Lecture given:
Objectives
List the most common causes of chronic kidney disease
All eGFR done with MDRD formula
CKD:
- presence of kidney damage or eGFR <60mL/min1.73m2 AND
- Present for >= 3 months AND
- Not treated with dialysis or transplant (if treated, then automatically ESRD)
Diagnosis of significant CKD is only present in patients with GFR >= 60 if other abnormalities (proteinuria, hematuria, anatomical) are also present
Classification:
Stage 1: > 90 (Kidney damage with normal or high GFR - hyperfiltration)
Stage 2: 60-89 (Kidney damage with mild decr in GFR)
Stage 3: 30-59 (Moderately decr in GFR)
Stage 4: 15-29 (Severely decr GFR)
Stage 5: <15 Kidney failure
Stage 3-5 are at risk for progression to ESRD
Even when asymptomatic, decline in kidney function is associated with death of any cause. Could be a marker of vascular disease for somewhere else in the body
- CV Disease
- Heart failure
- Peripheral artery disease
- stroke
Progression in Renal disease:
- once GFR falls <25% of normal, renal function declines even if the original insult has been removed
- Dimunition of renal reserve
- Renal insufficiency
- Overt renal failure
- Uremia with ESRD
When giving ACEi, there will be a very drastic drop in GFR if patient also takes NSAIDs, or have 100% renal artery stenosis, or is volume contracted
Risk factors for progression:
- Renal injury
- Reduction in nephron mass
- Glomerular capillary hypertension
- Increased glomerular permeability to macromolecules
- Increased filtration of plasma proteins
- Excessive tubular protein reabsorption
- Renal scarring
- Hypertension
- Fluid depletion
- Malignant hypertension
- UTI
- Obstruction
- Drug toxicity (NSAIDs, aminoglycosides, sulfas, diuretics, over exercise, contract)
- Pregnancy
Most common cause = diabetes nephropathy; second most common = hypertension
Also glomerulonephritis, cystic kidney
List the clinical manifestations of chronic kidney disease
Signs and symptoms of chronic renal failure
- General/constitutional symptoms - weakness, fatingue
- Cardio - HTN, pericarditis
- GI - N/V/D
- CNS - Lethargy, confusion, coma
- Muscles - Twitching, weakness
- Bones - osteodystrophy
- Metabolic - acidosis, incr PO4, incr K, incr BUN, incr Cr
- Endocrine - incr PTH
Complications of CRF (Uremia)
- Hyponatremia (can't pee out water)
- CHF and pulmonary edema (increase total body sodium)
- HyperK
- Metabolic acidosis
- GI inflammation, PUD
- Anemia (EPO, iron folate B12 deficiency, osteitis fibrosa cystica)
- Hemostasis problems from impaired platelets
- neurological system
Outline a management plan for optimizing the care of patients with chronic kidney disease
Goals of treatment:
- stop or slow the rate of GFR decline
- Prevent additional kidney damage caused by superimposed events
- Maintain nutritional status
- Prevent or limit the complications of uremia
Treatment:
- ACEi/ARB
- Strick BP control
- Dietary protein restriction if needed (make sure will not result in malnutrition)
- Manage hyperlipidemia
- Glycemic control
- Phosphate restriction + binders
- Activated vit D