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CKD is defined as either kidney damage or GFR less than
a) 15 ml/min/1.73m^2
b) 30 ml/min/1.73m^2
c) 60 ml/min/1.73m^2
d) 90 ml/min/1.73m^2
for at least 3 months
c) 60 ml/min/1.73m^2
What's the GFR of stage 1 CKD?
1: at least 90 ml/min/1.73m^2
2: 60-89
3: 30-59
4: 15-29
5: < 15
If you're on dialysis, what stage of CKD are you in?
5
Top 4 causes of ESRD
1: DM
2: HTN
3: Glomerulonephritis
4: Cystic kidney
How do you get AGEs in the glomerular mesangium and basement membrane?

AGE = advanced glycosylation end products
Nonenzymatic glycosylation to glomerular proteins
Diabetics get hyaline narrowing of the efferent artery. What's that do?
Hyperfiltration
leads to increased intraglomerular hypertension
ischemic injury
What causes Mesangial Expansion?
AGEs
Diabetic Nephropathy Risk factors
Older age at onset
Poorly controlled HTN or DM
Blacks, Mexican-Americans, and Pima Indians
GFR with hyperfiltration
Genetics
1st degree relative with DN
The earliest detectable sign of diabetic nephropathy is _____
microalbuminuria
Will you see hematuria in diabetic nephropathy?
maybe
BP goal for pt with Diabetic Nephropathy
BP goal < 130/80
BP goal < 125/75 if proteinuria > 1 gram
treatment of diabetic nephropathy
Control degree of proteinuria
Glycemic control
Anti-HTN control
ACEI or ARB
Weight loss
Lipid-lowering drugs
What's the dark side of "Benign" Nephrosclerosis?
more prominent proteinuria can occur, occasionally reaching as high 10 g/day with such affected patients more likely to have superimposed renovascular disease.
6 etiologies of Chronic Interstitial Nephritis
Analgesic use
Chronic urinary tract obstruction
Sickle Cell disease
Granulomatous Disease i.e. Sarcoid
Heavy Metals (lead, mercury, cadmium)
Lupus
Signs and symptoms of Chronic Interstitial Nephritis
frequency
nocturia
Urinalysis maybe normal
pyuria
mild proteinuria
low SG

moderate to advanced disease:
Hypertension and anemia
nephrotic syndrome
Ischemic Nephropathy is Associated with systemic atherosclerosis:
Physical exam may yield carotid, aortic or femoral _____.
bruits
Ischemic Nephropathy:

Describe pt's BP, race, smoking, age, lungs, etc
Hypertension that is often difficult to control.
White race, smoking history, and age over 50.
Progressive unexplained renal failure, with occasional acute deterioration
A unilateral small kidney, which has a 75 percent correlation with the presence of large vessel occlusive disease.
Recurrent pulmonary Edema
What disease should you expect if your pt has an
acute decline in renal function following therapy with an ACE inhibitor or ARB
Ischemic Nephropathy
Extra-renal manifestations of autosomal dominant PKD
hepatic cysts,
Diverticular disease
Abdominal wall hernias
Valvular disorders-MVP/AR
Intra-cerebral berry aneurysms
How old do you have to be before the PKD can be ruled out by U/S?
older than 30 to 35
Patients at risk for developing CKD
HTN
Cardiovascular disease
DM
Age > 60
FH
Recurrent UTI
Exposure to certain drugs
NSAIDs
Antibiotics
contrast agents or chemicals
A diabetic's GFR is 140ml/min. Is that okay?
No, it's hyperfiltration.
after some time the glomerulus will burn out.
Creatinine 1.9 with ACE or ARB.

What if it bumps to 2.1?
Don't worry. Keep him on his ACE or ARB
Why is sCr is not an accurate marker of GFR?
Secretion by proximal tubule
Altered by drugs (cimetidine, Septra)
Varies with protein intake, gender, ethnicity, body weight, muscle mass
Non-linear relationship between sCr & CrCl
Can plot 1/sCr vs time
Cockroft-Gault
GFR estimating eqn
CrCl(cc/min) = (140-age)Kg / (sCr x 72) x .85 for females
MDRD GFR estimating eqn
GFR (cc/min/1.73m2) = 186 (sCr)-1.154 (age)-0.203 (0.742 if female) (1.120 if AA)
Normal proteinuria def
<150 mg/day (<20mg/d=Albumin)
Microalbuminuria definition
30-300 mg/day
Macroalbuminuria or Overt proteinuria def
>300 mg/day
Heavy proteinuria def
>3 grams/day
Nephrotic Range
>3.5 grams/day
All proteinuria values are based on a body surface area of what?
1.73 m2
color of proteinuria
turns yellow to green if protein present
How might you get a false positive proteinuria?
Alkaline urine (urine ph >7.5)******
Specimen contaminated by chlorhexidine detergent
Dipstick immersed too long
Medications
Penicillin
Sulfonamide
Tolbutamide
How do you Delay progression of CKD?
Control HTN
BP < 130/80, < 120/70 if proteinuria
Reduce proteinuria: < 0.5 – 1 g/day
Control DM: AIC < 7%
Use ACE I / ARB
Control Lipids: LDL < 70
Quit smoking
K/DOQI's recommendation for target BP in CKD
less than 130/80
How does ACE-I transiently drop a GFR?


Goljan:"ACE-I's have a dark side"
by dilating the efferent arteriole
4 types of ACE-I side effects
1) interfering with the activity of the renin-angiotensin-aldosterone system

2)interfering with the activity of other enzymes and receptors

3) allergic reactions

4) effects on the fetus
____% of CKD pts have CAD at start of HD
often accelerated atherosclerosis
40
Best way to measure GFR is to use a ___-based formula
creatinine
if you have a woman with CKD with a GFR with 41 ml/min, what do you do?

(bad question, I know)
screen for comorbidities
compolications of uremic complications
anemia
acidosis
malnutrition
bone mineral metabolism
when do you screen for anemia in CKD (what stage)?
stage 3 (GFR< 60)
Treatment of Anemia in CKD:

When do you start?
Do not need an EPO level to start treatment
Hematocrit < 33%
If H/H fails to improve and no increase in reticulocyte count
Most common cause is Iron deficiency
Recheck B12, folate, PTH, Aluminum
What would not be seen when GFR is less than 25 ?
circulating levels of 1, 25 OH vitamin D
Active vitamin D (1,25-OH Vit D) is not made. what happens to phosphate excretion?
There is impaired urinary phosphate excretion
What's bad about not getting rid of phosphate?
Calcium and phosphorus can complex together and deposit in organ tissue
1º vs. 2º Hyperparathyroidism
Both have an elevated PTH
Primary is hypercalcemic
Secondary is hypocalcemic or normal
AT What GFR do you check PTH?
30-59 (Stage 3)
What is normal PTH?
12-60


but there are many qualifications of what is target
Start dialysis when?
AEIOU
GFR < 15 ml/min-DM
< 10 ml/min
Symptoms of uremia
Options for a patient faced with Stage V CKD
Renal Replacement Therapy
Hemodialysis
Peritoneal Dialysis
Renal Transplantation
Death
Start dialysis
Most important thing to take from Acute RF lecture
can't make assumption of acute vs chronic CKF based on one creatinine value
Acute renal failure is characterized by a deterioration of renal function over a period of ___
hours to days,
Reversibilty of Acute renal failure
Generally Reversible
Azotemia:
↑blood urea nitrogen not from an intrinsic renal disease
Oliguria vs non
Non-oliguria: Urine output > 400 ml/24 hours
Oliguria: Urine output < 400 ml/24 hours
• Anuria definition
Urine output < 50 ml/24 hours
How do you get anuria
– Most commonly: shock and complete bilateral urinary tract obstruction.
– Less commonly: hemolytic-uremic syndrome, renal cortical necrosis, bilateral renal arterial obstruction, and crescentic or rapidly progressive glomerulonephritis, particularly anti-GBM antibody disease.
– BUN:Creatinine ratio ≥ _____ is consistent with pre-renal azotemia
20:1
What is the matrix of renal casts?
– Their matrix is the Tamm-Horsfall glycoprotein which is physiologically secreted by the TAL
What do different casts mean?

– Hyaline casts-
– Granular casts-
– RBC Casts-
– WBC casts-
–
– Hyaline casts-Normal
– Granular casts-ATN
– RBC Casts-Glomerulonephritis
– WBC casts-Acute Interstitial Nephritis
– urinary electrolytes and creatinine to calculate FeNa
ATII for
a) efferent vasoconstriction
b) afferent dilatation
a) efferent vasoconstriction
PGE2 for
a) efferent vasoconstriction
b) afferent dilatation
b) afferent dilatation
When ATII and PGE2 are blocked, what happens to GFR?
drops
causes of pre-renal azotemia
• Decreased intravascular volume
• Decreased cardiac output
• Peripheral vasodilatation
• Increased renal vascular resistance
• Decreased intraglomerular pressure
• ACE/AT II inhibition
• Decreased intravascular volume
– Hemorrhage
– Renal losses
• Osmotic diuresis “GUM”
• Diabetes Insipidis
• Salt wasting nephritis
– GI losses
• Vomiting and diarrhea
– Insensible losses
– 3rd spacing
• Burns
• Pancreatitis
• Peritonitis
• Ileus
If you have hemolysis, what clogs up the kidney?

If you have a crush injury, what clogs up the kidney?
• Hemoglobin (hemolysis)
• Myoglobin (rhabdomyolysis)
Causes of • Acute Tubular Necrosis
– Ischemic (50%)
– Nephrotoxic (35%)
– Pigment
Diff b/w coarse granular and fine granular casts
fine: had more time to pass thru tube and smooth out.

coarse: happened quick
How long does ATN last usually?
• Generally lasts 7 to 21 days
Do you use diuretics to convert oliguric ATN to non-oliguric ATN?
DOES NOT DECREASE MORTALITY OR ALTER LIKELIHOOD OF RECOVERY
Why would you give diuretics to ATN pt?
• Used simply to make more room for medications and nutrition
Treat ATN with • Dopamine?
– Not helpful, may be harmful
Treat ATN with • Mannitol ?
– cell swelling and increasing intratubular flow might decrease intratubular obstruction and mitigate renal dysfunction.
– May be useful in prevention and treatment of early myoglobinuric acute renal failure.
– This agent is also used together with adequate hydration in an attempt to prevent the nephrotoxic effects of cisplatin.
– Effective in animals to help protect the kidney against ischemic injury, but studies in humans have failed to demonstrate any effectiveness in the prevention or treatment of ischemic or toxic acute renal failure.
Dialysis (AEIOU) stands for what?
• Acidosis
• Electrolytes (mainly K+)
• Intoxicants
• Overload
• Uremia
• Intoxicants (LISA MET BARB)
– LIthium
– SAlicylates
– Methanol
– Ethylene Glycol
– Theophylline
– BARBituates