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The normal annual mean decrease in GFR with age from the peak GFR (120 mL/min per 1.73 m2 attained during:

1. 3rd decade of life is ___ml/min/year/1.73m2
2. Age 70 is ____ ml/min/1.73m2
1. 1 ml/min/yr/1.73
2. 70 ml/min/1.73
4 leading categories of etiologies of CKD?

1. Diabetic Nephropathy
2. Glomerulonephritis
3. Hypertension associated CKD
4. Autosomal dominant polycystic kidney dis.
What is increase detected with other acute phase reactants in CKD?
C-reactive protein
What 2 negative acute-phase reactants which decreases as progressive decrease in GFR?
1. albumin
2. fetuin
Thiazide diuretic is limited utility in stage __to__ CKD.
stage 3 to 5
With worsening renal function, total urinary net daily acid excretion is usually limited to __-__ mmol & anion of retained organic acids leads to anion gap metabolic acidosis.
30-40 mmol
RTA which leads to anion-gap metabolic acidosis in progrossive CKD will respond to NaHCO3- considered when HCO3- decrease to __-__ mmol/L to avoid protein catabolic state seen with even mild metabolic acidosis & to slow the progressive of CKD.
20 to 23 mmol/L
What major bone disorder of CKD:
_____1. high bone turnover with inc. PTH 
_____2. low bone turnover with dec. or normal PTH
1. osteitis fibrosa cystica
2. adynamic bone disease and osteomalacia
is part of a family of phosphatonins and promotes renal phosphate excretion
-defend normal s. phosphorus by decreasing renal phosphate excretion, stimulate of PTH which increase renal phosphate excretion and suppression of the formation of 1,25(OH)2D31 which decrease phosphorus absorption from the GIT

also an indpendent risk factor for LVH and mortality in CKD, dialysis and renal transplant patient

indicate need for therapeutic intervention even s. phosphate levels are within the normal range
A hemorrhagic element of osteitis fibrosa cystica?
brown tumor
What bone dis. of CKD?
Clin. manif of hyperparathyroidism
-bone pain & fragility
-brown tumors
-compression syndrome
-erythropoietin resistance in part r/t the bone marrow fibrosis
Osteitis fibrosa cystica

PTH-cons. a uremic toxin assoc. with muscle weakness, fibrosis of cardiac muscle and nonspecific constitutional symptoms.
What bone dis. of CKD?
-inc. esp. in diabetics & elderly characterized by decrease bone volume and mineralization may result from excessive suppression of PTH production, chronic inflammation or both
Adynamic bone dis.

Suppression of PTH can result from:
-Vit. D preparation
-excessive calcium exposure in the form of calcium-containing phosphate binders
-high calcium dialysis solution
3 complications of adynamic bone dis.?
1. increase incidence of FRACTURE
It is called when calcium precipitate in soft tissues lead to large concretions.
Is a devastating condition seen almost exclusively in pts. with advanced CKD heralded by livedo reticularis & advances to patches of ischemic necrosis especially on legs, thighs, abdomen and breasts?
Pathologically vasculacur occlusion in assoc. with extensive vascular and soft tissue calcification.
Calciphylaxis (calcific uremic arteriolopathy)
One effect of warfarin is to decrease the Vit. K dependent regeneration of ________ protein which is impt. in preventing vascular calcification.
matrix GLA protein

-consd. a risk factor for calciphylaxis
Has direct suppressive effect on PTH secretion and indirectly suppress PTH secretion by increasing the concentration of iCa and may result in hypercalcemia &/or hyperphosphatemia through increase GI absorption of these minerals
Analogue of calcitriol which suppress PTH secretion with less attendant hypercalcemia
Quality initiative guidelines recommend a target PTH level bet. ____&_____ pg/mL
150 & 300

recognizing that very low PTH levels are assoc.  with adynamic bone dis. and possible conseq of fracture and ectopic calcification.
Largest increase CV mortalitity in CKD not directly assoc. with acute MI but with ______
MC complication of CKD?
Strongest Risk factors CV morbidity and mortality in pts. with CKD
1. left ventricular hypertrophy
2. dilated cardiomyopathy

thought to be related primarily but not exclusively to:
-prolonged hypertension
-ECFV overload
What mechanism in CKD wherein the presence of traditional risk factors such as hypertension, hyperlipidemia & obesity appear to portend a better prognosis?
Reverse causation

dec. BP, dec. BMI & hypolipidemia in late stage CKD indicate presence of advanced malnutrition inflammation state with poor prognosis.
In CKD pts with diabetes or proteinuria more than 1g per 24hrs. BP should be decrease to ____/____ mmHg, if achievable without prohibitive adverse effects.
130/80 mmHg
First line Non-pharma therapy of Hypertension in CKD
Salt restriction
Normocytic, normochromic Anemia in CKD is observed as early as
stage ___ and almost universal by stage ___.
stage 3
stage 4
Iron supp. essential to ensure an optimal response to ESA in pts with CKD.
_____1. the amt. of iron that is immed. available for erythropoiesis
_____2. the amt. in iron stores.
1. transferrin saturation
2.  serum ferritn

Iron therapy can increase the susceptibility to bacterial infections.

ESA may be assoc. with
inc. risk of stroke with DM II, inc. in thromboembolic events and faster progression to need for dialysis.
Current practice, the target hemoglobin conc. of ___to___ g/L
What stage of CKD?
_____1. Subtle clinical manif. of uremic neuromuscular dis. 
_____2. Peripheral neuropathy
1. stage 3
2. stage 4
2 early manif. of CNS complications?
1. mild disturbances in memory & conc.
2. sleep disturbance

Neuromuscular irritability is evident at later stages with
1. hiccups
2. cramps
3. twitching
Neuromusc AbN in CKd
Is char. by ill-defined sensations of debilitating discomfort of legs and feet relieved by frequent leg movement.
Restless leg syndrome
Is a urine-like odor on the breath derives from breakdown of urea to ammonia in saliva assoc. with unpleasant metallic taste (dysgeusia)?
Uremic fetor
Protein-energy malnutrition begin at stage __CKD
stage 3
When GFR decrease to 40mL/min, pregnancy assoc. increase spontaneous absorption with only __% of pregnancy to live births.
What retained pigmented metabolites is deposited as dermatologic AbN in CKD?
Skin condtion unique to CKD pts. consists of progressive SQ induration esp. on arms & legs similar to scleromyxedema?
Nephrogenic Fibrosing Dermopathy
Current recommendation at what stage?
_____1. minimize exposure to gadolinium
_____2. avoid gadolinium agents unless necessary.
1. 3 (GFR 30-59 mL/min)
2. 4-5 (GFR
Most useful imaging study in CKD?
Renal ultrasound
Finding of bilaterally small kidneys supports the diagnosis of CKD of long-standing duration except.
1. diabetic nephropathy
2. amyloidosis
3. HIV nephropathy
4. polycystic kidney dis.
Discrepancy more than 1 cm in kidney length sugg. either:
1. unilateral dev. abN
2. renovascular dis. with arterial insufficiency
Among CCBs _____&______ may exhibit superior antiproteinuric & renoprotective effects compared to dihydropyridines.
1. Diltiazem
2. Verapamil
7 Clear indications for initiation of renal replacement therapy for pts. with CKD
1. Uremic pericarditis
2. Encephalopathy
3. Intractable muscle cramping
4. Anorexia
5. Nausea not attributable to reversible causes: PUD
6. evidence of malnutrition
7. Hyperkalemia or ECFV overload, that are refractory to other measures.
The primary metric for kidney function
A radioactive isotope for direct measurement that is filtered at the glomerulus into the urinary space but is neither reabsorbed nor secreted throughout the tubule?
Inulin or
Is the most widely used marker for GFR, which is related directly to Urine creatinine excretion and inversely to Pcr?
Plasma creatinine

bec. it is small, freely filtered solute that is not reabsorbed by the tubules.
Can mask signficant changes in GFR with small or imperceptible changes in Pcr?
1. gradual loss of muscle from chronic illness
2. chronic use of glucocorticoids
3. malnutrition
-superfamily of cysteine protease inhibitors produced at a relatively constant rate from all nucleated cells proposed to be more sensitive marker of early GFR decline than is Pcr?
Cystatin C

is influenced by pt's age, race and sex and assoc. with diabetes, smoking and markers of inflammation.
GFR is maintained by:

______1. mediated relaxation of afferent arterioles
______2. mediated constriction of efferent arterioles
1. prostaglandin
2. angiotensin II
once the mean arterial pressure fall below _____mmHg. GFR declines steeply.
80 mmHg
What condition with urine sediment?
_____1. Normal or has hyaline and granular casts
_____2. Cellular debris, tubular epithelial casts and dark (muddy brown) granular casts.
1. prerenal
2. ATN
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