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Chronic Kidney Disease - Coggle Diagram

- - - - --> renal injury ischemia and systemic hypertension
        --> loss of nephrons
        --> increased angiotensin II
        --> glomerular capillary hypertension
        --> increased glomerular permeability and filtration
        --> proteinuria
        --> increased tubular protein reabsorption
        --> tubulointerstitial inflammation and fibrosis
        --> renal scarring
    - - Sodium and Water Balance
        
        Chronic renal failure causes sodium delivered to nephrons to increase, so excretion must increase; less is reabsorbed. Obligatory loss occurs, leading to sodium deficits and volume depletion. As GFR is reduced, ability to concentrate and dilute urine diminishes
      - Phosphate and Calcium Balance
        
        Changes in acid-base balance affect phosphate and calcium balance. Major disorders associated with chronic renal failure are reduced renal phosphate excretion, decreased renal synthesis of 1,25-dihydroxy-vitamin D3, and hypocalcemia
        
        Hypocalcemia leads to secondary hyperparathyroidism, GFR falls, and progressive hyperphosphatemia, hypocalcemia, and dissolution of bone result
      - Creatinine and Urea Clearance
        
        Chronic renal failure causes the GFR to fall and the plasma creatinine concentration to increase; no regulatory adjustment for creatinine causes plasma levels to continue to rise and serve as an index of changing glomerular function
        
        As GFR decreases, urea clearance increases
      - Hematocrit
        
        Anemia with chronic renal failure causes lethargy, dizziness, and low hematocrit
      - Proteinuria
        
        Glomerular hyperfiltration of protein contributes to tubular interstitial injury by accumulating in interstitial space and promoting inflammation and progressive fibrosis
      - Acid-Base Balance
        
        In early renal insufficiency, acid excretion and bicarbonate reabsorption are increased to maintain normal pH. Metabolic acidosis begins when GFR reaches 30%-40%
        
        Metabolic acidosis and hyperkalemia may be severe enough to require dialysis when end-stage renal failure develops
      - Potassium Balance
        
        Tubular secretion of potassium increases until oliguria develops
        
        Potassium-sparing diuretics also may cause elevated serum potassium levels
        
        As disease progresses, total body potassium levels can rise to life threatening levels and dialysis is required
      - Dyslipidemia
        
        Chronic hyperlipidemia may induce glomerular and tubulointerstitial injury, contributing to progression of chronic renal disease
  - - - Normal kidney function with normal or high GFR (>90 mL/min)
      - No symptoms, hypertension
    - - Mild kidney damage with mild reduction in GFR (60-89 mL/min)
      - Subtle S&S, hypertension, increasing creatinine and urea levels
    - - Moderate kidney damage, GFR (30-59 mL/min)
      - Mild S&S, same as Stage II
    - - Severe kidney damage, GFR (15-29 mL/min)
      - Moderate S&S, same as Stage II and III, deficiency in erythropoietin anemia, hyperphosphatemia, increased triglycerides, metabolic acidosis, hyperkalemia, salt/water retention
    - - End-stage kidney disease, established kidney failure, GFR < 15
      - Severe S&S
- - - - High blood glucose, blood sugar, can damage the blood vessels in the kidneys. When the blood vessels are damages, they don't work as well. Many people with diabetes also develop high blood pressure, which also damages the kidneys
    - - The nephrons in the kidneys are supplied with a dense network of blood vessels and high volumes of blood flow through them. Over time, uncontrolled high blood pressure can cause arteries around the kidneys to narrow, weaken, or harden. These damaged arteries are not able to deliver enough blood to the kidney tissue.
  - - - Can eventually progress to CKD
  - - - Increases capillary wall tension of the glomeruli (from hypertension and vasoconstriction)
      - Obesity may lead to the pathogenesis of kidney damage through inflammation, oxidative stress, endothelial dysfunction, prothrombic state, hypervolemia, and adipokine derangements
    - - Alcohol and drugs
- - - - End-Stage Renal Disease is about 3.7 times greater in African Americans, 1.4 times greater in Native Americans, and 1.5 times greater in Asian Americans
      - African Americans = 17.0%
      - Mexican Americans = 15.29%
      - Caucasians = 13.99%
    - - Women = 15.93%
      - Men = 13.5%
      - Women are more likely to have Stages I through IV CKD than men
    - - CKD has increased from 12% to 14% between 1988 and 1994 and from 1999 to 2004
      - Has remained relatively stable since 2004
    - - Ages 18-44 make up 7%
      - Ages 45-64 make up 13%
      - Ages 65+ make up 38%
- - - - < 60 possibly means kidney disease
      - < 15 is kidney failure
      - 60 is normal
  - - - Dipstick test
        
        Changes color if albumin is present
      - Urine albumin-to-creatinine ratio (UACR)
        
        Compares albumin to creatinine levels in urine
        
        30 mg/g or less is normal
        
        More than 30 mg/g could be kidney disease
- - - - Control BP if diabetic
      - Follow a low-salt, low-fat diet
      - Exercise at least 30 minutes most days of the week
      - Do not smoke or use tobacco
      - Maintain healthy weight
      - Avoid medications that may damage the kidneys
      - Treat UTI's
  - - - Erythropoetin supplements
        
        Procrit, Epogen
      - Iron supplements
    - - Diuretics
        
        Furosemide, Bumetanide
        
        See above for more information --> blood pressure medications
    - - Statins
        
        Atorvastatin
        
        PO: 10-80 mg/day
        
        Fluvastatin
        
        40 mg bid
        
        Adverse Effects: abdominal pain, rash, headache
    - - Calcium supplements
        
        Calcium carbonate/ calcium acetate
      - Vitamin D supplements
        
        Ergocalciferol
        
        Cholecalciferol
      - Phosphate binders
        
        Sevelamer
    - - ACE inhibitors
        
        Captopril
        
        PO: 25-150 mg bid-tid
        
        Enalapril
        
        PO: 2.5-5 mg/day, can increase to 10-40 mg/day
        
        IV: 0.625-1.25 mg every 6 hrs over 5 minute period
        
        Adverse Effects: fatigue, dizziness, mood changes, headaches, nonproductive cough, hyperkalemia, angioedema
      - Angiotensin II receptor blockers
        
        Losartan
        
        PO: 25-100 mg as single does or divided bid
        
        Adverse Effects: chest pain, fatigue, hypoglycemia, diarrhea, UTI, anemia, weakness
      - Diuretics
        
        Bumetanide
        
        1 mg equipotent to 40 mg furosemide
        
        Furosemide
        
        IM/IV: 20-40 mg/dose
        
        PO: 20-120 mg/day
        
        Adverse Effects: dizziness, headache, hypokalemia, dehydration and electrolyte loss