Signup and view all the answers

Which of the following is NOT a common mode of dialysis?

<p>Liver transplantation</p> Signup and view all the answers

The general population should be routinely screened for CKD.

<p>False</p> Signup and view all the answers

Which of the following groups should be tested for CKD?

<p>All of the above</p> Signup and view all the answers

Cardiovascular complications are a leading cause of death in patients with CKD.

<p>True</p> Signup and view all the answers

Albuminuria is a significant risk factor for cardiovascular disease.

<p>True</p> Signup and view all the answers

What is NOT a contributing factor to ischemic vascular disease in CKD?

<p>Hypertension</p> Signup and view all the answers

Hemodialysis can worsen ischemia by decreasing blood pressure and volume.

<p>True</p> Signup and view all the answers

Elevated cardiac troponin levels in CKD always indicate an acute heart attack.

<p>False</p> Signup and view all the answers

Low blood pressure in a patient with CKD is a better prognosis than high blood pressure.

<p>False</p> Signup and view all the answers

The recommended blood pressure target for patients with CKD is lower than the general population.

<p>True</p> Signup and view all the answers

ACE inhibitors and ARBs have shown to slow the progression of CKD.

<p>True</p> Signup and view all the answers

Dihydropyridine calcium channel blockers are typically recommended as a first-line therapy for hypertension in CKD.

<p>False</p> Signup and view all the answers

Non-dihydropyridine calcium channel blockers can be protective for the kidneys.

<p>True</p> Signup and view all the answers

Patients treated with ACE inhibitors or ARBs should have their potassium levels monitored.

<p>True</p> Signup and view all the answers

Beta-blockers are generally recommended for patients with ischemic heart disease or arrhythmia.

<p>True</p> Signup and view all the answers

Uremic pericarditis is characterized by retrosternal chest pain that worsens when lying down and improves when sitting up.

<p>True</p> Signup and view all the answers

Which of these is NOT a common ECG finding in Uremic pericarditis?

<p>T wave inversions</p> Signup and view all the answers

Beck's Triad is a clinical sign of pericardial effusion.

<p>True</p> Signup and view all the answers

Electrical alternans of the QRS complex on ECG is a common finding in pericardial effusion.

<p>True</p> Signup and view all the answers

The most common cause of anemia in adults is decreased erythropoietin production.

<p>True</p> Signup and view all the answers

Anemia is typically managed in CKD patients when their Hemoglobin levels are below 13 g/dL in men and 12 g/dL in women and their creatinine clearance is below 60 mL/min per 1.73 m2.

<p>True</p> Signup and view all the answers

Calcitriol, a vitamin D analog, is used to stimulate the production of parathyroid hormone (PTH).

<p>False</p> Signup and view all the answers

Calcimimetics like cinacalcet are indicated for patients with high calcium and phosphate levels.

<p>True</p> Signup and view all the answers

Treating hyperkalemia is important in managing metabolic acidosis.

<p>True</p> Signup and view all the answers

Sodium bicarbonate supplementation is NOT a part of managing metabolic acidosis in CKD.

<p>False</p> Signup and view all the answers

The Cockcroft-Gault equation is used to estimate creatinine clearance.

<p>True</p> Signup and view all the answers

In patients with CKD, dietary protein should be restricted to 0.8 g/kg/day in those with and without diabetes, and with a GFR less than 30 mL/min.

<p>True</p> Signup and view all the answers

The recommended daily sodium intake for patients with CKD is less than 2 grams.

<p>True</p> Signup and view all the answers

Vaccinations are recommended for patients with CKD at stage 3a or above.

<p>True</p> Signup and view all the answers

It is important to monitor and manage anemia in patients with CKD.

<p>True</p> Signup and view all the answers

Patients with CKD at stage 4 should be prepared for renal replacement therapy.

<p>True</p> Signup and view all the answers

Patients with CKD stage 5 will invariably require renal replacement therapy.

<p>True</p> Signup and view all the answers

Insulin therapy is often adjusted in CKD patients.

<p>True</p> Signup and view all the answers

Metformin is contraindicated in CKD patients who are undergoing contrast studies.

<p>True</p> Signup and view all the answers

The primary goal of dialysis is to remove waste products from the body.

<p>True</p> Signup and view all the answers

Study Notes

Approach to Chronic Kidney Disease

  • Chronic kidney disease (CKD) often progresses to end-stage renal disease (ESRD) requiring renal replacement therapy (RRT).
  • Patients with CKD often die from non-renal causes, especially cardiovascular events.
  • Early CKD diagnosis is crucial to delay progression and prevent cardiovascular complications.

Defining CKD

  • Kidney Disease: Improving Global Outcomes (KDIGO) defines CKD as abnormalities in kidney structure or function lasting more than three months, with implications for health.
  • National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (KDOQI) also defines CKD as kidney damage for at least three months.
  • Kidney damage is a structural or functional abnormality of the kidney, with or without a decreased glomerular filtration rate (GFR) and can be identified by urinalysis, imaging studies, or renal biopsy.

CKD Criteria

  • Kidney damage or reduced kidney function.
  • Duration exceeding three months.
  • Glomerular filtration rate (GFR) less than 60 mL/minute/1.73 m2, with or without kidney damage.
  • Structural or other abnormalities beyond GFR decrease.

Pathophysiology of CKD

Initiating Mechanism

  • CKD's initiating mechanism is specific to the underlying cause.
  • Genetic abnormalities in kidney development.
  • Immune complex deposition causing inflammation in glomerulonephritis.
  • Toxin exposure affecting renal tubules and interstitium.

Progressive Mechanism

  • Reduction in nephron number due to vasoactive hormones, cytokines, and growth factors.
  • Initial adaptations include hyperfiltration and hypertrophy of the remaining nephrons.
  • These adaptative responses eventually become maladaptive, causing glomerular architectural damage, sclerosis, and nephron loss.
  • Increased intrarenal activity of the renin-angiotensin system contributes to initial and subsequent maladaptive responses via hyperfiltration, hypertrophy, and sclerosis.
  • Ultimately, renal mass reduction from an initial insult contributes to a progressive decline in renal function over time.

CKD Pathophysiology Diagram

  • Renal injury leads to a decrease in nephron numbers, glomerular hypertension, and macrophage recruitment.
  • Systemic hypertension, proteinuria, and hyperlipidemia worsen the situation.
  • Increased extracellular matrix (ECM) production and glomerulosclerosis result in chronic kidney disease.

CKD Epidemiology

  • In 2017, CKD affected an estimated 850 million people globally.
  • Prevalence was 11.1%.
  • This condition has increased significantly and is currently the 19th leading cause of death globally and is projected to become the 11th most common cause by 2019 and 5th by 2040.
  • Risk factors include a 2x increase for diabetes and a 20x increase for HIV and cancer compared to the general population

Etiology

  • Diabetic glomerular disease.
  • Hypertensive nephropathy.
  • Primary glomerulopathy with hypertension.
  • Vascular and ischemic renal disease.
  • Glomerulonephritis.
  • Urinary tract disease.
  • Polycystic kidney disease.
  • Lupus and analgesic nephropathy.
  • Tubulointerstitial nephropathy.

Risk Factors

Susceptibility

  • Factors associated with an increased risk of CKD development, but not proven causes include;
  • Advanced age.
  • Reduced kidney mass.
  • Low birth weight.
  • Racial/ethnic minority status.
  • Family history.
  • Low socioeconomic status.

Initiation

  • Modifiable factors directly causing CKD include;
  • Diabetes.
  • Hypertension.
  • Autoimmune diseases.
  • Polycystic kidney diseases.
  • Drug toxicity.

Progression

  • Modifiable factors related to faster kidney function decline include;
  • Hyperglycemia.
  • Elevated blood pressure.
  • Proteinuria.
  • Smoking.

Significance of GFR & Albuminuria

  • Glomerular filtration rate (GFR) is the best overall indicator of kidney function.
  • Decreases in GFR correlate with increased symptoms and metabolic abnormalities.
  • A GFR below 60 mL/min/1.73 m2 is associated with an increased risk of complications, including drug toxicity, metabolic complications, cardiovascular disease, and death.
  • Albuminuria (or proteinuria) is a hallmark of chronic kidney damage and is associated with, a higher risk of cardiovascular disease and a poor prognosis for CKD progression.

Normal GFR

  • Normal GFR values are approximately 120 to 130 mL/min/1.73 m2 in young adults.
  • GFR declines with age at an average rate of ~1 mL/min/year.
  • GFR at age 70 is roughly 70 mL/min/1.73 m2.
  • GFR is lower in women than men.

Albuminuria/Proteinuria

  • Marker of chronic kidney damage.
  • High prognostic value for CKD progression.
  • Independent cardiovascular risk factor.
  • Recommended testing includes urine albumin/creatinine ratio (ACR), urine protein/creatinine ratio (PCR), and reagent strip analysis.

Use of GFR & Albuminuria

  • CKD diagnosis and staging.
  • Management strategies, including referral, lifestyle modification, and medication adjustments, and preventative care.
  • Risk assessment for complications including cardiovascular events.

CKD Classification

  • GFR categories (G1-G5) based on milliliters per minute per 1.73 sq meters (mL/min/1.73 m2)
  • Albuminuria categories (A1-A3) based on excreted albumin
  • The classification system helps in accurate diagnosis and monitoring.

History Taking

  • Detailed patient history is important for diagnosing CKD.
  • Prenatal/perinatal history.
  • Hypertension history and medications used.
  • Diabetes, including duration and severity.
  • Pregnancy history, including preeclampsia and losses.
  • Family history of CKD, Alport syndrome, or Fabry disease.
  • Previous documented abnormal urea and creatinine levels.
  • History of asymptomatic urinary abnormalities such as hematuria or proteinuria.
  • Urine frequency or urgency (evidence for obstructive uropathy).
  • Changes in urine character and appearance or unusual colors or frothy consistency.

Drug History

  • History of systemic infections or recurrent illnesses.
  • Recent gastrointestinal endoscopy procedures, particularly those involving phosphate-containing enemas.
  • Recent procedures required to use contrast.
  • History of nephrotoxic drug exposure (chemotherapy, antibiotics, NSAIDs, aminoglycosides).
  • Recent changes in drug dosages or the initiation of new medications.
  • Over-the-counter or homeopathic medicine use.

History of Uremia (symptoms)

  • Loss of appetite.
  • Loss of weight.
  • Nausea and hiccups.
  • Metallic taste.
  • Burning epigastrium.
  • Pruritus (itching).
  • Muscle cramps.
  • Edema.
  • Nocturia (frequent urination at night).

Clinical Features

  • CKD can be initially asymptomatic.
  • Reduced GFR triggers signs like anemia, nausea, and hyperkalemia.
  • GFR between 15 and 20 mL/min/1.73m2 is associated with tiredness, fluid overload, and potential vomiting and hiccups.
  • Very low GFR (<5 mL/min/1.73 m2) can lead to neuropathy, altered consciousness, seizures, uremic pericarditis, and uremic "frost."

Physical Examination

  • Appearance (skin edema, pallor, uremic breath).
  • Vitals (blood pressure, pulse, saturation).
  • Fundoscopy (assess for hypertension and diabetic retinopathy).
  • Cardiovascular system (apex beat, heave, murmurs, rubs).
  • Abdomen (distension, masses, bruits, renal angle assessment).
  • Central nervous system (neurological abnormalities).

Investigations

  • Basic blood count (CBC).
  • Urinalysis (dipstick and microscopic examination).
  • 24-hour urine protein.
  • Serum creatinine and urea.
  • Electrolyte panel (sodium, potassium, calcium, phosphorus).
  • Coagulation profile
  • Hepatitis B surface antigen (HBsAg), Hepatitis C virus (HCV), and Human immunodeficiency virus (HIV) tests.
  • Parathyroid hormone (PTH) level.
  • Serum iron, vitamin B12, and folate levels.
  • Urine albumin-to-creatinine ratio (ACR).
  • Glomerular filtration rate (GFR).
  • Renal ultrasound
  • Renal biopsy

Renal Ultrasound

  • Useful in assessing kidney size, shape, and echogenicity to detect shrunken kidneys, asymmetry, and any scars or masses.

AKI vs CKD

  • Distinguishing acute kidney injury (AKI) from chronic kidney disease (CKD) in patients with impaired renal function requires careful history, sequential creatinine measurements, and a renal ultrasound.
  • Patients with CKD are at higher risk of AKI.

CKD Screening

  • Generalized population screening for CKD is not recommended.
  • Target high-risk groups include patients with hypertension, diabetes mellitus, cardiovascular disease, hematuria, proteinuria detected on investigations, and those receiving nephrotoxic drugs or known to have structural renal disease or family history.

Heart in CKD

  • Cardiovascular complications are a leading cause of mortality and morbidity in CKD.
  • Albuminuria is a major risk factor.
  • Ischemic vascular disease is a complex interplay of classical and CKD-related factors, with hemodialysis sometimes worsening ischemia.
  • Cardiac troponin levels are often elevated in CKD, even without acute ischemia.
  • Cardiac function abnormalities, combined with sodium/water retention, causes heart failure and pulmonary edema.

Hypertension in CKD

  • Hypertension is a frequent and often progressive complication of CKD.
  • Hypertension can worsen disease progression if left uncontrolled.
  • Absence of hypertension may indicate poor left ventricular function. Low blood pressure carries a significantly worse prognosis than high blood pressure

KDIGO Guidelines for Blood Pressure Management

  • Different target blood pressure goals are recommended based on the presence or absence of diabetes and the level of urine albumin excretion.
  • Treatment regimens and agents should be tailored according to patients' age, comorbidities, risk of CKD progression, presence of retinopathy, tolerance to treatment, and other electrolyte conditions.
  • Management should consider acute kidney deterioration, and secondary causes of hypertension if the target blood pressure goal is not being met.

Preferred Antihypertensive Agents - (ACE Inhibitors or ARBs)

  • ACE inhibitors or ARBs are often the initial choices.
  • If target blood pressure is not met after 2-4 weeks, then other agents or a more involved approach to additional/alternative agents can be considered.
  • Dihydropyridine CCB are generally not recommended as first line therapy.
  • NDHP CCBs can be considered for situations where protienuria is present

Management of Anemia

  • Anemia is frequently observed in CKD patients characterized by hemoglobin concentration less than 12 g/dL in females and 13 g/dL in males.
  • Decreased erythropoietin production is a primary cause.
  • Blood loss during dialysis, iron deficiency, and anemia of chronic disease are other potential contributing factors.
  • Anemia diagnosis is initiated when creatinine clearance (CrCl) is below 60 mL/min/1.73 m2 or hemoglobin is below 12 g/dL in women and 13g/dL in men.

Metabolic Bone Disease Management

  • Vitamin D and vitamin D analogs are used to manage bone mineral disorders.
  • Calcimimetics (e.g., cinacalcet) are used for managing high calcium and phosphate.
  • Close monitoring of serum calcium levels (every 1-2 weeks) is critical during treatment.

Fluid and Electrolyte Abnormalities in CKD

  • Fluid overload may result from impaired kidney function needing aggressive diuretic treatment.
  • Conditions such as hyponatremia and hyperkalemia may need interventions ranging from dietary adjustments to more intensive drug therapies.
  • Dietary modifications, including restricting high sodium, potassium, or protein intake (as appropriate), are essential in CKD.
  • Medications such as potassium-sparing diuretics must be considered but cautiously in this population to avoid complications.

Metabolic Acidosis

  • Impaired renal ammonia production and impaired urinary acidification contribute to metabolic acidosis, which is common in advanced CKD.
  • Hyperkalemia and hyperchloremia often overlap with metabolic acidosis, thus treatment for acidosis can be challenging.
  • Targeting bicarbonate levels close to 22 mmol/L may necessitate interventions aimed at addressing the underlying causes of hyperkalemia.
  • Additional electrolyte management such as sodium bicarbonate may be needed.

Drug Dosing in CKD

  • Drug selection and dosages need to be adjusted very carefully based on the stage of CKD, presence or absence of renal replacement therapy, and individual patient characteristics.
  • Specific strategies are employed factoring in drug absorption differences, especially given the tendency for patients with CKD to take multiple medications simultaneously.
  • Estimated creatinine clearance is used as a guide to modify the dosages of many medications.

CKD Management Strategies

  • Preventing the progression of CKD is a key goal.
  • Lowering protein, salt, and potentially other dietary components as appropriate, and managing hypertension with aggressive and watchful interventions based on the KDIGO guidelines.
  • Encourage physical activity that is compatible with cardiovascular health and addressing comorbid conditions, such a diabetes, and addressing anemia.
  • Addressing other possible risk factors or complications such as infections, complications of RRT.

Glycemic Control in CKD

  • Targeting HbA1c (<7.0%) is crucial for delaying diabetes complications like diabetic kidney disease.
  • Insulin therapy may be needed and adjusted as kidney function declines.
  • Metformin must be discontinued once estimated GFR falls below 30 mL/min/1.73 m2. Metformin must be avoided if patient is undergoing contrast studies for clinical reasons.

Dialysis Therapy

  • Dialysis procedures are necessary to remove toxins and correct fluid and electrolyte imbalances in advanced CKD.
  • Indication for dialysis, including uremic symptoms, severe hyperkalemia, refractory acidosis, and low GFR (<10mL/min/1.73m2)
  • Various dialysis modalities exist, such as intermittent hemodialysis, continuous renal replacement therapy, hybrid therapies, or peritoneal dialysis.

Pericardial Disease (Uremic Pericarditis & Effusion)

  • Pericardial effusion and Uremia are associated with potentially dangerous conditions like uremic pericarditis and pericardial effusion, which may require specific treatment and monitoring.
  • Symptoms like retrosternal pain worsened by lying down, tachycardia, ECG changes, and potential fluid buildup in the heart space.

Anemia Management

  • Anemia is a frequent complication, with hemoglobin levels below 12 g/dL in women and 13 g/dL in men indicating the need for intervention.
  • Treatment frequently includes erythropoietin stimulating agents (ESAs) or iron supplementation and other therapies.

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Description

This quiz explores the crucial aspects of Chronic Kidney Disease (CKD), including its definitions, criteria, and progression to end-stage renal disease (ESRD). You'll learn about the implications of early diagnosis and the associated risks, particularly related to cardiovascular health. Test your knowledge on CKD's impact and management.

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