4. Renal & Liver Disease Flashcards
The _______ arteriole flows INTO the glomerulus, the _______ arteriole flows OUT of the glomerulus (where large, unfilterable substances stay in the blood)
Afferent = IN
Efferent = OUT
____ in the urine indicates kidney damage
Albumin
What drug works on the PROXIMAL tubule? What blood characteristic is regulated here?
SGLT-2is
Blood pH is regulated
What is reabsorbed in the descending limb of the loop of Henle? What is absorbed in the ascending limb?
Descending = WATER reabsorbed
Ascending = SODIUM reabsorbed
What is the mechanism of the DISTAL tubule of the nephron? What drug affects the distal tubule?
Regulates K, Na, Ca, and pH
Thiazide diuretics inhibit the Na-Cl pump, and increases Ca reabsorption
What drugs affect the COLLECTING DUCT (and distal tubule)?
**Potassium-sparing diuretics (including aldosterone antagonists [eg. spironolactone, eplerenone])
Decreased Na+ and water reabsorption, increased K+
What drugs can cause nephrotoxicity?
Aminoglycosides
Amphotericin B
Cisplatin
Cyclosporine + Tacrolimus
Loop diuretics
Contrast dyes
NSAIDs
Polymyxins
Vancomycin
What two lab markers can be used to estimate kidney function?
BUN
SCr
What is BUN?
Amount of nitrogen in blood from urea (waste of protein metabolism)
What is SCr? What is a normal range?
A waste product of muscle metabolism
Normal: 0.6 - 1.3 mg/dL
When is the Cockroft-Gault equation NOT PREFERABLE? (3)
Very young children
Kidney failure
Unstable, fluctuating renal function
What are two drugs dosed based on GFR?
SGLT2is
Metformin
Albumin in the urine is used to measure what?
Assess kidney disease
Albuminuria/proteinuria
What are the CKD guidelines?
KDIGO
What are the 2 criteria that confirms a CKD diagnosis?
eGFR < 60 mL/min/1.73 m2
Albumineria (AER ≥ 30)
What meds are used to delay CKD progression?
ACEi/ARBs SCr may increase up to 30%
SGLT2i
Finerinone
What drugs require dose reduction in CKD?
Anti-infectives (aminoglycosides, beta-lactams, fluconazole, quinolones, vanco)
Cardiovascular drugs (DOACs, enoxaparin)
GI drugs (H2RAs, metoclopramide)
Bisphosphonates
Lithium
What drug is contraindicated in CrCl < 60 mL/min?
Nitrofurantoin
What drugs are contraindicated in CrCl < 50 mL/min?
Tenofovir disoproxil
Voriconazole IV only
What drugs are contraindicated in CrCl < 30 mL/min?
Tenofovir alafenamide
NSAIDs
Dabigatran
What drug is contraindicated in CrCl < 30 mL/min?
Metformin
What some drugs that have CrCl limitations?
Meperidine
Rivaroxaban (Xarelto)
SGLT2i
What should be monitored in advanced kidney disease/CKD?
PTH (elevated)
Phosphorus (elevated)
Calcium (low)
Vitamin D (low)
What are some phosphate binders for CKD hyperphosphatemia?
Aluminum hydroxide
Calcium acetate/carbonate** (hypercalcemia risk)
Sucroferric oxyhydroxide
Ferric citrate
Lanthanum carbonate
Sevelamer (most common, may lower LDLs)
What drugs should be separated from phosphate binders administration?
Levothyroxine
Quinolones
Tetracyclines
What is vitamin D3 and what is vitamin D2? What is the active form?
D3 = cholecalciferol (from UV of the sun)
D2 = ergocalciferol (from diet)
Calcitriol = ACTIVE form
What are some treatments for hyperparathyroidism
Vitamin D analogs (ie. Calcitriol)
Calcimimetics (cinacalcet, etelcalcetide)
What are the treatments of anemia in CKD? What is needed for this medication to be effective? What is the Hgb limit?
Erythropoesis-stimulating agents (ESA)
- epoetin alfa, darbapoetin alfa
(Increased risk of HTN and thrombosis)
only for Hgb < 10! [even though Hgb <13 is anemia])
Adequate iron necessary (can give IV iron)
What is a normal potassium level?
Normal K = 3.5 - 5 mEq/L
What drug causes an increase in intracellular shift of potassium?
Insulin
(Pts w diabetes are at higher risk of hyperkalemia d/t lower insulin)
What is the most common cause of hyperkalemia?
Renal failure
What adverse events may occur in hyperkalemia?
Muscle weakness
Bradycardia
Fatal arrhythmias
What drugs raise K levels?
ACEi/ARBs
Aliskerin
Canagliflozin
Drospirenone COCs
K-sparing diuretics
Bactrim
Cyclosporine/tacrolimus
What drug may be given to prevent arrhythmias in the setting of hyperkalemia?
Calcium gluconate (preferred) or chloride
What medications can shift K intracellularly in the setting of hyperkalemia?
Insulin (regular) + dextrose
Sodium bicarbonate
Albuterol (nebulized)
What medications can be given to eliminate K from the body in hyperkalemia?
Loop diuretics
[Potassium binders]
Sodium polystyrene sulfonate
Sodium zirconium cyclosilicate
Patiromer
Hemodialysis
What factors affect if/how much drug is removed during dialysis?
Molecular weight/size
Vd (larger Vd = less removed by dialysis)
Protein-binding
Dialysis membrane
Blood flow rate
Define hepatitis
Inflammation of the liver
Describe hepatitis A
Acute & self-limiting
Transmission: fecal-oral
- improper handwashing, contaminated food/water
Sx: mild and non-specific
Describe hepatitis B and C (HBV, HCV). What is a preventative measure?
Acute + chronic illness
Sx: chronic infection, cirrhosis, liver cancer, liver failure, death
Transmission: blood (B+C), body fluids (B)
All adults should get the HBV vaccination
Treatments for hep A? B? C?
Hepatitis A = supportive only
Hepatitis B = Peg-interferon, NRTI (tenofovir, entecavir)
Hepatitis C = Direct-acting antivirals combo
Treatment for naive hepatitis C patients w/o cirrhosis (2)
Glecaprevir/pibrentasa (Mavyret) x 8 weeks [with food! Avoid w statins]
Sofosbuvir/velpatasvir (Epclusa) x 12 weeks [avoid amiodarone, PPIs]
All DAAs = avoid strong CYP3A4 inducers
What is the MOA of NRTIs?
Inhibit HBV replication by inhibiting polymerase
What NRTIs are primarily used for hepatitis B treatment?
Tenofovir disoproxil fumarate (TDF) [renal tox, Falcons syndrome, weak bones]
Tenofovir alafenamide (TAF) [renal tox, Falcons syndrome, weak bones]
Entecavir (Baraclude) [take wo food]
Lamivudine do not use for HIV, since hep B dose is lower and may cause resistance
Interferon alfa is used in hepatitis B treatment. What is the advantage of using pegylated interferon alfa (Pegasus)?
Pegylated = prolongs half life
Pegylated interferon alfa is used in hepatitis B treatment. What are its boxed warnings? Major AEs?
Boxed warnings:
Neuropsychiatric disorders
Autoimmune diseases
Ischemic diseases
Infectious diseases
AEs:
CNS effects, GI, increased LFTs, flu-like sx (pretreat w APAP and antihistamine)
Define cirrhosis
Advanced fibrosis/scarring of the liver, most commonly caused by hep C and alcohol abuse
What is the defining clinical presentation of cirrhosis
JAUNDICE
What are the lab values to look at for cirrhosis?
Increased AST/ALT (unless extremely advanced, then normal)
Increased Alk phos
Increased total bilirubin, lactate dehydrogenase
Increased PT INR
Decreased albumin
What assessment tool is used to assess severity of liver disease?
Child-Pugh
In alcoholic liver disease, is AST or ALT generally higher?
AST is generally 2x higher than ALT
What natural product is used for liver disease? Which natural product is a known hepatotoxins?
Treatment: Milk thistle
Hepatotoxins: Kava,
What lab value limit indicates that a hepatotoxic medication should be D/Ced?
> 3x ULN LFTs
What are some common hepatotoxic drugs? (10)
APAP
Amiodarone
Isoniazid
Ketoconazole
Methotrexate
Nefazodone
Nevirapine
PTU
Valproic acid
Zidovudine
What is the treatment for alcohol-associated liver disease?
Alcohol cessation
BZD = withdrawal
Naltrexone, acamprosate, disulfiram = prevent relapses
Thiamine = prevent Wernickes-Korsakoff
Portal hypertension can cause what secondary condition?
VARICEAL BLEEDING: portal HTN causes blood to back up and enlarge, with the risk of rupture
What non-pharm and pharm treatments can be used in variceal bleeding? What drug class can be used for prevention?
Non-pharm: Band ligation, sclerotherapy
Pharm: octreotide, vasopressin (splanchnic vasodilation)
Prevention: non-selective BB [nadolol, propranolol, carvedilol]
What are symptoms of hepatic encephalopathy?
Breath with musty odor
Neuro changes (confusion, forgetfulness)
Asterixis (hand flapping)
What are the treatments for hepatic encephalopathy?
Non-absorbable disaccharide (to flush out ammonia) + antibiotic
Lactulose + Rifaximin
All patients with cirrhosis and ascites should be considered for….?
Liver transplant
What are the non-pharm ways of managing ascites due to portal HTN?
Restrict dietary sodium intake to <2g per day
Paracentesis (if severe) with albumin replacement
What drugs may be used in patients with ascites?
Spironolactone monotherapy
OR
Spironolactone + furosemide
Furosemide alone is NOT effective
What is the ideal ratio of furosemide to spironolactone dosing for ascites threat ent (to maintain K+ balance)?
40 mg furosemide : 100 mg spironolactone
How much albumin should be replaced per liter of fluid removed via paracentesis from a patient w ascites?
If removing >5 L fluid, give 6-8 grams albumin per L removed
What is spontaneous bacterial peritonitis?
Acute infection of the ascitic fluid
What drug is used to TREAT SBP? What is used for secondary prophylaxis once a patient has had an episode of SBP?
Treatment: Ceftriaxone x 5-7 days
Secondary prophylaxis: PO ciprofloxacin or Bactrim
What is hepatorenal syndrome?
Development of renal failure in patients with advanced cirrhosis as a result of renal vasoconstriction mediated by RAAS and sympathetic nervous system by the hepatorenal reflex.
