CKD Overview
Per KDIGO CKD is defined by an eGFR less than this _____ for 3 months with or without kidney damage.
What is an eGFR <60 ml/min/1.73 m2 for 3 months.
OR
Structural or functional abnormality of the kidney, with our without decreased eGFR, manifested by either pathologic abnormalities or makers of kidney damage present in blood or urine.
These two lab monitoring parameters should be measured upon initiation of an ACEi or ARB.
1) Potassium
2) Serum creatinine
What factors are responsible for anemia in CKD?
-Decreased Erythropoietin (EPO) production
-Iron deficiency
- Decreased RBC lifespan
How often is hemodialysis done?
3x/week for 4 hours
60 y/o Asian male with h/o HTN + newly dx T2DM
Current meds: Atenolol 25 mg daily
BP: 149/92 P: 58 ACR category: A2
Labs: Scr 1.9 eGFR: 37
*Enalapril 20 mg daily is added for BP control
Two weeks later,
BP: 139/89 P: 60 SCr: 2.1 K: 5.2
What is the best recommendation for this patient?
A) Change enalapril to diltiazem 120 mg daily.
B) Add chlorthalidone 25 mg daily.
C) Change enalapril to valsartan 160 mg daily.
D) Increase atenolol to 50 mg daily.
B) Add chlorthalidone 25 mg daily.
The patient’s BP is not at goal <130/80. To improve BP control and enhance the effect of ACE-I, chlorthalidone should be added to the regimen. Adding chlorthalidone will also counter the tendency for hyperkalemia.
These are the two leading causes of CKD in the United States
What are diabetes (40%) and
hypertension (25%)
Per KDIGO, the goal blood pressure for patients with CKD is based on this parameter.
Per KDIGO, the goal blood pressure for patients with CKD is based on this parameter.
Degree of albuminuria
A1: BP <140/90 mmHg
A2: BP <130/80 mmHg
A3: BP <130/80 mmHg
At what Hgb should erythropoietin stimulating agents (ESA's) be considered?
Hgb < 10g/dL
What are the three hormones produced by the kidneys?
Renin, Calcitriol & Erythropoietin
45yoM HTN T2DM CKD3b
(NO Health Insurance)
Medications:
Atenolol Valsartan-HCTZ / Humulin 70/30
Labs:
Phosphorus 5.1 mg/dL (same as last month)
Calcium 9.4 mg/dL
Albumin 3.5 mg/dL
iPTH 40 pg/mL
eGFR 40 ml/min/1.73m2
Adherent to dietary restrictions.
Which is the most appropriate intervention:
A) add CaCO3 with meals
B) add Ca-acetate with meals
C) add Sevelamer with meals
D) add Calcitriol
Answer: A
A is the most appropriate as this patient is in need of a phosphate binder and CaCO3 is the most affordable
The presence of this is the first sign of CKD
Albuminuria
Upon review of potassium and serum creatinine after starting an ACEi or an ARB, these are the thresholds whereby the medication would need to be held.
1) Serum potassium > 5.6 meq/L
2) > 30 % rise in serum creatinine from baseline
This drug does not decrease potassium but stabilizes myocardial cells to prevent arrhythmias
Calcium gluconate
Metformin is contraindicated once GFR drops below this point
30mL/min/1.73m^2
60 y/o F, T2DM (+neuropathy), HLD, CKD,
Medications:
Metformin 500 mg (2 tabs) BID
Atorvastatin 10 mg daily
Gabapentin 600 mg TID
Labs:
A1c: 7.6% (today) 7.2% (3 months ago)
SCr: 1.28 eGFR: 42 (today) 43 (3 months ago)
Patient is in for DM follow-up. What, if any, medication changes would you like to make today?
1) Decrease metformin to 500 mg twice daily; will likely need to add an additional anti-diabetic agent
2) Decrease Gabapentin to a maximum of 700 mg BID
What are the risk factors for CKD?
Family history, chronic kidney injuries, and prolonged intake of OTC painkillers
This is the A1c goal for most patients with diabetes CKD.
A1c < 7%
What are the main abnormalities that contribute to secondary hyperparathyroidism due to CKD?
-phosphate retention
-decreased free calcium concentrations
-decreased 1,25-(OH)2 Vitamin D levels
-reduced expression of Vitamin D and Calcium sensing receptors
An antidiabetic agent that works in the PCT
SGLT2 inhibitors
What is the most predominate cause of death for pts with ESRD?
CV disease
Name two methods to assess kidney function in adults
-serum creatinine
-measured creatinine clearance (CrCl) via 12-24 hr urine collection
-measured GFR
-estimated CrCl (using Cockcroft-Gault eqn)
-estimated GFR (using MDRD)
-estimated GFR (using CKD-epi)
How do you treat Stage 5 CKD?
renal replacement therapy or kidney transplant
Name methods to manage hyperphosphatemia
1) dietary phosphorus restriction 800-1200 mg/d in CKD 3-5
2) Phosphate binders:
-Aluminum containing
-Calcium containing
-Nonabsorbable binding resins
This is not removed during kidney transplant.
The native kidney
Microvascular manifestations of CKD (name 3)
nephropathy
neuropathy
retinopathy