Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PDAT3 > 24 - CKD 3 Bone Disease > Flashcards

24 - CKD 3 Bone Disease Flashcards

1
Q

Pathophysiology

CKD - Mineral & Bone Disease

A

w/ progressive CKD, imbalance occurs with:
PHOS / Calcium / VIT D
VV
Secondary HypoThyroidism
&
↑FGF-23 / Bone Disease / Soft Tissue Calcification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

ParaThyroid Gland

CKD - Mineral & Bone Disease

A

3 Receptors;
Vitamin D + FGF-23
Ca-Sensing Receptor = CaSR
main regulator of PTH

PTH = Maintains Calcium Levels
Acts on:
Kidney / Intestine / Bone
Directly Stimulated by:
HypoCalcemia, PTH –> CaSR on PTGland

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

PTH Action on
KIDNEY

A

HypoCalcemia –> PTH release –> CaSR receptors on PTGland

  • *Kidney:**
  • *↑ Renal Absorption of Ca**

↑Renal EXCRETION of Phos

↑Synthesis of Calcitriol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

PTH Action on
INTESTINE

A

HypoCalcemia –> PTH release –> CaSR receptors on PTGland

indirectly:
↑Absorption of BOTH
Ca & P
in small intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

PTH Action on
BONE

A

HypoCalcemia –> PTH release –> CaSR receptors on PTGland

↑OsteoClasts
breakdown bone –> MORE Calcium

_↓OsteoBlasts_
inhibit “building” = bone formation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Secondary HyperParathyroidism

Causes an INCREASE in PTH due to WHAT?

A

↑PTH due to:
_↓serum Ca_ & ↓production of Calcitriol
indirectly ↑Phos

Progressive & starts @ GFR < 60 (CKD)
VVV
leads to HYPERplasia of Parathyroid Gland
lose sensitivity to:
CaSR & VDR
possible adenomatous transformation of the gland
–> HYPERcalcemia in some patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q
  • *Reduction in GFR**
  • Nephron LOSS*

has WHAT EFFECTS on

PTH

Phosphorus

Calcium

Calcitriol

A

↑PTH & ↑PHOS

↓CALCIUM*** & ↓***Calcitriol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

FGF-23

What Increases its production?

What is its function?

A

↑Phosphate & ↑Calcitriol [1,25(OH)2D]
leads to release of–> ↑FGF-23

FGF-23 –> feedback loop ↓Calcitriol
by supressing 1-a-hydroxylase @ proximal tubule

FGF-23 regulates:
Phosphate & Vitamin D homeostasis
&
INHIBITS PTH PRODUCTION

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Consequences of HYPERParaThyroidism

A
  • *#1 = CARDIOVASCULAR ISSUES**
  • Artery calcification –> ↑*Atherosclerotic load–> ↑MI risk

Vascular Calcification

Osteoporosis

Anemia / Itching

Parathyroidectomy
hungry bone syndrome / recurrence of HYPERparathyroidism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Types of Bone Disease
&
How are they Classified?

A

Dependent on the :
Degree of Abnormal bone turnover & imparied mineralization of the extracellular matrix

Osteitis Fibrosa Cystica

Adynamic Bone Disease

MIXED Uremic Bone Disease

Osteomalacia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Which type of BONE DISEASE?

Occurs when PTH is constantly ELEVATED

Woven Appearance
caused by increased # of osteoid

Accelerated formation & resorption of bone due to:
INCREASED # & activity of
OsteoClasts/Blasts+Marrow Fibrosis

A
  • *OSTEITIS FIBROSA CYSTICA**
  • *iPTH > 300**

WOVEN
Constant PTH elevation

INCREASED:
OsteoClasts + OsteoBlasts + OSTEOID + Marrow Fibrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Which type of BONE DISEASE?

HIGH CALCIUM & *low PTH levels (<150)*

Occurs from the:

  • Supression of PTH* via
  • *Phos Binders / Vit D treatment / Calcimimetics**

low turnover bone state
normal or reduced Osteoid thickness
no mineralization defect
low Osteoclasts & osteoblasts

A

ADYNAMIC BONE DISEASE

  • low everything*, except for Calcium
  • PTH / osteioid / osteoclasts+blasts*

Treatment:
_D/C or *reduce* dose of
Vitamin D or Calcimimetic_

since it is caued by the supression of PTH by:
phos binders / vit D / calcimemetics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

EXTRAskeletal Presentation

of CKD - Bone Disease

A

occurs from
HIGH CA & PHOS

Medical OVERsupression of PTH by VIT D
inefficient incoportation of Ca -> bone
leading to vascular calcification

HEART
leads to widened pulse pressure / increased AFTERLOAD & LVH

SKIN –> CALCIPHYLAXIS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

MusculoSkeletal Presentation

of CKD - Bone Disease

A

FRACTURES
hip fracture, highest incidence in stage 5

Tendon Rupture** + **Bone Pain

Calcification of VESSELS
frequent in stage 5, only INCREASES the longer on dialysis
large effects on:
blood vessels / heart valves / SKIN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Mineral & Bone Disease Goals

A

Stage 5
is where Phos + Calcium levels CHANGE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

HYPERPhosphatemia

CKD - Mineral & Bone Disease

A

↑Phos -> ↑PTH & ↓Calcitriol Synthesis

Most Phos comes from FOOD, dialysis is unable to remove it

Need:
*LOW phos Diet* + PHOS BINDER

Symptoms:
Pruritis, Rash / Bone+Joint Paint / Muscle Cramps + Tetany

17
Q

HIGH Phosphorus leads to what?

A

indirectly-> ↑PTH Production

&

↓Inhibits CALCITRIOL synthesis

18
Q

PHOSPHORUS BINDERS

Important Counseling Advice

A
  • dependent on DIETARY phos control:*
  • *800-1000 mg/day**

try and AVOID:
_Calcium Based products_
due to HYPERcalcemia

  • *TAKE WITH FOOD**
  • do NOT take if NOT eating*

Seperate from certain Meds
Antibiotics / LEVOthyroxine

Caution in patients with:
Bowel Obstruction / Ileus-Fecal Impaction / Hypomotility Disorders

19
Q

Calcium Carbonate

A

OTC Phosphorus Binder

Try not to use CALCIUM BASED products, due to hypercalcemia, ExtraSkeletal Calcification​

1-2 Tabs
WITH EACH MEAL

Max 7 Tabs of TUMS

20
Q

Calcium Acetate

A

PRESCRIPTION Phosphorus Binder

  • Try not to use CALCIUM BASED products*, due to hypercalcemia
  • ExtraSkeletal Calcification*
  • *GREATER PHOS BINDING** > Ca Carbonate
  • but is RX only*

2 caps w/ each meal

21
Q

Sevelamer Carbomate/HCL

RENVELA / RENAGEL

A
  • *Phosphorus Binder**
  • *PREFERRED -> does NOT induce ACIDOSIS**

Tabs or Packets
_SEPERATE FROM:
Mycopehnolate / Cyclosporine / Tacrolimus_

  • CONSTIPATION*
  • nausea / vomiting / diarrhea / dyspepsia*
22
Q

Lanthanum Carbonate

A

Phos Binder

Chewable or Powder

Must be taken WITH or AFTER meals

ab pain / NV

23
Q

Sucroferric Oxyhydroxide
Velphoro

A

Phos Binder

  • *Chewable Tabs**
  • minimal Fe absorption*
  • DARKENING OF STOOLS*
  • diarrhea / constipation / NV*

SEPERATE FROM VITAMIN D

24
Q

Ferric Citrate
Auryxia

A

Phos Binder

INCREASES TSAT

do NOT use in IRON OVERLOAD

DARKENING OF STOOLS
diarrhea / constipation / NV

25
Q

What Drugs do we need to seperate from

Phos Binders?

A
  • *Antibiotics**
  • *Tetracyclines + Fluoroquinolones**

Levothyroxine

For Sevelamer:
Mycophenolate / Cyclosporine / Tacrolimus

for Sucroferric Oxyhydroxide:
PO Vit D

26
Q

Aluminum for Phos Binding

A

not used often:
Only in in EMERGENT situations
or
P > 7mg/dL

Al-OH or Al-Carbonate

Use no longer than < 4 weeks, due to toxicities:
bone / bone marrow / CNS

27
Q

iPTH

A
  • *Directly Measures Parathyroid Gland FXN**
  • Indirectly Measures* Bone Remodeling
  • NOT ACCURATE ASSAY*
  • *–> better to LOOK AT TRENDS** rather than individual result

iPTH > 300 = possible Osteitis Fibrosa Cystica

iPTH <150 = possible adynamic bone disease

28
Q

Vitamin D & Vitamin D Analogues
(Calcitriol)
For:
CKD - Mineral & Bone Disease

A

KDOQI: Only use if:

  • *Ca <9.5** — P <5.5
  • still used in practice though*

Vitamin D –> supresses PTH

Increases:

  • *Gut Absorption of PHOSPHORUS**
  • *AND CALCIUM**

caution with HYPERphosphorus

29
Q

Comparible Doses of

Calcitriol / Viamin D Analogs

A

“Alphabetical Order - 1 - 2 - 4”

Calcitriol - 1 mcg
MOST HYPER-Ca & HYPER-Phos

DoxerCalciferol - 2 mcg
Pro-drug, less HYPERcalcemic, PO is MORE HYPERcalcemic vs IV

  • *Paricalcitol -** 4 mcg
  • least hypercalcemic & hyperphosphatemic*
30
Q

Cinacalcet = Sensipar
30/60/90 mg tablets
Taken with food & WHOLE
adjust dose in 4 weeks

USES

A

reduce PTH
by ↑CaSR sensitivity on PT Gland

  • *Ca needs to be > 8.4mg/dL**
  • may cause HypoCalcemia*

Uses:

  • *PTH is NOT controlled by VitD Analogs**
  • *HYPERcalcemia** / Calciphylaxis

ensure med is held 12 hours b4 PTH lab draw
can have FALSELY low PTH levels

31
Q

Cinacalcet = Sensipar

ADR / Precautions / Drug Interactions

A

TAKEN WHOLE & WITH FOOD

Vomiting / Diarrhea / Nausea

Precaution:
SEIZURES –> associated with low Calcium

DI:

  • *Strong Inhibitor of CYP2D6
  • partially metabolized by 3A4***
32
Q

Etecalcetide = Parsabiv

MoA / Uses

A

Binds to CaSR
and enhances its activation by extracellular calcium

ONLY FOR HEMODIALYSIS PATIENTS
IV formulation –> need to restart to 5mg/ML if missed dose

Calcium should be >8.4 b4 starting
check q4weeks

33
Q

Etelcalcetide

ADR / Concerns

A

only for HEMODIALYSIS patients

IV, store in FRIDGE

ADR:

  • HypoCalcemia* –> Worsening heart Failure
  • possible IMMUNOGENECITY –> AB formation*

Better GI Tolerance > Cinacalcet

Switching From Cinacalcet –> D/C for 7 days pror

34
Q

Inactive Vitamin D

A

Serum 25(OH)D goal level > 30 ng/mL

not for Adjusting PTH
role mainly for preventing:
cancer / diabetes / Autoimmune dzs / CV dzs / infxns

Treatments:
Ergocalciferol 50k units qweek - q2week - qmonth

Cholecalciferol 1k-5k QD

  • *Calcifediol = Rayaldee** 30mcg pq qHS
  • drug interactions with CYP3A & THIAZIDE diuretics*
35
Q

Mineral & Bone Disease Goals

KDOQI - CKD Stage 3 & 4

A

Both the SAME for Phos & Ca (normal ranges)

Phos = 2.7 - 4.6

Corrected Ca = 8.4 - 10.2

Ca x P = —-

CKD 3 iPTH = 35 - 70

CKD 4 iPTH = 70 - 110

36
Q

Mineral & Bone Disease Goals

KDOQI - CKD Stage 5

A

Phos = 3.5 -5.5

Corrected Ca = 8.4 - 9.5

Ca x P = < 55

iPTH = 150 - 300

37
Q

Mineral & Bone Disease Goals

KDIGO 2017

CKD G5D

A

iPTH

2-9x Upper Limit
~150 - 600

Phos: lower towards normal range

Ca = AVOID HYPERcalcemia

PDAT3 (23 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions