Chronic Kidney Disease

reduction of GFR <60 for 3 or more months that is damaging (structural or functional) the kidney; progressive and irreversible loss of renal function

GFR <15; stage V of kidney disease; need renal replacement therapy (dialysis or transplant)

any of the following that happens abruptly within 48 hours: 1) absolute increase in serum Cr of > or equal to .3 mg/dL; 2) percentage increase of > or equal to 50% (relative increase of serum creatinine level); reduction in urine output (oliguria <.5mL/kg/hr for >6 hrs)

elevated BUN and Cr; hyperkalemia; elevated PTH (secondary hyperparathyroidism); hyperphosphatemia; hyponatremia; hypocalcemia; low Hgb; low albumin; low GFR; metabolic acidosis

multiple myeloma and DM
also polycystic kidney disease, HIV-associated nephropathy, amyloidosis, obstructive uropathy

DM (leading cause of ESRD) and HTN (next highest cause)

when the kidney function goes down, it can't excrete phosphate properly so this leads to hyperphosphatemia; the excess phosphate leads to low calcium which stimulates the parathyroid to release more PTH, the excess PTH leads to calcium leaching from the bones, the calcium leaching leads to bone changes like osteodystrophy

refers to s/s associated with accumulation of nitrogenous wastes due to impaired to renal function-- usually don't appear until BUN >60; decreased attentiveness, N/V, anorexia, taste changes, weight change, dyspnea, orthopnea, leg swelling, fatigue, bone pain/fractures, muscle cramps, muscle weakness, restless legs, peripheral neuropathy, pruritis, urinary urgency, urinary frequency, nocturia, dysuria

height, weight, orthostatic vital signs, volume assesment (rales, JVD, peripheral edema, cardiac gallop/rub), vascular exam (pulses, bruits), abdominal exam (mass, bruit, palpable bladder, flank tenderness), DRE (prostate), Neurologic exam, skin exam (look for uremic frost), smell breath (uremic fetor), joint exam

stage 5 and ALL uremic pericarditis pts; need to get access (AV fistula) in stage 4

cimetidine (tagamet) and sulfa drugs like Bactrim

therapy based on stage of CKD, management of underlying conditions!!!!, interventions to slow progression of CKD, reduction of CV risk factors, treatment of complications, preparation for kidney failure and kidney replacement therapy

medication review at all visits!-- dosage adjustments, detection of drug interactions, therapuetic drug monitoring if possible, id potentially adverse effects on kidney function

15-30% rise in serum creatinine, then they typically will return to baseline in 4-6 weeks, can generally continue therapy as long as GFR doesn't rise more than 30%

use liver metabolized ones whenever possible (metoprolol, propanolol, labetalol, carvedilol)-- no renal adjustment necessary. Hydrophilic ones need dose adjustments

diltiazem and verapamil may help but not nifedipine and amlodipine (can make proteinuria worse)

acetaminophen generally considered safe (metabolized by the liver); other analgesics like demerol, darvon, morphine, tramadol, and cocaine should not be used in stage 4 or 5 CKD bc metablolites may accummulate causing CNS and respiratory adverse effects; also need dosing adjustment for CKD stage 2 and 3; avoid extended release ultram in CKD pts stage 3, 4, and 5

short-term use ok as long as well-hydrated and renal function is ok (no CHF, DM, or HTN); AE: HYPERKALEMIA (can make it worse than it already was), peripheral edema, higher blood pressure, decompensation of CHF, risk of ARF 3x higher

kidney damage with normal or increased GFR: >90

kidney damage with mild decrease in GFR (60-89)

moderate decrease of GFR (30-59)

severe loss of GFR (15-29)

kidney failure (<15 or dialysis)

monitor GFR annually, smoking cessation, ECASA 81mg po daily, ACE-I and/or ARB, BP goal (<130/80), LDL-C goal <100

same as stage I, consider nephrology referral if GFR declines >4 mL/min/year, evaluation by renal nutritionist (specific recommendations on protein, salt, water, potassium, and phosphorus intake)

everything previously stated plus consult nephrology, referral for vascular access, CKD patient education classes

renal replacement therapy, not a cure, treatment of chronic condition, hemodialysis-- vascular access before need arise, peritoneal dialysis possible, transplant= best solution but not a cure, better survival

nutritional status: albumin (low), pre-albumin, creatinine (high)

metabolic acidosis

a person with CKD is 70% more likely to develop CAD

a person with CKD is 2 to 3x more likely to develop CHF

a person with CKD is 74% more likely to develop TIA/CVA

CKMB will go up, serum Cr will be normal (the kidneys aren't affected)

LDLs <100, triglyceride level <200

every visit

Cockcroft-Gault ad MDRD (used at LSU, preferred-best available)

overweight, underweight, children, extremes in muscle mass or nutritional status

have to work it up, can't assume it is related to kidneys, will be normocytic/normochromic; consider EPO treatment if uncorrected with Fe replacement (Hgb <10); monitor risks of thrombotic embolism