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Pharmacotherapy 1 > 2 - CKD (Shepler) > Flashcards

2 - CKD (Shepler) Flashcards

1
Q

Define CKD and ESRD.

A

abnormalities of kidney structure, present for >3 mos w/ implications for health

Stage 5 is ESRD.

GFR <60 mL/min/1.73m^2 (cat 3a and greater)
markers of kidney damage: albminuria,
urine sediment abnormalities,
electrolyte and other abnorm d/t tubular disorders
histological/structural abnormalities
hx of renal transplant

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2
Q

Differentiate 5 stages of CKD w respect to kidney fxn/GFR.

A 
G1 - >= 90 --> normal or high
G2   60-89 --> mildy decr'd 
G3a 45-59 --> mildly to mod decr'd
G3b 30-44 --> mod to sev decr'd 
G4 15-29 -->sev decr'd 
G5 <15 --> kidney failure =ESRD
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3
Q

Explain how diuretic resistance develops and how it can be overcome.

A

…

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4
Q

Describe the relationship btw Ca2+, PO4-, vit D, and PTH in a pt w CKD.

A

…

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5
Q

Decribe G2 category for GFR for CKD

A

G2 60-89 –> mildy decr’d

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6
Q

Decribe G2 category for GFR for CKD

A

G2 60-89 –> mildy decr’d

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7
Q

Decribe G3a category for GFR for CKD

A

G3a 45-59 –> mildly to mod decr’d

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8
Q

Decribe G3b category for GFR for CKD

A

G3b 30-44 –> mod to sev decr’d

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9
Q

Decribe G4 category for GFR for CKD

A

G4 15-29 –>sev decr’d

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10
Q

Decribe G5 category for GFR for CKD

A

G5 <15 –> kidney failure =ESRD

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11
Q

How should kidney fxn be estimated for stable kindey fxn?

A

Cockroft and Gault for CrCl

MDMR for GFR

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12
Q

What is the Cockroft Gault eqn?

A

CrCl (mL/min)=(140-age)IBW/(SCrx72) for women x0.85

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13
Q

Decribe the Cockroft Gault eqn.

A

used to esimate CrCl (GFR) for pts w stable kidney fxn

-tends to overestimate renal fxn in mod to sev kindey imp

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14
Q

What is the use of the MDMR eqn?

A

stage kidney fxn
most accurate measure of GFR
includes adj for race and gender

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15
Q

What occurs is kidneys are unable to excrete waste products of metabolism?

A

urea, ammonia, bilirubin, uric acid etc.

build up in blood, resulting in incr BUN, pruritus, confusion, N/V, anorexia) ==>uremia

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16
Q

What occurs if kidneys are unable to regulate fluid and electrolyte balance?

A

edema, fluid overload, CV complications (incr systemic vascular resistance)

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17
Q

What happens if kidneys are unable to maintain acid balance of plasma? (secrete H+ ions)

A

metabolic acidosis

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18
Q

What occurs if the kidneys are unable to secrete hormones?

A

erythropoietin, rennin, PGAs…

anemia

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19
Q

What happens if the kidney is unable to syntehsize calcitriol?

A

calcitriol-actve form of vitD

–> mineral and bone disorder (incr in PTH)

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20
Q

What is the definition of uremia?

A

a cluster of sx which is assoc’d w ESRD from any cause.
Sx are d/t accumulation of waste molecules in the blood that are normally removed by the kidneys.
Clinicians monitor the BUN to assess S/Sx of uremia.

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21
Q

What are the effects of uremia?

A
  • CNS: encephalopathy, confusion
  • EENT: uremic fetor
  • pulm: non-cariogenic pulm edema from volume overload
  • cardio: sodium retention, volume overload, LVH
  • GI: anorexia, NV, constipation, metallic taste
  • MS: mineral and bone disorder and Restless Leg Syndrome
  • anemia
  • skin-uremic frost
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22
Q

Describe fluid retention in CKD.

A

water retention is a problem, pts devo pitting edema and BP incr

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23
Q

What is the Tx for fluid retention in CKD?

A
  1. fluid restrict? not nec is sodium controlled. avoid large amts free water.
  2. diuretics for volume overload or HTN
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24
Q

What are considerations for using diuretics in fluid retention with CKD?

A
  1. thiazides are ineffective when CrCl <30 mL
  2. loops will work when CrCl <30 mL/min
  3. furosemide bioavailability (~100-100) is ~50%, so po dose may be 2x IV dose
  4. avoid K-sparing diuretics
  5. as renal fxn declines, and loop dose is max’d, may add thiazide to overcome diuretic resistance
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25
Q

How should you use different loop diuretics if a pt doens’t respond well?

A

loop diuretics are all similar. if poor response to one then poor response for all.

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26
Q

Describe (loop) diuretic resistance.

A

loops block NaCl, K reabs in ascending loop.
Over time cells in DCT hypertrophy and incr Na reabs to compensate–> resistance

–> can add a thiazide to block this effect if CrCl <30 mL/min

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27
Q

Ethacrynic acid is useful as a

A

loop diuretic for pts with sulfa allergies. (not a sulfonamide)

but carries a high risk for ototoxicity

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28
Q

How should electrolyte imbalances be treated in pts with CKD?

A

Na–no need to sev restrict beyond no salt die unless Tx for HTN or edema

Ka–restrict to 3 g/d

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29
Q

How should salt imbalances be treated in pts with CKD?

A

no need to retrict beyond a no salt added diet unless HTN or edema

  1. use saline IV solns w caution
  2. make oupts aware of hidden high Na foods (hot dogs, canned soups, etc.)
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30
Q

If a CKD pt is being treated for HTN or edema what should their sodium intake be restricted to?

A

<2 g Na/d

<5 g NaCl/d

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31
Q

What is the potassium intake restriction for CKD pts?

A

restrict to 3 g/d

goal for ESRD pts is pre-dialysis K of 4.5-5.5 mEq/L)

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32
Q

What are high-potassium foods?

A

tomatoes
dried fruits
salt substitutes
fresh fruits

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33
Q

How should hyperkalemia be treated in CKD pts?

A
  1. dialysis
  2. calcium gluconate IV (cardio-protective)
  3. nebulized albuterol
  4. insulin + glucose
  5. sodium polystyrene sulfnate (Kayexalate) (15-30 g btw dialysis sessions)
  6. NaHCO3 (not used for ESRD pts)
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34
Q

What are the key points to remember for mineral and bone disorder (CKD-MBD)?

A
  1. hyperphosphatemia (can’t elim)
  2. decr vit D
  3. hypocalcemia

–>increase in iPTH

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35
Q

What are the consequences of increased iPTH?

A

increased calcium mobilization from bone

–> weakened bone fracture more easily

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36
Q

How does hyperhposphatemia cause hypocalcemia?

A

phosphate binds calcium and preciptates

–>soft tissue calcifications

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37
Q

Describe hyperphosphatemia for ESRD pts.

A

affects nearly all

–>nearly all receive phosphate binders

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38
Q

How are phosphate binders given?

A

WITH FOOD

bind dietary phosphate in GI–elin in kidneys

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39
Q

What are the two main types of phosphate binders?

A

calcium and non-calcium

don’t use calcium if hypercalcemia!

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40
Q

What are the calcium-containing phosphate binders?

A 
calcium carbonate (Tums)
calcium acetate (PhosLo)
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41
Q

How much elemental calcium is in Tums? What is the dose as a phosphate binder?

A

40% elemental calcium

500 mg (as elemental Ca) tid c meals

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42
Q

How much elemental calcium is in PhosLo? What is the dose as a phosphate binder?

A

25% elemental calcium

2-3 tab tid c meals

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43
Q

Compare phosphate binding between calcium carbonate and calcium acetate?

A

acteates binds 2x as much PO4- compared to carbonate.

acetate may produce fewer hypercalcemic events

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44
Q

What are the non-calcium containing phosphate binders?

A 
Sevelamer carbonate (Renvela)
lanthanum carbonate (Fosrenol)
sucroferric oxyhydroxide (Velphoro)
Auryxia (ferric citrate)
AlOH (Amphojel)
Magnesium carbonate (Mag-Carb)
nicotinic acid and nicotinamide
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45
Q

What are the dose and adverse effects of sevelamer carbonate (Renvela)?

A

Phos 5.5-7.5 mg/dL –> 800 mg tid

Phos >=7.5 mg/dL –> 1600 mg tid

Adverse (rare): GI upset, N/V/D, decreased LDL by 15-30%

not abs’d –> low risk of systemic toxicitiy
decr uric acid serum conc

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46
Q

What is the dose of Lathanum carbonate (Fosrenol)?

A

250-750 mg tid c meals

titrate to 1500-3000 mg/d

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47
Q

What is the brand number of sevelamer carbonate?

A

renvela

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48
Q

What is the brand name of lanthanum carbonate?

A

Fosrenol

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49
Q

What is the claim to fame for lanthanum carbonate (Fosrenol)?

A

binds phos at lower pH

not sure if clinically relevant

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50
Q

Describe the distribution and SE of lanthanum carbonate.

A

eliminated in feces
no long-term accumulation
dose not cross BBB

SE: mostly GI: N/V/D

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51
Q

Which two phosphate binders contain iron?

A 
sucroferric oxyhydoxide (Velphoro)
Auryxia (ferric citrate)
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52
Q

Descibe the dose and affects of sucroferric oxyhydroxide (Velphoro).

A

500 mg chewable tab tid c meals

titrate by 1 tab/d q week

may cause darkened stools d/t iron
ironot abs’d, does not affect TSAT or ferritin

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53
Q

What is the dose and affects of Auryxia (ferric citrate)? What pt pop is this phosphate binder used in.

A

2 tab tid c meals

q tab has 1 g ferric citrate –> incr TSAT and ferritin

may cause discolored feces

used in CKD pts on dialysis

54
Q

Describe the dose and use of aluminum hydroxide (Amphojel) as a phosphate binder?

A

300-600 mg tid c meals

old therapy, not used much anymore
causes alumnium toxicity

55
Q

What is the dosing of magnesium carbonate (Mag-Carb) as a phosphate binder?

A

1-3 tab tid c meals

56
Q

How is dietary phosphate restricted in CKD pts?

A

restict to 800-1000 mg/d if

CKD 3&4: Phos >4.6 mg/dL
CKD 5: Phos >5.5 mg/dL
PTH > target range for stage 3, 4, or 5

57
Q

What are foods that contain high phosphorus

A 
meat
nuts
dairy
dried beans
colas
beer
58
Q

Describe the relationship between Vitamin D and SHPT in CKD?

A

yperhpos and the kidneys inability to activate vit D –> decr serum calcium –> incr PTH secretion –> incr Ca mobilization

59
Q

What are the two main types of Tx used to treat SHPT dd/t vit D deficiency?

A

Vitamin D therapy
active vitamin D sterols

these incr vit D conc and decr PTH through neg feedback

60
Q

Describe vit D synthesis pathway.

A

cholcalciferol (from 7-dehydrocholesterol in skin after sun) and egocalciferol (from food)

  • -> 25-hydroxvitamin D in liver
  • -> 1, 25-dihydroxyvitamin d or calcitriol) in kidney

–> binds to vit D R to cause biological actions

61
Q

Which CKD patient population requires active forms of vit D?

A

not enough kidney fxn to convert 25-hydroxyvitamin D to calcitriol

Stage 5 ESRD

62
Q

What are the inactive vitamin D products?

A

ergocalciferol (Calciferol) - vit D2

Cholecalciferol - vit D3

63
Q

What is the dose and use of ergocalciferol (Calciferol)?

A

1x 50,000 IU cap per month

For vit D insuff in CKD stage 3 and 4

64
Q

What is the dose and use of cholecalciferol?

A

1000 IU po d

for vit D insuff in CKD 3 & 4

65
Q

What is the dose of calcitrol (Rocaltrol and Calcijex)

A

Roacltrol 0.25 mcg po d or qod; may incr q4-8 wk up to 0.5-1 mcg /d

Calcijex 0.5 mcg/d IV 3x q wk

66
Q

What are the adv/disadv of calcitriol?

A

approved for pediatric use
cheapest

greatest risk for hypercacemia (soft tissue calc)

67
Q

What are monitoring parameters for calcitriol?

A

S/Sx hypercalcemia (fatigue, weakness, HA, N/V, muscle pain, constipation)

68
Q

What is the dose of paricalcitol (Zemplar)?

A

IV: 0.04-0.10 mcg/kg 2-3x/wk

PO: PTH <=500 pg/mL –> 1 mcg d or 2 mcg qod

PTH >500 pg/mL; 2 mcg d or 4 mcg qod

69
Q

What are the active vit D products used to treat SHPT in CKD?

A

Calcitriol (Rocaltrol and Calcijex)
Paricalcitol (Zemplar)
Doxercalciferol (Hectorol)

70
Q

What are the monitoring parameters for paricalcitol (Zemplar)?

A

ca
Phos
iPTH
vit D (lab is for inactive form)

71
Q

You have a patient with CKD who is receiving an inactivated vitamin D supplement. Both their vit D (inactive) and iPTH levels are high. What do you do?

A

change to activated vit D form bc kidney does not seem to be activating vitD

72
Q

What are the adv/disadv to paricalcitol (Zemplar)?

A

> =30% reduction in iPTH
approved for peds
most favorable ADE profile
less calcemic activity compared to calcitriol

73
Q

What is the does of Doxercalciferol (Hectorol)?

A

2.5-10 mcg po or IV 2-3x/wk

74
Q

What are the three parts of CKD-BMD?

A

hyperphosphatemia
vit D and SHPT
calcium and SHPT

75
Q

What are the adv/disadv of doxercalciferol (Hectorol)?

A

hepatically-activated prohormone

  • -> can’t be used in severe alcholics, heaptic failure
  • produces more even serum conc that more closely mimic normal
  • > +30% reduction in iPTH
  • higher incidence of hyperphosphatemia compared to paricalcitrol
  • lower incidence of hypercalcmia compared to calcitriol
76
Q

What drug is in the calcimimetic class?

A

Cinacalet (Sensipar)–type II calcimemtic

77
Q

What is the moa of cinacalecet (Sensipar)?

A

mimics action of ca but does so by binding to CaR and inducing conformation change to the R, triggering the parathyroid gland to decr PTH secr

78
Q

What is the dose of cinacalcet (Sensipar)?

A

30 mg po d
incr dose to achieved desired PTH serum conc

max daily dose 180 mg

79
Q

** When in cinacalcet (Sensipar) contraindicated?

A

hypocalcemia!

if Ca <7.5 mg/dL, withohold cinacalcet until Ca >=9 mg/dL

80
Q

What is the corrected calcium eqn?

A

Ca corr= Ca measured + 0.8 x (4-serum alb)

81
Q

What are the monitoring parameters for CKD-MBD

A

Ca
Phos
25(OH)D
iPTH

82
Q

What is the goal Ca for CKD-MBD?

A

8.5-10.5 mg/dL

83
Q

What sit he goal phos for CKD-MBD?

A

2.5-4.5 mg/dL

84
Q

What is the goal 25(OH)D for CKD-MBD?

A

~30 ng/mL

85
Q

What is the goal iPTH for CKD-MBD?

A

ND: 11-54 pg/mL
D: 100-500 pg/mL

86
Q

What are the mechanisms by whih ESRD patients develop anemia?

A
  1. decr erythropoietin prod
  2. uremia decreases RBC lifespan
  3. vit losses during dialysis-folate, B12, B6
  4. dialysis–loss of blood through dialyzer (hemolysis)
87
Q

What are macrocytic anemia?

A

folate, B12 def

88
Q

What are normocytic anemias?

A

anemic of chronic disease
GI bleed
erythropoietin def

89
Q

What are causes of microcytic anemia?

A

iron def

aluminum tox

90
Q

What are S/Sx of anemia?

A 
fatigue!!!
dizziness
HA
pallor
decr cognition
91
Q

***What is the normal MCV range?

A

80-96 microm^3

92
Q

**What is the normal RDW range?

A

11.5-14.5 %

93
Q

What are tx goals for anemia in CKD pts?

A
  1. reverse S/Sx of tissue hypoxia and LVH
  2. incr exercise tolerance and capacity
  3. optimize survivial
  4. incr QOL
94
Q

What are monitoring parameters for anemia in CKD pts?

A

Hb–>best

Hct is less stable w storage, non-standardized assay, and increases w hyperglycemia

Hg doesn’t have these probs

95
Q

How often should Hb be montiored in CKD pts?

A

CKD3: annually
CDK4-5ND: 2x/yr
CDK-5K: q 3 mos

if existing anemia then for CKD3-5ND q3mo, CKD5D q mo

96
Q

When should anemia be diagnosed in CKD pts? (Hg cutoff)

A

<12 g/dL in females

<13 g/dL in males

97
Q

What are Txs for anemia in CKD pts?

A

iron

ESAs

98
Q

According to KDIGO, when should iron be supplemented?

A

TSAT <30%
serum ferritin <500 ng/mL

if above these then enough for erythropoiesis

99
Q

What is functional iron def?

A

low TSAT

100
Q

How often should TSAT and ferritin be monitored?

A

at least q 3 mo

101
Q

Describe the use of po iron in CKD pts?

A

will not likely be sufficient for HD pts

–> CKD pts (3&4) or periotoneal dialysis pts

102
Q

What is the dose of oral iron?

A

200 mg of elemental iron qd

usually 64 mg elemental in 325 mg ferrous sulfate

103
Q

What are the adv of heme iron over ferrous salts

A

greater abs
different abs site
not subject to 200 mg elemental iron rule

104
Q

What are heme iron products and their doses?

A

Proferrin ES and Proferrin Forte

2-3 tab/d (24-36 mg/d
12 mg elemental iron/tab)

105
Q

What are the SEs of oral iron? How are these dealt w?

A

Se: stomach upset

Fe abs’d in acidic environment

  • -food decr abs
  • take w orange juice (watch vit C! b/c renal elim)

separate from Ca by 2 hr d/t binding

may not be appropriate for pts on meds that incr pH (antacids, PPIs, H2 blockers)

106
Q

What are IV iron agents used in CKD?

A 
iron dextran (InFed, Dexferrum)
sodium ferric gluconate (Ferrlicit)
iron sucrose (Venofer)
ferric carboxymaltose (Injectafer)
ferumoxytol (Feraheme)
107
Q

Describe the effects of low MW vs high MW in IV iron agents.

A

high MW such as Dexferrum cause the most complications.

108
Q

Which IV iron products require a test dose?

A

iron dextran (InFed, Dexferrum)

109
Q

What are possible SE of iron IV products?

A

flushing
dizziness
hypotension

iron dextran—> anaphylactic rxns

110
Q

What IV iron product interferes w MRI? How long does this effect last?

A

ferumoxytol (Feraheme)

for up to 3 mos after 2nd inj!

111
Q

What is the dosing of iron dextran (InFed, Dexferrum)?

A

25 mg test dose**
100 mg IV q HD session x 10 doses

25-100 mg /wk maintenance

112
Q

What is the dosing of sodium ferric gluconate (Ferrlicit)?

A

125 mg IV q HD session x 8-10 doses

31.25-125 mg/wk maintenance

113
Q

What is the doing of iron sucrose (Venofer)

A

100 mg IV q HD session x 10 doses

OR

200 mg IVP x 5 doses (for ND-CKD pts)**

25-100 mg/wk maintenance dose

114
Q

What is the dosing for ferric carboxymaltose (Injectafer)

A

750 mg IV once, repeat in 7 days

115
Q

What is the dosing for ferumoxytol (Feraheme)

A

510 mg IV once, repeat in 3-8 d

116
Q

What are the monitoring parameters for IV iron agents?

A

HR, BP, RR< q 15 min

Ferritin, TSAT q1-3 mo

for all agents except Feraheme.

Feraheme: ferritin, TSAT q1-3 mo

117
Q

What iron agent can be added to dialysate?

A

triferic (ferric pyrophosphate citrate)

118
Q

What is it suggested to begin ESA?

A

after all other correctable cause sof anemia have been address

CKD 3-5ND HB <10g/dL; Hb falling at a rapid rate; needed to avoid blood transfusion

CKD 5D Start when Hb 9-10 g/dL

119
Q

Do not use ESA to push Hb above ___ d/t incidence of ___

A

11.5 g/dL

cerebrovascular events

120
Q

What are the FDA recommendations for ESAs?

A

CKD3-5ND: Hb<10 g/dL and falling rapidly; reduce or interrupt dose i Hb>10g/dL

CKD5D: initiate if Hb<10 g/dL; reduce of interrupt dose if Hb approaches or exceeds 11 g/dL

121
Q

What are the two ESAs?

A 
recombinant human erythropoietin (rHuEPO, epoetin alfa, Epogen, Procirit, EPO)
darbepoietin alfa (Aranesp)
122
Q

What is the dose of recombinant human erythropoietin?

A

120-180 U/kg/wk IV divided into 3 doses

80-120 U/kg/wk SC divided into 2-3 doses

SC-preferred
IV-increased cost

If target Hb/Hct reached, SC dose is 2/3 IV dose. Below target then use same dose.

123
Q

What is the dosing for darbepoetin alfa?

A

3x longer t1/2 then epoietin alfa

dosed once /wk IV or SC

starting dose 0.45 mcg/kg–titrate to maintain Hb of 12g/dL

124
Q

What are adverse effects of ESA use?

A

PRCA: pure red cell aplasia: antibodies devo to erythropoietin –> d/c drug permanently

HTN:
23% of CKD pts have HTN
w incr Hb w ESA –> incr cardiac arrest, stroke, CHF, HTN, acute MIs

125
Q

What are clinical considerations for dose titration of ESAs based on Hb?

A

-monitor Hb wkly during initiation
-adjust no more oft then q 4 wks
goal=1-2 g/dL rise/month
-incr dose by 25% if Hb does not incr by 1 g/dL in 4 wks
-decrease dose by 25% when Hb approaches 11-11.5 g/dL or incr by more than 2 g/dL in 4 wks

126
Q

What are causes of ESA therapy failure?

A 
lack of vitamins or iron
aluminum toxicity
active bleed
drug-induced bone marrow suppression
acute inflamm or infx
127
Q

Describe acid-base disorders in ESRD pts.

A

cannot excrete H+ ions –> metabolic acidosis

128
Q

What is the tx for metabolic acidosis in ESRd pts

A
  1. dialysis –incr bicab in dialysate
  2. Shohl’s soln–1 mEq sodium + 1 mEq bicarb (as sodium citrate) per mL of soln
  3. NaHCO3 tab 325 and 650 mg strength (1 g NaBicab=11.9 mEq Na and 11.9 mEq bicarb)
  4. Dose (mEq) = [0.5 L/kg (IBW)] x (12-actualHCO3-)
129
Q

What are the protein requirements if GFR <30 mL/min?

A

0.8 g/kg/d

130
Q

What are the protein requirements for ESRD on HD?

A

1.2 g/kg/d

131
Q

What vitamins are replaced in renal nutrition?

A

B and C –> pulled off in water by dialysis

Nephrocaps, Nephron FA

132
Q

What are the energy requirements for CKD?

A

<60 yoa 35 kcal/kg/d

>60 yoa 30-35 kcal/kg/d

Pharmacotherapy 1 (26 decks)

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