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Therapeutics I > Block 4: CKD Complications > Flashcards

Block 4: CKD Complications Flashcards

1
Q

What are the symptoms of CKD-MBD?

A
  1. Bone pain
  2. Skeletal fracture
  3. Vasculature calcification
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2
Q

What are the symptoms of anemia?

A
  1. Fatigue
  2. SOB
  3. Cold tolerance
  4. Tingling in extremities
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3
Q

What is CKD-MBD?

A

Systemic disorder of mineral and bone metabolism from CKD

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4
Q

What are the manifestations of CKD?

A
  1. Abnormal phosphorus, calcium, PTH, FGF23, or vitamin D
  2. Abnormal bone turnover
  3. Vascular or soft tissue calcifications
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5
Q

What are the clinical manifestations of CKD?

A

symptomatic = irreversible damage

Prevention is key

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6
Q

How should we monitor the stages of CKD?

A
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7
Q

What are the goals of CKD monitoring?

A
  1. Avoid hypercalcemia
  2. Maintain Phos towards normal range
  3. Avoid PTH elevations (2-9 x ULN in ESRD)
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8
Q

What are the normal lab values for CKD?

A
  1. Corrected Calcium 8.4 -10.2 mg/dL
  2. PTH (normal 10-65 pg/mL):
    Stage 3 CKD: 35-70 pg/mL
    Stage 4: 70-110 pg/mL
    Stage 5: 200-300 pg/mL (2-5 x ULN)
    HD: 2-9 x ULN
  3. Phosphorous 3-4.5 mg/dL
  4. 25(OH)D >30 ng/mL
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9
Q

How should you first manage elevated PTH?

A

Evaluate phosphorus, calcium, vitamin D, PTH

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10
Q

What do you do if phosphorus is the cause of CKD?

A
  1. Reduce dietary phosphorus (reduction of protein sources)
  2. Phosphate binders
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11
Q

What is the first line phosphate binder?

A

Calcium-based binders:
Carbonate and acetate

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12
Q

What are the resin binders? When do you use it?

A

Sevelamer HCl and carbonate

If patient has normo or high calcium

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13
Q

What are iron-based binders?

A
  1. Ferric citrate: anemia, iron overload
  2. Sucroferric oxyhydroxide
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14
Q

What are the ADRs of phosphate binders?

A
  1. Constipation
  2. NVD
  3. Abdominal pain
  4. Hypercalcemia with calcium binders
  5. Iron overload with ferric citrate
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15
Q

What are the counseling points of phosphate binders?

A
  1. Take with food → binds to food in intestine
  2. Space out with iron, zinc, quinolone ABX (1-2 hr before or 3 hr after binder)
  3. Have blood work done regularly to check phosphate levels
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16
Q

What are KDIGO rec for phosphate binders?

A
  1. Calcium based binders max 1500 mg elemental calcium (can add non-calcium binders if max dose is reached)
  2. Consider non-calcium based binder in HD patients with calcifications
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17
Q

What is the treatment if vitamin d def is a cause of the CKD?

A
  1. Nutritional
  2. Calcitriol
  3. Vitamin D analogs
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18
Q

What are the nutritional vit d?

A
  1. Ergocalciferol (D2)
  2. Cholecalciferol (D3)
  3. Calcifedial (prohormone): already activated
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19
Q

What are the vitamin d analogs?

A
  1. Paracalcitol
  2. Dovercalciferol
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20
Q

What is the difference between D2 and D3?

A

D3: animal
D2: plant

Activated by the liver then kidney

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21
Q

What are the dosing of D2 and D3?

A

D<30: 50,000 IU PO QM x 6 months
D<5: 50,000 IU PO QW x 12 weeks then monthly x 6 months

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22
Q

How does calcifediol differ from D2 and D3? Dosing?

A

No need liver activation but kidney activation

Dose: 30 mcg PO QD

Increase the level more rapidly

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23
Q

What is calcitriol? ADRs?

A

Activated form increases 25 OHD quicker than the other

Risk of hypercalcemia and phospatemia

Extensive PPB

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24
Q

How is calcitriol dosed?

A

0.25 mcg po daily or 1-2 mcg IV TIW

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25
Q

in what instance would you not use calcitriol?

A

Cautioned for CKD 5 cause it is non-dialyzable

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26
Q

What is the MOA of vitamin D2 analogs?

A

Mimic Vitamin D without increasing Ca/P due to its direct action on the PT gland

27
Q

What is the dosing for paracalcitol? Metabolism?

A

ND: PTH </=500: 1 mcg po daily or 2 mcg po TIW
PTH >500: 2 mcg po daily or 4 mcg po TIW

ESRD: 0.04-1 mcg/kg IV TIW

Active as given and undergoes CYP3A4 metabolism

28
Q

What is the dosing of doxercalciferol? Metabolism?

A

ND: 1 mcg po daily
ESRD: 10 mcg po TIW

Requires conversion by liver to active form

29
Q

What is first line vitamin D for CKD-ND?

A

1st: Nutritional vitamin D

Calcitriol and vitamin D analogs for G4-5 with severe and progressive hyperPT

30
Q

What vitamin D recommended for HD?

A

Calcitriol, vit d analog and/or calcimimetics

31
Q

What are the ADRs of vitamin D?

A
  1. Hypercalcemia
  2. Hyperphosphatemia
32
Q

What are examples of calcimimetics?

A
  1. Cinacalcet
  2. Etelcalcetide
33
Q

How do you dose cinacalcet? Counseling point? Metabolism?

A

30 mg PO QD

CYP metabolism and high PPB

Take with food

34
Q

How do you dose etelcalcetide? Metabolism?

A

5 mg IV TIW

Renal cleared

35
Q

What is the MOA of calcimimetics? Warning?

A

↑ sensitivity of Ca-sensing receptor on PTH gland

Only approved for ESRD

Don’t start if corrected Ca below normal

36
Q

What is the ADR of calcimimetics?

A

Hypocalcemia, N/V

37
Q

What is the primary cause of anemia?

A

↓ EPO production and ↓ RBC production

38
Q

What is the secondary cause of anemia?

A

↑ hepcidin → ↓ GI iron absorption

39
Q

What are the symptoms of anemia?

A
  1. Fatigue
  2. SOB
  3. Cold intolerance
  4. Tachycardia
  5. Tingling in extremities
  6. HA
  7. Malaise
40
Q

How do you diagnose anemia?

A
  1. Symptoms
  2. Hgb <13 in males; ,12 in females
  3. Iron saturation: normal range 20 -50 % , if < 30 %
  4. Ferritin normal range 15-200 ng/Ml, higher in CKD. If < 500 ng/dL
41
Q

How often do you monitor Hgb?

A

CKD 3: yearly
CKD 4-5: Bianually
CKD 5D: Q3M

42
Q

What are the treatment options for anemia?

A
  1. PO and Injectable iron
  2. Injectable ESA
43
Q

What are the types of PO iron?

A
  1. Ferrous (sulfate, fumarate, gluconate)
  2. Ferric maltol
  3. Polysaccharide iron complex
  4. Carbonyl iron
44
Q

How do you dose PO iron?

A

200 mg elemental iron/day

45
Q

How much elemental iron is in oral preparations?

A

Ferrous sulfate 20%: 325mg
Fumarate 33%: 325 mg
Gluconate 12%: 324 mg
Iron polysaccharide 100%
Carbonyl iron 100%
Ferric maltol 100%

46
Q

What are the IV iron preps?

A

Iron dextran (1st gen)
Iron sucrose
Sodum ferric gluconate (2nd gen) → HD
Ferric carboxymaltose (3rd gen) → anemia
Ferumoxytol (3rd) → anemia

47
Q

What IV iron preps can cause anaphylaxis?

A

Ferumoxytol
Iron dextran

48
Q

What are the ADRs of PO iron?

A
  1. GI: constipation, nausea, cramping
  2. Take w/ food to reduce but will reduce absorption
  3. DI with calcium products, antacids, tetracyclines
49
Q

What are the ADRs of IV iron?

A
  1. Allergic reaction, hypotension, DZ, dysnpea, HA → reduce dose
  2. Anaphylaxis for dextran and ferumoxytol
  3. Avoid in active infections
50
Q

What is the KDIGO rec for iron therapy?

A

PO: 1st line in non-HD patients (1-3 month trial before initiating IV)
IV: 1st line for HD/PD patients (2nd line for non-HD patients)

51
Q

When should you give iron for anemia?

A

Hgb <13 in males; <12 in female
+
TSAT <30 % and Ferritin < 500 ng/mL

52
Q

When do you give ESA?

A

Hgb <10 without iron deficiency

Do not target Hgb >11.5

53
Q

What are the ESA products?

A
54
Q

What are the ADRs of ESA therapy?

A
  1. HTN
  2. Thrombosis
  3. Anitbody-mediated PRCA (pure red cell aplasia)

ESA >8 weeks with sudden Hgb drop (0.5-1 per week or 2 transfusion/week) with ARC (reticulocyte count) <10 with normal platelet and WBC

DC ESA

55
Q

What is the recommendation of ESA for Non-HD?

A

Darbepoetin and methoxy PEG-epoetin preferred due to longer half-lives

Consider costs of each agent

SQ preferred for patients w/o IV access

56
Q

How do you monitor ESA?

A

Initiated when Hgb <10

Weekly Hgb levels after initiation

Monthly Hgb levels once stable

Do not INCREASE the dose more frequently than monthly

Reduce or DC if Hgb approaches 11 in HD patients or 10 in non-HD patients

57
Q

How do you monitor ESA weekly based on Hgb levels?

A

DECREASE dose by 25% if Hgb rises >1 g/dL in 2 weeks

Increase dose by 25% if Hgb hasn’t increased by 1 g/dL in 4 weeks

58
Q

How do you monitor ESA monthly based on Hgb levels?

A

Acceptable Hgb increase is 1-2 g/dL per month

59
Q

What is ESA hyporesponsiveness?

A
  1. No increase from baseline after 1 month
  2. Do not escalate beyond double the initial dose
  3. If inadequate response after 12 weeks of dosing escalations, patients will likely not respond
60
Q

What is the MOA of antibody-mediated PRCA?

A

Antibodies that inhibit erythopoiesis

61
Q

When do you use antibody-mediated PRCA?

A

Patients on >8 weeks of ESA who’s:
1. Hgb decreases 0.5-1 g/dL per week OR
2. Require 1-2 transfusions per week, with Normal platelets and WBCs, AND
Abs reticulocyte count <10,000

62
Q

How do you manage antibody-mediated PRCA?

A
  1. DC ESA
  2. Give peginesatide 0.04 mg/kg SQ/IV QM
63
Q
A

Therapeutics I (32 decks)

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