1. Pathophysiology
   1. hyperfiltration theory
      1. damage to nephrons somehow (where does this damage come from?)
      2. increase in blood flow to intact nephrons
      3. increase in SNGFR (single nephron glomerular filtration rate
      4. increase in hydrostatic pressure
         1. hyperfiltration injury
         2. further nephron damage
         3. protein leaks out --> proteinuria and microalbuminuria
2. Staging of CKD
   1. stage 1
   2. stage 2
   3. stage 3
   4. stage 4
   5. stage 5
   6. Subtopic 6
3. Causative Factors
   1. diabetes
      1. diabetes
         1. hyperglycemia increases capillary endothelial dysfunction and membrane thickening
         2. glucose-protein conjugates accumulate in tissue causing abnormal structural protein function and vascular permeability resulting in renal damage
      2. glycemic control
         1. type 1
            1. goal is Hgb A1C < 6 %
         2. type 2
            1. ACCORD
            2. A1C of 7 - 7.5 is new target
   2. glomerular diseases (SLE, system infections, drugs)
   3. interstitial disease/cystic disease
   4. interstital diseases/cystic disease
   5. kidney grafts
   6. acute renal failure
4. Risk Factors for Progression of CKD (WHAT IS DIFFERENCE BETWEEN CAUSATIVE, RISK AND SUSCEPTIBLE)
   1. proteinuria
   2. hypertension
      1. second leading cause of CKD
      2. MRFIT and HDFP
         1. suggest good target mean arterial pressure of 98 mmHg (BP < 130/80)
         2. with proteinuria (>1gm/d) a BP target of 125/75
      3. HTN control
         1. diabetic HTN
            1. recommended treatment protocol
            2. use ACEI or ARB as primary treatment
            3. ACEI
            4. reduces glomerular capillary pressure and volume and preserves renal function
            5. begin w/ low dose; increase at 4 week intervals to reduce microalbuminuria
            6. ARBs
            7. work similarly to ACEI
            8. dose drug to albumin levels; don't just target BP
            9. if BP < 130/80 not met (JNC VII) add thiazide or loop diuretic
            10. add Ca channel blocker or B blocker if above does not work
            11. nondihydropyridine Ca channel blockers
            12. drugs
            13. verapamil
            14. diltiazem
            15. MOA
            16. decreases glomerular injury without changing renal hemodynamics
            17. mainly dilates afferent arterioles
            18. affects proteinuria
            19. many px will require 2-3 agents
         2. non-diabetic HTN
            1. ALLHAT trial
            2. diuretics, ACEI, ARBs all work
            3. ACEI have most data against progression to CKD
            4. recommended treatment protocol
            5. BP reduction is key to decreasing CV and renal complications
            6. ACEIs or ARBs 1st line in CKD px
   3. smoking
   4. hyperlipidemia
   5. obesity
5. Lab Tests
   1. Early Detection of CKD
      1. tests recommended for those at risk
         1. Susceptible for CKD (WHY??)
            1. advanced age
            2. reduced kidney mass/low birth weight
            3. ethnic minorities
            4. family history
            5. low income
            6. dyslipidemia
      2. tests
         1. BP
         2. glucose
         3. Scr to estimate GFR
         4. spot urine specimen for protein or albumin
         5. in selected px
            1. ultrasound
            2. electrolytes
            3. full urinalysis
   2. Expected Lab Abnormalities in CKD
      1. elevated BUN
      2. elevated Cr
      3. anemia
      4. hyperparathyroid hormone
      5. hypocalcemia
      6. hyperphosphatemia
      7. hyperkalemia
      8. hyponatremia
      9. low bicarbonate
      10. low pH (acidosis)
   3. Lab Tests for Proteinuria and Microalbuminuria
      1. for px not at increased risk
         1. std. dipstick for protein (> 1+) - (spot urine test)
         2. then perform protein:creatinine ratio
            1. < 200 mg/g recheck periodically
            2. > 200 mg/g go to a diagnostic evaluation
      2. for px at increased risk
         1. albumin specific dipstick (+) - (spot urine test)
         2. then perform albumin:creatinine ratio using 24-hr urine (ACR)
            1. if < 30 mcg/mg recheck periodically
            2. 30-300 mcg/mg considered microalbuminuria; go to diagnostic evaluation
            3. a 24 hr urine collection having > 300 mg/day albumin is considered clinically significant (albuminuria)
6. Nutritional Management
   1. for px w/ low GFR < 25, 0.6 gm protein/kg/day associated w/ decreased rate of progression of kidney function decline
   2. for avg. person change in protein doesn't help that much
7. Complications of CKD
   1. sodium and water balance
      1. pathophysiology
         1. lose ability ot adjust to abrupt changes in Na intake
         2. Na balance is maintained but in a volume-expanded state
         3. kidneys ability to dilute/concentrate urine is impaired
         4. volume overload may lead to HTN or pulmonary edema
      2. treatment
         1. significant sodium/water restrictions are not necessary
         2. maintain urine output with loop diuretics
         3. thiazides ineffective is GFR < 30 ml/min
         4. combination of thiazide + loop can act synergistically
   2. metabolic acidosis
      1. pathophysiology
   3. potassium homeostasis
   4. anemia of CKD
   5. secondary hyperparathyroidism (SHPT)