Updated: 10/17/2018

Chronic Kidney Disease (CKD)

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Snapshot
  • A 54-year-old man presents to his primary care physician with chest pain. His chest pain began approximately 2 weeks ago and worsens when taking deep breaths. He reports that sitting up and leaning forward improves his symptoms and that his chest pain is not associated with exertion. He says that his symptoms are associated with mild shortness of breath and fatigue. Medical history is significant for type 2 diabetes mellitus, hyperlipidemia, and hypertension. He has been non-adherent to his medications. Social history is notable for smoking 1 pack of cigarettes per day for 20 years. Vital signs are significant for a blood pressure of 163/112 mmHg. On physical examination, there is a pericardial friction rub and peripheral edema. On laboratory testing, his glomerular filtration rate (GFR) 48 mL/minute/1.73 m2.
Introduction
  • Clinical definition
    • chronic kidney disease (CKD) describes abnormalities in kidney structure or function occuring for > 3 months
      • e.g., glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2 for > 3 months 
      • when CKD requires renal transplantation or dialysis, the patient is said to have end-stage renal disease (ESRD)
  • Epidemiology
    • incidence
      • 1 in 10 American adults have some form of CKD
    • risk factors
      • older age
      • diabetes mellitus
      • hypertension
      • acute kidney injury
      • microalbuminuria or proteinuria
      • overweight or obesity
      • smoking, alcohol, and drug abuse
  • Etiology
    • insults that result in renal damage
      • e.g., diabetes mellitus, autoimmune disease (such as lupus), and hypertension
  • Pathogenesis
    • in normal conditions
      • the kidneys have the ability to maintain glomerular filtration rate (GFR) in the setting of nephron loss
        • this is accomplished by hyperfiltration and hypertrophy of the remaining nephrons
        • when GFR decreases to 50% there will be an increase plasma substances such as creatinine and urea
    • a number of sequela occur as the GFR continues to decrease such as 
      • hyperkalemia
      • metabolic acidosis
      • normochromic normocytic anemia
        • secondary to decreased synthesis of erythropoietin
      • secondary hyperparathyroidism
      • hyperphosphatemia
      • hypocalcemia 
        • secondary to decreased hydroxylation of 25-hydroxyvitamin D to calcitriol
      • impairment of sodium and free water excretion
        • this results in extracellular fluid (ECF) expansion and total-body volume overload
          • this leads to peripheral and pulmonary edema and hypertension
  • Prognosis
    • typically progressive loss of renal function and may result in ESRD
Presentation
  • Symptoms
    • typically asymptomatic in early stages of the disease
    • clinical presentation secondary to uremia include
      • fatigue
      • nausea and vomiting
      • pruritis
      • chest pain
        • secondary to pericarditis or pleuritis
      • seizure
  • Physical exam
    • hypertension
    • uremic frost
    • growth retardation in children
    • peripheral edema
    • osteitis fibrosa cystica
    • osteomalacia
    • "renal rickets"
Imaging
  • Renal ultrasound
    • indication
      • considered the first-line imaging modality when working up a patient with CKD
      • used to evaluate between obstructive and intrinsic parenchymal disease
      • to assess for retroperitoneal involvement and renal cysts
Studies
  • Labs
    • complete blood count (CBC)
      • can see normochromic, normocytic anemia
    • basic metabolic panel
      • ↑ blood urea nitrogen (BUN), creatinine, and potassium
    • ↑ phosphate
    • ↑ parathyroid hormone
    • ↓ calcium
    • ↓ calcitriol
    • cystatin C
      • it is secreted but not reabsorbed
      • an endogenous marker of renal function
    • urine studies
      • to assess for proteinuria
      • can see waxy-casts on urinalysis in patients with ESRD and CKD
  • Biopsy
    • percutaneous renal biopsy is typically performed when there is renal impairment (or nephrotic range proteinuria) and the diagnosis is unclear after extensive workup
Differential
  • Acute on chronic kidney disease
Treatment
  • Conservative
    • protein restriction
      • indication
        • a method of managing dietary protein that may reduce the rate of renal decline
  • Medical
    • ACE inhibitors or ARBs
      • indications
        • considered first-line for strict blood pressure control
          • blood pressure goal of < 130/80 mmHg
          • blood pressure control can help delay worsening of CKD
        • to manage proteinuria in patients with diabetic kidney disease
    • vitamin D supplementation
      • indication
        • for prevention and treatment of secondary hyperparathyroidism
    • erythropoiesis-stimulating agent
      • indication
        • can be considered to manage anemia in patients with CKD
          • hemoglobin goal is 10-12 g/dL
    • phosphate binders
      • indication
        • to treat hyperphosphatemia in patients with CKD
    • statins
      • indication
        • used as cholesterol lowering therapy in patients with CKD
    • dialysis
      • indication
        • in patients with severe metabolic acidosis, hyperkalemia, pericarditis, intractable volume overload, and encephalopathy
  • Operative
    • renal transplant
      • indication
        • a treatment option for patients with CKD
Complications
  • Anemia
  • Mineral and bone disease
  • Hypertension
  • Hypervolemia
  • Depression
  • Cardiovascular disease
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RL.44) A 65-year-old man with a longstanding history of poorly-controlled hypertension and no recent illness or cardiac disease presents to clinic complaining of chest pain that is worse on inspiration and relieved by sitting forward. Vital signs are stable. On exam, you detect a friction rub. Routine labs show K 7.5 and Cr 5.1. If this patient's clinical signs and laboratory findings are indicative of a chronic condition, what would be expected on urinary analysis? Review Topic

QID: 104491
1

Muddy brown granular casts

25%

(4/16)

2

Red blood cell casts

12%

(2/16)

3

White blood cell casts

25%

(4/16)

4

Fatty casts

0%

(0/16)

5

Broad and waxy casts

38%

(6/16)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M1.RL.12) A 55-year-old man with a history of chronic glomerulonephritis due to IgA nephropathy presents to your office with bone pain. Which of the following laboratory findings would you most expect upon analysis of this patient's serum? Review Topic

QID: 100966
1

Increased PTH, decreased calcium, increased phosphate, decreased calcitriol

61%

(55/90)

2

Decreased PTH, increased calcium, increased phosphate, increased calcitriol

6%

(5/90)

3

Increased PTH, increased calcium, decreased phosphate, decreased calcitriol

13%

(12/90)

4

Decreased PTH, decreased calcium, increased phosphate, decreased calcitriol

9%

(8/90)

5

Normal PTH, normal calcium, normal phosphate, normal calcitriol

8%

(7/90)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.RL.56) A 72-year-old female recently fractured her hip in a fall. She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density. She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease. Serum phosphate levels are markedly elevated. Which of the following likely contributes to her orthopedic problems? Review Topic

QID: 101010
1

Decreased serum aldosterone

4%

(3/78)

2

Increased serum parathyroid hormone

83%

(65/78)

3

Increased serum glucose

6%

(5/78)

4

Chronic hypertension

4%

(3/78)

5

Chronic hypovolemia

0%

(0/78)

M1

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PREFERRED RESPONSE 2
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