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standardized definition/diagnosis of CKD
structural or functional abnormalities of the kidneys for >=3 mo and manifested by either: kidney damage OR GFR <60ml/hr/1.73m2
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markers of kidney damage
- urine protein (albumin of globulin)
- albuminuria (normal <30mg/gmCr)
- -microalbuminuria 30-300
- -macro >300
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when to use MDRD
for screening and staging of CKD, ages 18-70yo, pts with diabetic kidney disease, chronic kidney disease in middle age, blacks with hypertensive chronic kidney disease, pts with kidney transplant
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when to use cockccroft-gault eq
used 4 adjusting drug therapy, preferred method, older pts
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24 hr urine-situations for use
extremeties of age, prego, malnutrition, skeletal muscle disease, para or quadriplegic, vegetarians and people with rapidly changing kidney fxn
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etiology-susceptibility factors for CKD
- elderly >60
- familyy hx of CKD
- ethnic minorities-african amer(4X), american indian (2X), hispanic (1.5), alaskan
- low income or education
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etiology-initiation risk factors
- diabetes(40-50% risk of CKD)
- HTN(systolic more indicative)
- autoimm disease
- envir toxins (i.e. heavy metal
- drug toxicity
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etiology-progression risk factors
- uncontrolled proteinuria
- uncontrolled BP
- poor glycemic control
- smoking
- -all associated with a faster rate of GFR decrease
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incidence of kidney failure by primary diagnosis in descending order
- diabetes
- HTN
- glomerulonephritis
- cystic kidney disease
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stage 1 kidney disease-description and GFR
kidney damage prob with markers with normal or dec GFR, >=90ml/min
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stage 2 CKD-desc and GFR
kidney damage with mild decr GFR, 60-89ml/min
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stage 3 CKD, desc and GFR
mod decr GFR, 30-59
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stage 4 CKD desc and GFR
severe decr GFR, 15-29ml/min
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stage 5 desc and GFR
kidney failure, <15 or RRT
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signs and sx of waste remove dysfxn
uremia and malnutrition
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signs and sx of RBC formation dysfxn
anemia
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signs and sx of bone health dysfxn
renal osteodystrophy
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signs and sx of acid base misbalance
metabolic acidosis is most common
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signs and sx of fluid and electrolyte imbalance
dehy, edema
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complications of stage 1 CKD
complications from initiating insult to kidneys
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complications of stage 2 CKD
HTN-also initiation factor and complication of CKD because CKD progression can result in HTN if not treated appropriately
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complications of stage 3 CKD
anemia, mild decr in serum calcium
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complications of stage 4 CKD
- hyperphosphatemia
- renal bone disease
- dyslipidemia
- neuropathy
- left ventricular hypertrophy
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complications of stage 5 CKD
uremia, malnutrition, metabolic acidosis
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traditional risk factors for CVD risk factors in CKD
advanced age, male, HTN, dyslipidemia, DM, tobacco use, menopause
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CKD-related risk factors for CVD risk
decr GFR, proteinuria, RAAS overactivity, fluid overload, abn calc and phos metabolism, anemia, inflammation, uremic toxins, homocysteinemia, malnutrition
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assess for CKD risk
- socio-demographic profile(older age, ethnic background, low income/education, family history)
- AND
- clinical profile(DM, HTN, autoimm diseases, recovery from acute renal failure-envir or drug-induced)
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evaluation of CKD-if at risk
- estimate GFR using MDRD,
- screen for proteinuria(albumin)-diabetes age 12-70 annually, pts with uncontrolled BP, persons with FH of CKD or >60 yrs of age of belong to ethnic risk group,
- stage,
- identify complications,
- screen for co-morbid conditions
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persistent proteinuria (albumin)
make sure persistent b4 make an intervention, albumin excretion >30 mg on 2 or more consecutive urine samples separated by at least 1-2 weeks
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disease management goals
- prevention
- slow progression
- prevent and treat complications
- manage co-morbidities
- timely referral
- RRT
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goal urea-reduction ratio (URR)
>=65%, reduction in urea from pre-dialysis to post-dialysis
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goal kinetic modeling formula Kt/V
>=1.2, determines adequecy of dialysis
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dextrose soln euvolemic
1.5%
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dextrose soln-edema + SOB
3.86%
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dextrose soln-severe SOB
4.25%
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volume PD dialysate-small
1-1.5L
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volume PD dialysate-average
2L
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volume PD dialysate, large
2.5-3L
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points for antigen mismatch
0-2 points, lower number of ags, higher points
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time waiting
1 point per yr
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panel reactive antibody >=80%
4 ppints
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pediatric points
3-4 points
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previous living donation
4 points
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delayed graft fxn
need for dialysis in the postop period or the failure of the serum cr to fall below 4mg/dl or 30% ofo pre-transplant value
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basiliximab (simulect), Daclizumab (Zenapax)
2nd dose anaphylaxis, moAb
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muromonab (OKT3)
1st dose rxn-cytokine release-give benadryl prophylaxis, moAb
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antithymocyte globulin
ATG-rabbit, ATGAM-equine, not equiv, thrombocy, leukopenia, polyclonal ab
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SEs of CSs
HTN, edema, wt gain, hyperglyc, osteopor, cataracts, leukocytosis, hypophos, delayed wound healing, acne, steroid psychosis, adren insuff, cushing's, growth retard, N/V
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azathioprine (AZA)
leukopenia, anemia, thrombocytopenia, lots of drug INX
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mycophenolate mofetil (MMF, CellCept)
GI (N/V/D), delayed wound healing, drug inx w antacids, iron, acyclovir
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cyclosporine
sandimmune and neoral w/ generics, CNS toxicity (tremor, seizures), nephrotox, hyperkal, hypomag, htn, dyslipi, gingivial hyperplasia, hirsutism
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tacrolimus, Prograf
similar SE to CsA plus plus transplant DM, similar drug inx to CsA
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sirolimus
profound dyslipidemia
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