Chapter 18: Renal Disease Flashcards
Most common causes of CKD?
HTN and diabetes
Which diuretic works at the loop of henle?
loop diuretics
Which diuretic works at the distal convoluted tubule?
thiazide diuretics
Loop diuretics block which pump & where?
Na-K pump in the ascending limb of the loop of Henle
Thiazide diuretics block which pump?
Na-Cl
Loop diuretics cause (increased/decreased) Ca reabsorption back into the blood
while thiazide diuretics cause (increased/decreased) Ca reabsorption
Decreased; increased
Long-term use of loop diuretics can (increase/decrease) bone density
whereas long-term use of thiazide diuretics can (increase/decrease) bone density
Decrease
increase
When aldosterone antagonists like spironolactone and eplerenone block aldosterone, more ___ and ___ are excreted in the urine and serum ___ increases
Na, water
K
What is the normal range for Scr?
0.6-1.3 mg/dL
CKD is generally defined as GFR ____ and/or _____
<60 ml/min
albuminuria
What drugs are first-line in preventing progression of disease in pts with CKD, diabetes and/or HTN if albuminuria is present?
ACE-I and ARB
When starting treatment with an ACEi or ARB, the baseline SCr can increase by up to ___%. This is normal and treatment should not be stopped
30%
What should you counsel a patient on when taking an ACE-I or ARB?
Avoid potassium supplements and salt substitutes
Patients with advanced kidney disease require monitoring of
PTH
phosphorous
Ca
Vitamin D levels
What is the MOA of phosphate binders?
Block absorption of dietary PO4 by binding to it in the intestine
When are phosphate binders taken? What is the frequency?
TID with meals or right before a meal
Which phosphate binders are first line?
Calcium-based (i.e. Ca acetate, Ca carbonate)
What is a side effect of calcium-based phosphate binders?
hypercalcemia
especially when used with vitamin D due to increased Ca absorption
Which phosphate binders are non-Ca and non-aluminum
Sevelamer carbonate
Sevelamer Hcl
What is unique about sevelamer?
Can lower total cholesterol and LDL by 15-30%
What are high levels of PTH treated with?
vitamin D
How does Vitamin D deficiency occur?
when the kidneys cannot hydroxylate vitamin D to the active form
1,25-dihydroxy vitamin D
What is the difference between vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol)
D3 is synthesized in the skin after UV exposure
D2 is produced by plant sterols and is the primary source of dietary vitamin D
What is the MOA of vitamin D analogs?
increase intestinal absorption of Ca
raising serum calcium concentrations
inhibit PTH secretion
What is the MOA of calcimimetics?
increases sensitivity of Ca-sensing receptor on PT gland
causing decreased PTH
decreased Ca
decreased phosphate
What is an ADE of cinacalcet?
hypocalcemia
A sudden loss of kidney function due to a non-renal condition (e.g., drugs)
Acute Kidney Injury (AKI)
Common cause of AKI
dehydration
How can AKI present
BUN:SCr ratio > 20:1
plus decreased urine output
dry mucous membranes
tachycardia
What drug class works at the proximal tubule
SGLT2 inhibitors
Where does aldosterone work in the kidney
DCT
collecting duct
What does aldosterone do
Increases Na and water reabsorption
decrease K reabsorption
Which key drugs can cause kidney disease
Aminoglycosides Amphotericin B Cisplatin Cyclosporine Loop diuretics NSAIDs Polymyxins Radiographic contrast dye Tacrolimus Vancomycin
Besides renal impairment, what else can cause increased BUN
dehydration
Low muscle mass = ____ SCr
low
When is the Cockcroft-Gault formula not preferred
Very young children
in ESRD
in unstable renal function
Which two drugs use GFR instead of CrCl for dose adjustments
SGLT2 inhibitors
metformin
Which key drugs require dose decrease or increase interval in CKD
- Aminoglycosides (increase dosing interval)
- BL antibiotics (except antistaphylococcal PCNs and ceftriaxone)
- Fluconazole
- Quinolones (except moxifloxacin)
- Vancomycin
- LMWHs (enoxaparin)
- Rivaroxaban (for AFib)
- Apixaban (for AFib)
- Dabigatran (for AFib)
- H2RAs (famotidine and ranitidine)
- Metoclopramide
- bisphosphonates
- Lithium
Key Drug(s) that are CI in CrCl < 60 mL/min
Nitrofurantoin
Key Drug(s) that are CI in CrCl < 50 mL/min
- Tenofovir disoproxil fumarate containing products
- e.g., Stribild
- Complera
- Atripla
- Symfi
- Symfi Lo
- Voriconazole IV
Key Drug(s) that are CI in CrCl < 30 mL/min
- Tenofovir alafenamide containing products (e.g., Genvoya, Biktarvy, Descovy, Odefsey, Symtuza)
- NSAIDs
- Dabigatran (DVT/PE)
- Rivaroxaban (DVT/PE)
Key Drug(s) that are CI in GFR < 30 mL/min/1.73m2
- SGLT2 inhibitors
canagliflozin
dapagliflozin
empagliflozin
- Metformin
Treatment of hyperphosphatemia is initially focused on
Restricting dietary phosphate
e.g.,
avoid dairy products
cola
chocolate
nuts
If a dose of a phosphate binder is missed and a patient has already eaten, what should be done
The dose should be skipped
What are the 3 types of phosphate binders
- aluminum based
- calcium based
- aluminum free, calcium free drugs
What is a side effect of aluminum hydroxide
“dialysis dementia”
Benefits of aluminum-free, calcium-free phosphate binders
No aluminum accumulation
less hypercalcemia
Counseling point for lanthanum carbonate
Must chew tablet thoroughly to reduce risk of severe GI adverse effects
Side effect of ferric citrate
Iron absorption
dose reduction of IV iron may be necessary
Side effects of Lanthanum carbonate
Nausea/vomiting
diarrhea
constipation
Side effects of sevelamer
N/V/D
Phosphate binders must be separated from ____ and ___
levothyroxine
and antibiotics that chelate (e.g., quinolones and tetracyclines)
Calcium-based phosphate binders interact with many drugs, including
Quinolones
tetracyclines
oral bisphosphonates
thyroid products
What drug must be taken 1 hour before both Sucroferric oxyhydroxide and ferric citrate
Doxycycline
What drug should be separated by 2 hours from ferric citrate
ciprofloxacin
Which drug should not be used with sucroferric oxyhydroxide
levothyroxine
Which drug class should be given 1 hour before or 2 hours after lanthanum
quinolone antibiotics
Which drug should be separated by at least 2 hours from lanthanum
Levothyroxine
Which drug class should be given 2 hours before or 6 hours after sevelamer
quinolone antibiotics
____ serum concentrations can be decreased and doses of these medications should be given several hours before sevelamer
Levothyroxine
What is the active form of vitamin D3
Calcitriol
Which drug is a calcimimetic
Cinacalcet (Sensipar)
Side effect of Vitamin D analogs
Hypercalcemia
Cinacalcet brand name
Sensipar
Side effects of etelcalcetide
Muscle spasms and paresthesia
Which drug class can prevent the need for blood transfusions
Erythropoiesis-stimulating agents (ESAs)
Which ESA is long-acting
darbepoetin alfa
Brand names of epoetin alfa
Procrit
Epogen
Brand name of darbepoetin alfa
Aranesp
Risks of ESAs
elevated BP
thrombosis
ESAs should only be used when Hgb is < ___ g/dL
The dose of ESAs should be held or d/c if the Hgb exceeds ___ g/dL
10
11 (risk of thromboembolic disease is increased with higher Hgb levels)
ESAs are only effective if adequate ____ is available to make Hgb
iron
What is the most abundant intracellular cation
Potassium
Renal K excretion is increased by ___ & ___
aldosterone diuretics (loops > thiazides)
What causes K to shift into the cells
insulin
Which patients are at a higher risk for hyperkalemia
Pts with diabetes
insulin deficiency reduces the ability to shift K into the cells
many pts with diabetes take ACEi or ARBs
Symptoms of hyperkalemia
Muscle weakness
bradycardia
fatal arrhythmias
Key drugs that can increase K levels
ACEi Aldosterone receptor antagonists Aliskiren ARBs Canagliflozin Drosperinon-containing COCs Potassium-containing IV fluids (including PN) K supplements Trim-Sulfa Transplant drugs (cyclosporine, everlomius, tacrolimus)
What should be done to the pts meds if they have hyperkalemia
D/c all K sources
What is done first if hyperkalemia is severe
There is an urgent need to stabilize the myocardial cells to prevent arrhythmias
want to rapidly shift K intracellularly or induce elimination from the body
Which med is used in hyperkalemia to stabilize the heart/prevent arrhythmias
Calcium gluconate (IV) Onset: 1-2 min
Which meds are used in hyperkalemia to shift K intracellularly
Include route and onset
Regular insulin (IV)
Dextrose (IV)
Sodium bicarb (IV)
Albuterol (nebulized)
Onset: all 30 min
Which meds are used in hyperkalemia to eliminate K from the body
Furosemide (IV) Onset: 5 min
Sodium polystyrene sulfonate (oral) Onset: 1 hr
Patiromer (oral) Onset: 7 hrs
Sodium zirconium cyclosilicate (oral) Onset: 1 hr
Hemodialysis Onset: immediately
sodium polystyrene sulfonate brand name
Kayexalate
sodium polystyrene sulfonate warning
Can bind to other oral meds
patiromer warnings/SE
WARNINGS
Hypomagnesemia
Binds to many oral drugs, separate by at least 3 hours before or 3 hours after
SE
Constipation
sodium zirconium cyclosilicate warning
can bind other drugs
separate by at least 2 hours before or 2 hours after
What is required if CKD progresses to failure (Stage 5 disease)
Dialysis
Drug removal during dialysis depends primarily on which factors
Molecular weight/size
Vd
Protein-binding
High-flux and high-efficiency HD filters & higher dialysis blood flow rates
