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Studying for the Naplex > Chapter 18: Renal Disease > Flashcards

Chapter 18: Renal Disease Flashcards

1
Q

What are the two most common causes of renal disease?

A
  1. Diabetes

2. Hypertension

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2
Q

What are the less common causes of chronic kidney disease?

A
  1. Polycystic kidney disease
  2. Infections
  3. Renal artery stenosis
  4. Drug-induced kidney disease
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3
Q

What are the conditions related to chronic kidney disease that a pharmacist must treat?

A

Anemia
Hypertension
Acid-base and electrolyte disturbances
Mineral and bone disorders (Calcium, vitamin D, PTH, and phosphorus)

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4
Q

What is the functional unit of the kidney? What is its job?

A

It is the nephron. It’s job is to maintain sodium and water balance in the kidneys. It reabsorbs what is vital back into the blood and it excretes garbage out into the urine. This is what maintains blood volume and then ultimately blood pressure.

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4
Q

What is the functional unit of the kidney? What is its job?

A

It is the nephron. It’s job is to maintain sodium and water balance in the kidneys. It reabsorbs what is vital back into the blood and it excretes garbage out into the urine. This is what maintains blood volume and then ultimately blood pressure.

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5
Q

On average, how many nephrons are there in a kidney?

A

1 million

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6
Q

What parts make up the nephron?

A
  1. Bowman’s capsule
  2. Afferent and efferent arterioles
  3. Glomerulus
  4. Proximal tubule
  5. Descending limb of the loop of henle
  6. Ascending limb of the loop of henle
  7. Distal convoluted tubule
  8. Collecting duct
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7
Q

What parts make up the nephron?

A
  1. Bowman’s capsule
  2. Afferent and efferent arterioles
  3. Glomerulus
  4. Proximal tubule
  5. Descending limb of the loop of henle
  6. Ascending limb of the loop of henle
  7. Distal convoluted tubule
  8. Collecting duct
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8
Q

What happens in the glomerulus?

A

Blood enters into the glomerulus through the afferent arteriole. If the material in the blood is less than 40000 daltons, it will not be filtered out and it will enter the tube of the nephron. If the glomerulus is healthy, materials larger than 40000 daltons will be filtered out and they will re-enter into the blood by using the efferent arteriole. If the glomerulus was not healthy, it would not be able to filter out the materials and it would be excreted out into the urine. We would see albumin or protein-bound drugs in the urine. This is actually how we diagnose CKD. We look at CrCl and albumin in the urine.

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9
Q

What happens in the proximal tubule?

A

The proximal tubule is the part following the bowman’s capsule. Here, the Na, Ca, K, and H20 that managed to get filtered into the nephron tube by the glomerulus gets reabsorbed back into the blood here.

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10
Q

What drugs act on the proximal tubule?

A

SGLT2 inhibitors

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11
Q

What are some examples of SGLT2I’s? Give me brand and generic names. What do they do

A

Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
They treat Type 2 Diabetes by lowering blood sugar. They do this by acting on the proximal tubule to excrete sugar out into the urine.

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12
Q

What happens in the loop of henle?

A

The loop of henle is the part after the proximal tubule. It consists of two parts which are the descending loop and the ascending loop of henle. In the descending loop, water is reabsorbed into the blood but Na and Cl continue on. In the ascending loop, Na and Cl are reabsorbed into the blood but water continues on. If ADH is present, water will reabsorb back into the blood in the ascending loop. Vasopressin is another name for ADH. As a result of the ADH, there will be less water in the urine.

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13
Q

What do loop diuretics do? What are some examples?

A

Loop diuretics act on the loop of henle by inhibiting the Na-K pump. This prevent Na and K from reabsorbing back into the blood and there is more of it in the urine. This also causes more calcium to be excreted into the urine and as a result, the patient has less Ca in them. This can actually cause bone disorders.

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14
Q

What happens at the distal convoluted tubule?

A

Material such as Na, K, Ca, and water continue to pass through here, just at a much smaller amount. This location is the furthest part away from the bowman’s capsule. Thiazide diuretics work on this area. Thiazide diuretics work by blocking the Na-Cl transporters. This causes Na and Cl to be excreted out. Thiazide diuretics actually do not waste calcium so it does not cause hypocalcemia. This is a benefit over the loop diuretics.

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15
Q

What happens in the collecting duct?

A

The collecting duct is a network of tubules that connects the kidneys with ureters. These ureters then drain the urine into the bladder and then in the end, the urine gets excreted out of the bladder. Aldosterone antagonists and potassium sparing diuretics act on the distal convulated tubules and collecting duct to excrete out Na and Cl but keep serum K high in the body. Loop diuretics and thiazude diuretics waste potassium and cause hypokalemia.

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16
Q

What is drug-induced kidney disease?

A

There are nephrotoxic drugs that can cause damage to the kidneys. This could be reversible in which the drug is stopped and then the damage ceases. However, it could also be irreversible. The risk of it increases when there is renal artery stenosis, old age, hypertension, obesity, etc…

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17
Q

Where is drug-induced kidney disease most common?

A

In the hospital setting

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18
Q

What are drugs that cause damage to the kidneys?

A 
Aminoglycosides
Amphoterecin B
Cisplatin
Cyclosporine
Loop diuretics
NSAIDS
Polymyxin B
Radiographic Contrast Dye
Tacrolimus
Vancomycin
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19
Q

What are the lab values most commonly used to assess kidney dysfunction?

A

BUN and Scr. Blood urea nitrogen is a byproduct of protein metabolism. It is nitrogen in the blood that comes from urea, the byproduct of protein metabolism. As kidney dysfunction progresses, the higher BUN becomes. However, this may be inaccurate because BUN also increases during dehydration. Serum creatinine is a product of muscle metabolism. It is filtered by the glomerulus but it will show up in the urine if kidney dysfunction progresses.

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20
Q

What is the normal range for Scr?

A

0.6-1.3 mg/dl

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21
Q

What equation is used to determine kidney function?

A

Cockroft-Gault equation

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22
Q

What certain conditions can have an effect on muscle turnover and therefore make the cockroft-gault equation inaccurate? (Overestimation)

A

Old age, obesity, liver damage, pregnancy

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23
Q

Write down the cockroft-gault equation on paper. This should be engraved in your brain as a pharmacist.

A
24
Q

What are examples of drugs that require dose determination by the cockroft gault equation?

A

SGLT2-inhibitors and Metformin

25
Q

What equations are used to determine GFR?

A

MDRD (Modification of Diet in Renal Disease)

CKD-EPI

26
Q

What guidelines recommend looking at GFR and albumin levels to determine kidney function?

A

KDIGO

KDOQI

27
Q

What are the GFR Categories?

A 
G1: >90 mls/min + kidney damage
G2: 60-89 mls/min + kidney damage
G3a: 45-59 mls/min
G3b: 30-44 mls/min
G4: 15-29 mls/min
G5: <15 mls/min
28
Q

What are the Albuminuria categories?

A

A1: <30 mg/g
A2: 30-300 mg/g
A3: >300 mg/g

29
Q

Hypertension is a condition that must be treated when treating CKD. What is the goal SBP?

A

To be below 120 mmHg

30
Q

What is the first-line treatment for treating hypertension in a patient with CKD?

A

ACEi or ARB.

31
Q

What criteria must the patient meet before being considered treatment with an ACEi or ARB?

A

Must have: Hypertension, CKD, and Albuminuria.

32
Q

Diabetes is another condition that correlates with CKD and must be treated. What are the first-line medications for treating it?

A
  • Metformin

- SGLT2i’s

33
Q

What criteria must the patient meet in order to be treated with the first-line medications for diabetes?

A

The patient must have CKD, type 2 diabetes, and an eGFR above 30 mls/min. If the patient cannot tolerate using an SGLT2i, the patient should use a GLP-1 inhibitor instead.

34
Q

As CKD progresses, Drug dosages and drug selections may need to change (Drug modification). There are certain scenarios with it.

A
  1. The drug is eliminated through the kidneys. The drug may need to have its dose decreased or have its dosing interval extended.
  2. The drug is nephrotoxic and can cause further damage (NSAIDS)
  3. The drug has decreased effectiveness as the kidney worsens (Thiazide diuretics, nitrofurantoin)
  4. The drug that is usually beneficial can actually cause damage when the kidney is now functioning at a low level (low eGFR). This includes anticoagulants.
35
Q

About what point should drug modifications be made during CKD?

A

When the eGFR reaches about 60 mls/min, drug modifications are more than likely to be made. At less than 30 mls/min, further modifications must be made or the drug may just be fully contraindicated at that point.

36
Q

Know the key drugs that require decreased dose or increased interval with CKD

A

Page 296: I can’t write it here. It has to be drawn out. You must know it though.

37
Q

What is one of the complications of Chronic Kidney Disease?

A

Mineral and bone disorders

38
Q

What is there an increased risk of when there is mineral or bone disorders present?

A

Fractures, cardiovascular disease, and mortality.

39
Q

What lab values need to be monitored in mineral and bone disease?

A

Calcium
Vitamin D
Phosphorus
Parathyroid hormone

40
Q

What is hyperphosphatemia? Why do we care about it?

A

This is when there is too much phosphate in the body. Too much phosphate in the body contributes to large parathyroid levels (This is secondary hyperparathyroidism) and it causes bone disease. This is why we need to have healthy levels of phosphate.

41
Q

How do we treat hyperphosphatemia?

A

Initially, we want to restrict dietary sources of phosphate (dairy products, cola, nuts, chocolate.) As CKD progresses however, we will need to use phosphate binders.

42
Q

How do phosphate binders work?

A

They bind to phosphate in the intestines and then get excreted out in the feces.

43
Q

What are the 3 types of phosphate binders?

A
  1. Aluminum-based
  2. Calcium-based
  3. Aluminum-free, calcium-free, based.
44
Q

What are some examples of phosphate binders? What are side effects to watch out for?

A 
Aluminum Hydroxide: Osteomalacia, constipation, Nausea
Calcium Acetate: Hypercalcemia, constipation, nausea
Calcium Carbonate (Tums): Hypercalcemia, constipation, nausea
45
Q

Explain how chronic kidney disease causes the disproportions of the minerals in the body?

A

When the kidneys are not healthy, the kidneys are not able to eliminate phosphorus and we get an accumulation of it. When the kidneys are not healthy and functioning properly, they are unable to activate vitamin D and this causes calcium to not be reabsorbed back into the body. We lose calcium. So now we have high phosphorus and low calcium. This causes high PTH which then leads to cardiovascular disease. With low calcium, the body compensates by pulling calcium out of the bones and this hurts the bones. The bones are then unable to create erythropoietin.

46
Q

What other drugs do phosphate binders interact with?

A

All 3 types of phosphate binders can interact badly with synthroid products, quinolones, and tetracyclines.

47
Q

How is hyperparathyroidism treated?

A

After phosphorus has been treated, PTH levels need to be lowered down by being treated with Vitamin D supplementation. Vitamin D is needed to help with calcium reabsorption. Bad kidneys are not able to synthesize Vitamin D into its final active form, 1,25 dihydroxyvitamin D. When phosphorus and calcium are controlled, the PTH will decrease.

48
Q

What are the alternative names for vitamin D2 and Vitamin D3?

A

Vitamin D2: Ergocalciferol
Vitamin D3: Cholecalciferol

Both of these are usually used in early CKD.

49
Q

What vitamin D analogs are used to treat hyperparathyroidism in a deep stage of CKD?

A

Calcitriol (Rocaltrol)

Cinacalcet (Sensipar)

50
Q

What is anemia? How does it happen?

A

Anemia is defined as having a hemoglobin level that is below 13 g/dl. Anemia occurs when the bad kidneys are not able to produce erythropoietin (EPO) and the bones are unable to create red blood cells. Red blood cells are what carry hemoglobin and travel around the body to deliver oxygen.

51
Q

What are the symptoms of anemia?

A

Fatigue, pale skin

52
Q

How is anemia treated?

A

Anemia is treated by providing erythropoietin-stimulating agents (ESA’s). Examples of these would be Epoietin Alfa (Procrit) or Darbepoietin Alfa (Aranesp). These should be initiated when hemoglobin level is below 10 g/dl. Once used, ESA’s should be stopped when the hemoglobin level reaches 11 g/dl to prevent unwanted side effects (thrombosis, DVT, etc…) However, ESA’s are only effective if iron levels in the patient are adequate. If they are not adequate, the ESA’s will not work.

53
Q

What is looked at on an iron label?

A
  1. Ferritin
  2. TSAT
  3. Iron
54
Q

What is the normal level of potassium?

A

3.5 - 5 mEq/L

Greater than 5 is considered hyperkalemia and should be of concern to healthcare providers.

55
Q

How is potassium normally obtained?

A

Potassium is usually obtained in the diet (Meat, fruits, and vegetables). Hyperkalemia occurs when the bad kidneys are not able to excrete out potassium. Hyperkalemia also occurs in diabetes patients because insulin deficiency causes potassium to be unable to enter into the cells and that accumulation causes hyperkalemia.

56
Q

What are the symptoms of hyperkalemia?

A

Muscle cramps, bradycardia, or fatal arrhythmias. Usually the person doesn’t know they have hyperkalemia until these things occur.

57
Q

What drugs cause hyperkalemia?

A 
ACEI's
ARBs
Aliskiren
Aldosterone Antagonists
Canagliflozin
Drosperinone Containing COC's
Sulfamethoxazole/Trimethoprim
Potassium containing supplements
Transplant drugs (Tacrolimus/Sirolimus)

Studying for the Naplex (13 decks)

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