Chronic Kidney Disease, treatment
questions with correct solutions
Definition of CKD ✅✅GFR <60 ml/min for > 3 months with or without markers of
kidney damage
OR
Signs of renal failure seen on imaging or urinalysis (regardless of GFR) for more than 3
months. This includes microalbuminuria.
Donation from brain dead donor ✅✅Heart
Lungs
Liver
Intestines
Stomach
Pancreas
Kidneys
eye
bone
tissue
Donation from after cardiac death ✅✅Liver
kidneys
pancreas
eye
bone
tissue
Controlled Cardiac death donation ✅✅eye
bone
tissue
Blood supply for transplanted kidney ✅✅Iliac artery
Human kidney uses convection or diffusion? ✅✅Exclusively convection
(ultrafiltration): fluid filtration through a porous membrane with the clearance directly
related to the volume of fluid removed
Dialysis uses convection or diffusion? ✅✅Mostly diffusion, but some convection.
In diffusion: The rate of mass transfer between 2 compartments separated by a semi-
permeable membrane determined by the characteristics of the membrane and the
solute concentration gradient between the 2 compartments : plasma and dialysate
compartments
,For any given serum creatinine who has better GFR? ✅✅Males > females
Black > white
Young > old
This is all based on higher muscle mass.
Risk for CVD in CKD ✅✅Higher stage of CKD has higher risk for CVD.
Atrial fibrillation and stroke risk is very high in those on dialysis.
Stages of CKD ✅✅Stage 0: Increased risk group, no measurable change in GFR or
evidence of disease
Stage 1: GFR >90 but some evidence of kidney damage, cysts, or proteinuria. No GFR
decline.
Stage 2: GFR <90 with evidence of disease.
Stage 3: GFR <60
Stage 4: GFR <30
Stage 5: GFR <15 or dialysis
ESRD: dialysis or transplant required
Stage 4 CKD ✅✅GFR <30
Stage 5 CKD ✅✅GFR <15 or dialysis
Stage 3 CKD ✅✅GFR <60
Stage 1 CKD ✅✅GFR >90 but some evidence of kidney damage, cysts, or
proteinuria. No GFR decline.
Stage 0 CKD ✅✅Increased risk group, no measurable change in GFR or evidence of
disease
Normal 24 protein excretion ✅✅<150 mg in 24 hours
Most of this is Tamm-horsfall proteins.
10-30mg is albumin.
Microalbuminuria ✅✅Still total protein less than 150mg in 24 hours
But, albumin is represented in a larger percentage (30-300 mg)
This means there something going on in the glomerulus (early injury) that is allowing
albumin to pass more readily.
How to test for micro/macro albuminuria ✅✅Spot ratio of albumin/Creatinine
Microalbuminuria: early glomerular injury
, 30-300 mg albulmin / g creatinine
Macroalbuminuria: advanced glomerular injury
>300mg albumin / g creatinine
Macroalbuminuria ✅✅More advanced damage to the glomerulus.
> 300mg albumin in the urine.
Ultrasound evidence of CKD ✅✅Increased echogenicity
No cortico-medullary differentiation
Kidney may be small
Waxy casts ✅✅Never normal
Indicative of CKD
Accumulation of Tamm-horsfall protein over time.
Risk factors for CKD ✅✅Ethnicity: black
Diabetes mellitus (1 or 2): highest risk factor
Systemic hypertension
Family history kidney disease
Autoimmune disease (SLE)
Elderly
Normal rate of kidney function decline ✅✅0.8 cc/min/year above age 40
GFR will reduce but they may not actually have kidney disease.
% of preventable CKD ✅✅72% preventable because it is due to uncontrolled HTN or
DM2
Intact nephron hypothesis ✅✅The pool of functioning nephrons diminishes with CKD.
Each remaining nephron hypertrophies and hyperfunctions to pick up the work load.
1. Compensatory hyperfiltration: each nephron increases its own GFR and maintain
GFR of the renal system
2. Ammonia generation: each nephron proximal tubule increases their own
ammonia/urea/H+ secretion to maintain the BUN (prevent azotemia > uremia)
3. Each nephron increases its own H20 and Na excretion to maintain water balance
Compensatory hyperfiltration ✅✅Increase the capillary pressure in the glomerulus.
Dilate the afferent vessel (NO, PGE2/PGI2) = increase Pgc.
Constrict the efferent vessel (AngII) = increase Pgc.
questions with correct solutions
Definition of CKD ✅✅GFR <60 ml/min for > 3 months with or without markers of
kidney damage
OR
Signs of renal failure seen on imaging or urinalysis (regardless of GFR) for more than 3
months. This includes microalbuminuria.
Donation from brain dead donor ✅✅Heart
Lungs
Liver
Intestines
Stomach
Pancreas
Kidneys
eye
bone
tissue
Donation from after cardiac death ✅✅Liver
kidneys
pancreas
eye
bone
tissue
Controlled Cardiac death donation ✅✅eye
bone
tissue
Blood supply for transplanted kidney ✅✅Iliac artery
Human kidney uses convection or diffusion? ✅✅Exclusively convection
(ultrafiltration): fluid filtration through a porous membrane with the clearance directly
related to the volume of fluid removed
Dialysis uses convection or diffusion? ✅✅Mostly diffusion, but some convection.
In diffusion: The rate of mass transfer between 2 compartments separated by a semi-
permeable membrane determined by the characteristics of the membrane and the
solute concentration gradient between the 2 compartments : plasma and dialysate
compartments
,For any given serum creatinine who has better GFR? ✅✅Males > females
Black > white
Young > old
This is all based on higher muscle mass.
Risk for CVD in CKD ✅✅Higher stage of CKD has higher risk for CVD.
Atrial fibrillation and stroke risk is very high in those on dialysis.
Stages of CKD ✅✅Stage 0: Increased risk group, no measurable change in GFR or
evidence of disease
Stage 1: GFR >90 but some evidence of kidney damage, cysts, or proteinuria. No GFR
decline.
Stage 2: GFR <90 with evidence of disease.
Stage 3: GFR <60
Stage 4: GFR <30
Stage 5: GFR <15 or dialysis
ESRD: dialysis or transplant required
Stage 4 CKD ✅✅GFR <30
Stage 5 CKD ✅✅GFR <15 or dialysis
Stage 3 CKD ✅✅GFR <60
Stage 1 CKD ✅✅GFR >90 but some evidence of kidney damage, cysts, or
proteinuria. No GFR decline.
Stage 0 CKD ✅✅Increased risk group, no measurable change in GFR or evidence of
disease
Normal 24 protein excretion ✅✅<150 mg in 24 hours
Most of this is Tamm-horsfall proteins.
10-30mg is albumin.
Microalbuminuria ✅✅Still total protein less than 150mg in 24 hours
But, albumin is represented in a larger percentage (30-300 mg)
This means there something going on in the glomerulus (early injury) that is allowing
albumin to pass more readily.
How to test for micro/macro albuminuria ✅✅Spot ratio of albumin/Creatinine
Microalbuminuria: early glomerular injury
, 30-300 mg albulmin / g creatinine
Macroalbuminuria: advanced glomerular injury
>300mg albumin / g creatinine
Macroalbuminuria ✅✅More advanced damage to the glomerulus.
> 300mg albumin in the urine.
Ultrasound evidence of CKD ✅✅Increased echogenicity
No cortico-medullary differentiation
Kidney may be small
Waxy casts ✅✅Never normal
Indicative of CKD
Accumulation of Tamm-horsfall protein over time.
Risk factors for CKD ✅✅Ethnicity: black
Diabetes mellitus (1 or 2): highest risk factor
Systemic hypertension
Family history kidney disease
Autoimmune disease (SLE)
Elderly
Normal rate of kidney function decline ✅✅0.8 cc/min/year above age 40
GFR will reduce but they may not actually have kidney disease.
% of preventable CKD ✅✅72% preventable because it is due to uncontrolled HTN or
DM2
Intact nephron hypothesis ✅✅The pool of functioning nephrons diminishes with CKD.
Each remaining nephron hypertrophies and hyperfunctions to pick up the work load.
1. Compensatory hyperfiltration: each nephron increases its own GFR and maintain
GFR of the renal system
2. Ammonia generation: each nephron proximal tubule increases their own
ammonia/urea/H+ secretion to maintain the BUN (prevent azotemia > uremia)
3. Each nephron increases its own H20 and Na excretion to maintain water balance
Compensatory hyperfiltration ✅✅Increase the capillary pressure in the glomerulus.
Dilate the afferent vessel (NO, PGE2/PGI2) = increase Pgc.
Constrict the efferent vessel (AngII) = increase Pgc.
