Chronic Kidney Disease Flashcards
CKD incidence and prevalence
-estimated 1 million pt w ERSD by 2030
Major causes of CKD
-diabetes mellitus**
-HTN**
-glomerulonephritis
CKD staging
-abnormal kidney structure
-present for >3 months
-implications for health
-look mostly at CrCl and GFR
CKD classification
-cause
-GFR (less than 90)
-albuminuria (more than 30 mg/g or 3 mg/mmol)
-5 stages (stage 1 and 2 not noticible)
GFR categories
-G1: >90
-G2: 60-89
-G3a: 45-59
G3b: 30-44
G4: 15-29
G5: <15 (ESKD)
-lower value worse
Albuminuria categories
A1: <30mg/g or <3mg/mMol
A2: 30-300 or 3-30
A3: >300 or 30
-higher value worse
Life expectancy in CKD (ESKD)
-20 y/o might make it to 40
-60 y/o might make it to 65
Estimations of kidney function
- Cockroft and Gault formula
- MDRD formula
Cockroft and Gault formula
-estimate CrCl
-most common
-accurate for pt w stable kidney function
-good predictor of GFR
-tends to overestimate renal function in kidney impairment (10% of CrCl bypasses filtration)
-used most by Rph
Modification of Diet in Renal Disease (MDRD)
-most accurate measure of GFR
-accounts for race and gender
-eGFR used for staging
-CrCl used for dosing
Cockroft and Gault formula
Men: CrCl = (140-age)IBW / (Scr*72)
-multiply by 0.85 in women
-IBW 50 or 45.5+2.3(inches over 5ft)
-use AjBW if patient is 130% of IBW
AjBW = IBW+0.4(ABW-IBW)
MORD equation
-GFR = 170 x (Scr)^-0.999 x age x (SUN)^-0.170 x Alb^0.318
multiply by 0.762 if pt is female and 1.180 if pt is black
Why is albumin in kidney a big deal
-it’s a big protein and should have been filtered earlier
-indicates problem with filter
Complications from kidney disease
-Uremia
-Fluid Retention (diuretics wont work)
-Electrolyte imbalance (put some in dialysis fluid)
-mineral and bone disorder
-anemia
-not really seen until stage 4 and 5
Uremia
-accumuulation of waste molecules in the blood
-pruritus, confusion, N/V
Uremia assessment
-increased BUN value
Uremia effects
-encephalopathy
-Uremic fetor
-pulmonary edema
-sodium retention and volume overload in heart
-anorexia, N/V, constipation metallic taste
-mineral bone disorder, rstless leg
-anemia
-uremic frost: tiny urea crystals deposit on skin
Fluid Retention complications
-water retention = edema
-BP increase
Fluid retention tx
-restricting fluids not necessary if sodium intake is controlled
-diuretics will not work if kidneys dont work
-loop diuretics +/- thiazide
Diuretic tx for fluid retention
-tx volume overload and HTN
-patient must be making some urine (functioning ish kidney)
-loops +/- thiazide
-if one loop doesnt work none will
Diuretic considerations
-thiazides ineffective at CrCl< 30
-but loops work
-furosemide bioavailabilty at 50% so oral dose can be double the IV dose
-AVOID potassium-sparing diuretics
-as renal function declines, loop dose is maximized and a thiazide can be added to overcome resistance
-consider etharynic acid if sulfa allergy concern
Tx Na imbalance
-no salt added diet
-more restricting if HTN or edema bad (less than 2g sodium, 5g NaCl)
-use saline IV solutions w CAUTION
-make pt aware of hidden high sodium foods
K imbalance tx
-restrict to 3g/day
-goal concentration 4.5-5.5 (upper range but pt less sensitive to K)
-avoid high K foods
-tx for hyperkalemia
-easy to control on dialysis
Which diuretic least likely to cause sulfa allergy
-ethacrynic acid
Oral bioavailability
-furosemide has lowere bioavailability
-may need to titrate dose
Mineral and Bone Disorder (CKD-MBD) causes
- inc phosphorus
- decreased production of active Vit D
- dec calcium
-all increase PTH production (take Ca out of bone and into blood)
Common MBD fracute
-vertebrae
Hyperphosphatemia
-normal 2.5-4.5
-excess phosphorus binds calcium
-little white deposits in blood go to soft tissue organs and blood vessels
-tx w phosphate binders
Phosphate binders
-bind dietary phosphate
=MUST TAKE W FOOD
-Ca carbonate **
-Ca actetate
-Sevelamer carbonate **
-Lanthanum carbonate
-Sucroferric oxyhydroxide
-Auryxia (anemia)
-Aluminum Hydroxide (dont use)
-Mg carbonate
Calcium Carbonate (TUMS)
-40% elemental Ca
-Ca can get absorbed into blood and bind phosphorus there = more calcium deposits
-side effects: constipation
-500mg TID wf
Max amount of Ca you can take
-1500mg/day
Calcium acetate (PhosLo)
-25% Ca
-2-3 tab TID wf
-binds 2x phosphate than tums
-may produce fewer hypercalcemic events than tums
Sevelamer Carbonate
-best but not as cheap as tums
-also decreases LDL, uric acid (good for gout)
-maybe mild tummy ache but pretty safe
Lanthanum Carbonate
-eliminated in feces
-no long term accumulation
-GI side effects
-binds phosphorus better in acidic environments (tummy)
Sucroferric Oxyhydroxide
-minimal effect on iron stores
-dark stools
Auryxia (Ferric Citrate)
-for pt on dialysis
-inc TSAT and ferritin
-inc iron (good for anemia)
-discolored feces
Aluminum hydroxide
-not gonna use this one
-all eliminated by kidney = accumulation
-only short term use <4weeks
Mg Carbonate
??
-nicotinic acid and nicotinamide??
Which of the following phosphate binders will affect the patient’s calcium serum concentrations?
Tums (calcium carbonate)
JT is a 78 year old male starting hemodialysis. His current lab values are:
11 (H)
6 (H) 1200 (H) 12 (H)
8 (H)
Which of the following would be the best option for treating JT’s hyperphosphatemia?
Sevelamer carbonate
Dietary phosphorus should be restricted to
-800-1000mg/day if:
->4.6mg/dl in stage 3 and 4
->5.5 in stage 5
-PTH > target range in 3-5
High phosphorus foods
-meat
-nuts
-dairy
-beans
-cola and beer
Vit D deficiency and PTH
-need to be activated by kidneys
-dec = dec calcium concentrations = PTH inc
-stage 3-4 can still kind of convert
-stage 5 cannot convert (need active form)
Inactive Vit D
-Ergocalciferol (D2)
-Cholecalciferol (D3)
-first line for stage 3-4
-will NOT work in stage 5
-PO
Activated Vit D drugs
-Calcitriol
-Paricalcitol *
-Doxercalciferol
-use in stage 5 and some 3-4 cases
-PO or IV
Calcitriol
-activated vit D
-IV or PO
-approved for pediatrics
-greater risk of hypercalcemia
-cheap
Paricalcitol
-activated vit D
-30% dec in PTH
-pediatric use too
-less calemic activity
-prob best bet
Doxercalciferol
-active vit D
-30% dec in PTH
-more even serum concentration
-higher risk of hyperphosphatemia
-prodrug activated in LIVER
Monitoring parameters for activated vit D
-hypercalcemia (fatigue, headache, NV, muscle pain, constipation)
Drugs for calcium homeostasis in SPTH
-Cinacalcet
-Etelcalcetide
-do NOT use in HYPOcalcemia
Cinacalcet and Etelcalcetide
-type II calcimimetic agent
-mimics calcium by binding at inactive site and forcing conformational change
=dec PTH
Cinacalcet and Etelcalcetide contraindications
-HYPOcalcemia
-if Ca is <7.5 until gets up to 8
Monitoring parameters for CKD-MBD
-Calcium: 8.5-10.5
-Phos: 2.5-4.5
-Vit D (inactive): 30
-PTH: 11-54 ND or 100-500D
Which of the following Vit D products does not require activation by a body organ prior to activation
-calcitriol
Mrs. Jenkins is an 82 year old hemodialysis patient who presented to the clinic today with persistent secondary hyperparathyroidism. Her most current labs are as follows:
Ca
Phos
PTH Vitamin D
7.2 mg/dL (L) 4.0 mg/dL 1300 pg/mL (H) 35 ng/mL
Which of the following medications should be recommended for treating her secondary hyperparathyroidism?
-paricalcitol
-cant use D2 or D3 bc on dialysis and Ca too low for cinacalcet
Anemia monitoring parameters
-Hb
-MCV
-RDW
-TSAT
-Ferritin
Causes of anemia in CKD
-dec EPO
-uremia lowers RBS lifespan
-Vit loss during dialysis
-loss of blood through dialysis
-almost all ERSD pt get anemia
Anemia symptoms
-fatigue
-dizziness
-confusion
-headache
Mean Corpuscular Volume (MCV)
-80-96
-bell curve
-left is iron deficiency
-right is B12 deficiency (folate)
Micro MCV
-left
-iron deficiency
Macro MCV
-shift right
-B12 (folate) deficiency
macro and micro?
-MCV still in the middle but larger RDW
-iron and B12 deficiency
RDW
-RBC distribution width
-11.5-14.5%
-normal or abnormal distribution
Anemia tx goals
-reverse sx of tissue oxygen deprivation and left ventricular hypertrophy
-inc excercise tolerance and capacity
-optimize survival
-inc quality of life
Hb monitoring in anemia
-best parameter bc of inc stability over hematocrit
-CKD 3 test once a year
-CKD4-5ND twice a year
-CKD 5D q3months
-every 3 months if existing anemia
-every month if CKD5D w anemia
goal Hb
-12g females
-13g males
-hard to achieve
-depends if ESA is being used
Anemia Tx
- Iron therapy
- ESAs
Iron tx of anemia
-Oral iron
-Heme Iron
-IV iron
Oral iron tx of anemia
-NOT for hemodialysis pt
-use on CKD and peritoneal dialysis pt
-ferrous sulfate/gluconate/fumarate
-200mg/day minimum
-tummy hurt
-works better in acid
-no food (raises pH)
-no enteric coating
-pt could be on meds that inc pH
-separate from Ca by 2 hours
Heme iron
-better absorption
-dif absorption site
-Proferrin
-not subject to 200mg/day
Why IV iron
-Hepcidin from CKD inflammation destroys FPN
-FPN cannot transport iron to blood
-PO useless
IV iron
-Iron dextran
-Sodium Ferric gluconate
-Iron sucrose
-Ferric carboxymaltose
-Ferumoxytol
-sugar shells to make body more comfy w it
-tx dose and maintenance doses
iron dexferrum
-IV iron for anemia tx
-requires 25mg test dose
-higher incidence of anaphylactic rxs
-flushing, dizzines, hypOtension
Feraheme (ferumoxytol)
-dont use before MRI
Triferic
-ferric pyrophosphate citrate
-iron compound added to diasylate
-less common
-tx anemia
low molecular weight vs high molecular weight iron?
idk
Erythropoiesis Stimulating Agents (ESAs)
-use after trying everything else for anemia
1.rHuEPO
2. Darbepoeitin alfa
3. Methoxy polyethylene glycol (beta)
when to being ESA
-try iron first
-CKD3-5ND: Hb<10 to avoid blood transfusion
-CKD 5D: 9-10
ESA consideration
-QOL inc w Hb
-inc risk of stroke and heart attack tho
-do NOT use ESA to push Hb above 11.5!!!
-goal Hb 10-11
-reduce need for blood transfusion
Recombinant Human EPO (rHuEPO)
-first line ESA for anemia
-Epogen, Procrit, epoeitin alfa
-stimulates erythroid progenitor cells
-SC preferred or IV (expensive)
Darbepoeitin alfa (aranesp)
-3x longer half life than rHuPO
-IV or SC
-titrate dose
-2nd choice ESA for anemia
Methoxy polyethylene glycol
-Epoeitin beta (miracera)
-long half life
-dose every 2 weeks instead of one
ESA side effects
-pure Red Cell aplasia: abx develop to EPO
-must D/C drug
-23% of pt get HTN
-still give to pt with HTN tho
Causes of ESA failure
-lack of vitamins or iron
-aluminum toxicity
-active bleed
-drug induced bone marrow suppresion
-acute inflammation or infection
New therapy for anemia in CKD
-Daprodustat
-PO
Daprodustat
-new anemia tx
-pt that have been on dialysis at least 4 months
-PO dosing
-hypoxia inducible factor (HIF) Proyl Hydroxylase Inhibitors (HIF-PHIs)
-prevent feedback from shutting of hypoxia conditions (making more EPO in low O2)
ESA considerations
-DC if Hb > 12
-dec dose by 0.5 if hepatic impairment
-do NOT give w strong CYP208 inhibitor (genfibrozil)
Which of the following IV iron products requires a test dose the first time it is administered?
iron dextran
JB is a 77 year old male hemodialysis patient reporting to the clinic today feeling tired and lethargic with not much energy. He is evaluated by the nephrologist for his anemia. Current meds: Aranesp, iron sucrose, and calcium carbonate.
Labs: Hb 9.1 g/dL(L), TSAT 35% (H), Ferritin 525 ng/mL (H)
Which is the appropriate recommendation?
-inc Aranesp dose
-Hb too low
-iron high
BW is a 50-year-old male (5’ 11” tall, 190 lbs.) with end stage renal disease (ESRD) secondary to diabetes. He has been receiving hemodialysis on Monday, Wednesdays, and Fridays at the outpatient dialysis center for the past year. He presents today for his dialysis session with anorexia, nausea, and occasional headaches for which he has started taking ibuprofen (Advil) over the counter. The nephrologist is concerned about the risk of soft tissue calcification. BW’s laboratory report and medication list are as follows:
Labs: BUN 137 mg/dL, SCr 4.2mg/dL, Glu 272 mg/dL, HbA1C 7.8%, Hgb 10.5 g/dL, Hct 30%, Alb 3.0 g/dL, iPTH 500 pg/ml, Ca 10 mg/dL, PO4 7.4 mg/dL, Ferritin 309 ng/ml, Iron 77 mcg/dL, Tsat 36% , Digoxin 2.9 ng/mL Medications: Erythropoietin alpha (Epogen) 4,000 units IV 3 times per week, Sodium ferric gluconate (Ferrlecit) 125 mg IV every Wed, coumadin 5 mg by mouth every other day, enalapril(Vasotec) 5 mg by mouth every
day, hydralazine 50 mg by mouth twice daily (1 AM and 1 PM), nitroglycerin 0.4 mg sublingual as needed, glipizide (Glucotrol) 10 mg twice daily, nitrodur 0.8 mg patch apply daily, calcium carbonate 500 mg (Tums) 1 tab three times daily with meals, sodium bicarbonate 3 tabs three times daily, aspirin 325 mg daily, ibuprofen (Advil) 200 mg 2 tabs as needed for headache, digoxin 0.25 mg by mouth daily
Which of the following treatment options would be the most appropriate choice for managing BW’s iron therapy?
A. Discontinue sodium ferric gluconate (Ferrlecit)
B. Increase the dose of sodium ferric gluconate (Ferrlecit)
C. Add iron sucrose (Venofer) and discontinue sodium ferric gluconate (Ferrlecit)
✤✎ Continue sodium ferric gluconate (Ferrlecit) dose as written, no adjustment is needed
✤✎ Continue sodium ferric gluconate (Ferrlecit) dose as written, no adjustment is needed
-iron levels are fine
Acid-base disorders in CKD
-ESRD pt cannot excrete protons
=metabolix ACIDOSIS
-start tx when bicarb < 20 mEq/L
Nutrition in CKD
-protein 0.8 if GFR less than 30
-1.2 for ESRD (can be filtered out in dialysis)
-60-65Kcal/day
-water soluble vit replacement (B and C) (removed by dialysis)
-nephrocaps?
