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chronic kidney disease
RPM I
39
Medical
Graduate
05/04/2010

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Term
what is renal insufficiency? renal failure?
Definition
renal insufficiency: a measurable reduction in renal function. renal failure: a further reduction to the point that biochemical homeostasis cannot be maintained
Term
what is azotemia?
Definition
increased BUN
Term
what is uremia?
Definition
symptoms of kidney failure
Term
what is oliguria?
Definition
less than 400 mL of urine/day
Term
what is anuria?
Definition
less than 100 mL urine/day
Term
what is chronic kidney disease defined as?
Definition
kidney damage for 3+ months, as defined by 1) structural or functional abnormalities (even if GFR is normal) manifested by: pathologic abnormalities, markers of kidney damage (blood/urine testing/imaging techniques) OR 2) if GFR is <60 for 3+ mo with or without kidney damage
Term
what are the current stages for CKD?
Definition
stage 1: GFR >90, stage 2: GFR 80-60, stage 3: GFR 59-30, stage 4: GFR 29-15, stage 5: renal failure/dialysis/GFR <15. stage 1-2 are not really a problem, other than the fact that they lead to 3,4,5
Term
are rates of CKD in the US increasing?
Definition
yes
Term
how do CKD and CHF compare in terms of % of total medicare budget?
Definition
CHF: 35%, CKD: 25%
Term
what is the link between CVD and CKD?
Definition
risk of CVD is increased up to 2x w/creatinine 1.4-1.5 or microalbuminuria (between 30 and 300 is microalbuminuria). annual mortality from CVD is incresaed 100x w/kidney failure
Term
are certain ethnic groups more susceptible to developing CKD?
Definition
yes, african americans are a higher risk for ESRD (end stage renal disease), potentially due to the fact that DM and HTN are more prevalent in this population
Term
what is the intact nephron hypothesis?
Definition
the concept that each nephron is either a fully functional unit or does not function. surviving nephrons can increase their functional capacity by undergoing hypertrophy
Term
what is the general progression of CKD?
Definition
basically anything that changes total nephron mass will be associated with CKD progression. the intact nephrons will vasodilate, increasing protein/blood sugar intake along with pressure resulting in glomerular hyperfiltration and increasing membrane permeability. this leads to increased protein flux – albuminuria, which can cause mesangial cell injury, leading to cellular proliferation, followed by glomerular sclerosis (endpoint of all these injuries)
Term
what are the six mechanisms of renal disease progression?
Definition
1) persistent glomerular injury leading to glomerular HTN and increased single nephron GFR 2) protein leak increasing angiotensin II 3) downstream cytokine bath 4) neutrophils, then macrophages, T cells leading to interstitial nephritis (*even though glomerular filtration rate is going down, much of pathology is in the interstitial areas) 5) tubular epithelium respond by detaching from BM and forming new interstitial fibroblasts 6) surviving fibroblasts lay down collagenous matrix, disrupting adjacent tubules and surrounding vessels - leaving an acellular scar
Term
what characterizes the pathogenesis of albuminuria in terms of nephropathy?
Definition
the BM becomes less anionic, and is less able to repel proteins (also anionic), capillary pressure increases, the mesangium expands, the glomerular capillary BM thickens, and interstitial fibrosis occurs - further compromising blood flow
Term
are lipids contributing agents to CKD?
Definition
yes. oxidized LDLs, LpA impair endothelial function and attenuate vascular tone and oxizides lipoproteins stimulate O2 production which inactivates NO
Term
how does angiotensin II contribute to renal disease?
Definition
angiotensin II will increase intraglomerular pressure, SMC proliferation, mesangial cell proliferation, Na+ reabsorption, activation of inflammatory transcription factor NF-kB, vascular endothelial cell proliferation, transforming growth factor beta, nephrosclerosis/interstitial fibrosis, ECM levels, expression of vasoactive factors, and aldosterone (therefore, a lot of therapy is aimed at reducing angiotensin II)
Term
what are the effects of high aldosterone levels, such as those seen in CKD?
Definition
aldosterone increases: K loss, Na retention, plasminogen activator inhibitor 1 (decreased fibrinolysis), proinflammatory COX-2/osteopontin, norepi, endothelial dysfunction, and decreases vascular compliance. *this all leads to an increased risk of: stroke, renal failure, and CAD/MI (major culprit in progression of disease)
Term
what are reversible conditions that may eventually lead to chronic renal failure?
Definition
anatomic, obstructive, vascular, HTN, RAS, and infection
Term
what are reversible conditions that may quickly lead to chronic renal failure?
Definition
increased Ca++, increased uric acid, decreased K+, primary glomerulopathies, nephrotoxins, vasculitis, and connective tissue diseases
Term
what are conditions that may aggravate chronic renal failure?
Definition
acidosis, CHF, increased Ca++, HTN, infection, decreased K+, obstruction, hypotension, hypovolemia, pericardial effusion/tamponade
Term
is PTH an important mediator of CKD?
Definition
yes, there is increased tubular PO4 which cuts down 1-alpha-hydroxylase activity (=less active 1-25-dihydroxy vitamin D), which stimulates hyperPTH via gene transcrption b/c of decreased calcitriol and subsequent increased PTH gene transcription (secondary hyperparathyroidism)
Term
what is the trade off hypothesis?
Definition
a description of how hyperparathyroidism occurs in CKD: *every time the GFR drops - PO4 levels increase*, causing Ca++ levels to drop. decreased Ca++ causes increased PTH, which raises Ca++ again, and levels out PO4, until the next GFR drop. this keeps everything pretty even, but just includes a progressive decrease in GFR and increase in PTH
Term
what are the consequences of secondary hyperparathyroidism?
Definition
renal osteodystrophy, myopathy, dermatological manifestations, neurological manifestations, anemia, CHF, and *vascular calcification*
Term
what are some of the skeletal manifestations of hyperparathyroidism?
Definition
rugger jersey spine, calvaria, demineralization of the skull, lost lamina dura of teeth, subperiosteral bone reabsorption in fingers, loss of distal clavicle (radiolucent) -> all due to Ca++ loss
Term
how is soft tissue affected by hyperparathyroidism?
Definition
deposits of calcium phosphate salts in the kidney, lung, the eye (keratinopathy), and vasculature
Term
how is hyperparathyroidism secondary to CKD treated?
Definition
phosphate binding compounds: calcium supplements (calcium carbonate and calcium acetate) or non-calcium supplements (sevelamer, lanthanum), vit D supplements (do decrease stimulation of PTH secretion, but can raise Ca++ levels), and cinacalcet (calimimetic agent that mimics the affects of elevated Ca++ levels - fairly effective in dropping PTH)
Term
what are CV manifestations of CKD?
Definition
accelerated ASCVD, HTN, CMP, LVH, and pericardial disease
Term
what are the hematologic consequences of chronic renal failure?
Definition
*anemia (due to decreased RBC production/decreased erythropoietin, marrow fibrosis, Fe/folate deficiencies, inhibitors), hemolysis, blood loss, bleeding tendencies (platelet dysfunction/anemia), and altered neutrophilic chemotaxis/depressed lymphocyte function
Term
what are neurologic manifestations of CKD specific to the CNS?
Definition
CNS: decreased level of consciousness, sleep reversal, coma, decreased memory, decreased attentiveness/cognitive tasking, asterixis, myoclonus, and seizures
Term
what are neurologic manifestations of CKD specific to the PNS?
Definition
peripheral neuropathy, singultus, muscle fatigue, and muscle cramps
Term
are pulm manifestations of CRD significant?
Definition
not really, but atypical pulm edema, pneumonitis, and pleuritis are possible
Term
what are GI manifestations of CRD?
Definition
anorexia, N/V, stomatitis, parotitis, gastritis, enterocolitis, and pancreatitis (rare, but lethal)
Term
what are dermatological manifestations of CRD?
Definition
uremic calcific arteriolopathy/calciphylaxis - causes necrosis of the skin and kyrle's disease (hyperkeratosis follicularis), not lethal, but itchy and common
Term
what are endocrinological manifestations for CRD?
Definition
secondary hyperparathyroidism, carb intolerance (due to insulin resistance, vit D derivatives can help), type IV hyperlipidemia, altered thyroxine metabolism, testicular atrophy, and ovarian dysfunction (most pts are sterile)
Term
how is acid-base regulation affected by CRD?
Definition
impaired excretion of PO4, sulfates. decreased ammonia synth. impaired bicarb reabsorption. decreased distal H+ secretion. and reduced excretion of titratable acid = all this can be improved with bicarb (HCO3) supplementation
Term
what are tx considerations for CRD?
Definition
ACE inhibitors, ARBs, renin antagonists, (all these address HTN, proteinuria, DM), aldoesteron antagonists, erythropoietin, & diet (protein, phosphorus restriction). (**regardless of reason for kidney disease, aggressive blood pressure control – for blood pressures around 120/70ish is the most important thing that can do)
Term
what does renal replacement therapy consist of?
Definition
dialysis (hemodialysis or peritoneal dialysis) or transplantation
Term
what does peritoneal dialysis do?
Definition
uses your own peritoneal membrane to dialyse blood
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