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Therapeutics 1 > Chronic Kidney Disease (CKD) > Flashcards

Chronic Kidney Disease (CKD) Flashcards

1
Q

What are the therapeutic goals of CKD?

A

-early detection
-treatment of reversible causes
-prevention or slowing of CKD
-treatment of complications
-education and adequate preparation of the patient when dialysis will be required

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2
Q

What is the function of the kidneys?

A

-20-25% of cardiac output is devoted to kidneys
-selective blood filtration, tubular reabsorption, and tubular secretion
-maintain homeostasis (fluid volume, electrolytes, acid-base, waste excretion, drug and metabolite elimination)
-regulate blood pressure
-stimulate erythropoiesis

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3
Q

Define: Chronic Kidney Disease (CKD)

A

presence of kidney damage, drop in renal function (chronic renal insufficiency, chronic renal failure, chronic renal disease), nephron damage, GFR < 60mL/min/m2 for 3+ months

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4
Q

How is kidney damage assessed using proteinuria?

A
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5
Q

What is the GFR value for G1 CKD Staging?

A

90+ mL/min/m2

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6
Q

What is the GFR value for G2 CKD Staging?

A

60-89 mL/min/m2

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7
Q

What is the GFR value for G3a CKD Staging?

A

45-59 mL/min/m2

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8
Q

What is the GFR value for G3b CKD Staging?

A

30-44 mL/min/m2

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9
Q

What is the GFR value for G4 CKD Staging?

A

15-29 mL/min/m2

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10
Q

What is the GFR value for G5 CKD Staging?

A

<15 mL/min/m2

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11
Q

What are the risk factors for CKD?

A

-dyslipidemia
-uncontrolled hypertension
-uncontrolled diabetes
-smoking
-cardiovascular disease
-nephrotoxic agents
-age
-ethnic minorities
-family history
-autoimmune disease
-primary glomerulopathies
-systemic infections
-systemic inflammation

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12
Q

What are the risk factors for initiation of CKD?

A

-diabetes
-high blood pressure
-glomerulonephritis
-elderly (more susceptible)
-autoimmune disease
-urinary tract infections (pyelonephritis), obstruction
-drug toxicity

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13
Q

What are the risk factors for the progression of CKD?

A

-continued progression of initiation factors
-smoking
-obesity
-higher level of proteinuria

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14
Q

What are the complications of CKD?

A

-renal tubule damage (impaired H2O, Na, K excretion, reabsorption, and secretion)
-metabolic acidosis (reduced pH and HCO3-)
-decreased erythropoietin synthesis (anemia of CKD)
-hyperphosphatemia (secondary hyperparathyroidism and bone disease)
-impaired vitamin D synthesis (vitamin D deficiency and bone disease)
-cardiovascular disease
-impaired drug filtration, secretion, and reabsorption

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15
Q

What is the diagnosis of anemia according to KDOQI anemia guidelines?

A

males= Hb < 13 g/dL and females= Hb <12 g/dL

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16
Q

What is the TSAT value threshold for treatment according to KDOQI anemia guidelines?

A

<30%

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17
Q

What is the serum ferritin value threshold for treatment according to KDOQI anemia guidelines?

A

< 500 ng/mL

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18
Q

When should a patient’s hemoglobin be monitored?

A

-before anemia diagnosis -> annually CKD 3, bi-annually CKD 4-5, and every 3 months if on dialysis
-if diagnosed with anemia -> every 3 months CKD 3-5 and peritoneal dialysis and monthly if on hemodialysis

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19
Q

When would oral iron be used?

A

non-hemodialysis patients, IV is typically preferred in the hemodialysis patient

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20
Q

What is the recommended daily dose of elemental iron?

A

200mg

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21
Q

What are the adverse effects of oral iron?

A

GI UPSET (constipation, dark stools, nausea, cramping, vomiting)

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22
Q

What are the drug interactions of oral iron?

A

levothyroxine, fluoroquinolone antibiotics, antacids- oral iron needs an acidic environment to be absorbed

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23
Q

What dose of IV Iron is needed for repletion?

A

1000mg

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24
Q

What is the maintenance dose of IV Iron?

A

25-125mg/weekly

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25
Q

What IV Iron product requires a test dose?

A

Iron dextran

26
Q

What are important points regarding IV Iron?

A

-avoid rapid infusion
-may cause hypotension
-possible GI effects
-headache
-flushing

27
Q

What are the common side effects of IV Iron?

A

-hypotension
-dizziness
-N/V

28
Q

What can be used as an antidote for IV Iron overload?

A

deferoxamine

29
Q

What are the less common and life threatening side effects of IV Iron?

A

-angioedema
-cardiovascular shock
-dyspnea and diaphoresis

30
Q

What is the mechanism of action of erythropoiesis stimulating agents (ESAs)?

A

stimulates erythrocyte progenitor cells in the bone marrow to increase RBCs, Hb, and Hct

31
Q

What is the goal of ESAs therapy?

A

increase Hb to the minimum amount to avoid symptoms and improve the quality of life

32
Q

When would ESA therapy be considered for a patient?

A

address all other correctable causes of anemia first
-non HD Hb < 10 g/dL and benefits outweigh risk
-HD Hb between 9-10 g/dL

33
Q

What are the monitoring parameters for ESA therapy?

A

-Hb= every 1-2 weeks with new dose and every 4 weeks when stable
-CBC w/ differential
-BP
-iron stores

34
Q

When would dose modification be considered for patients on ESA therapy?

A

-increase dose 25-50% if Hb increase <1 g/dL in 4 weeks
-decrease dose 25% if Hb increases >3 g/dL in 4 weeks or Hb> 11 g/dL

35
Q

What is the BLACK BOX warning of ESAs?

A

increased risk of death, MI, stroke, venous thromboembolism, thrombosis of vascular access, and tumor progression/recurrence

36
Q

What are the signs/symptoms of hyperparathyroidism?

A

-gradual onset of fatigue, N/V, and musculoskeletal pain
-can see vascular calcification on radiology scans
-potential for bone fractures or pain
-abnormal phosphorus, calcium, PTH, and vitamin D

37
Q

What is the goal lab values of phosphorus?

A

-CKD= 2.5-4.5 mg/dL (normal goal)
-ESRD= lower towards normal

38
Q

What is the goal lab values of calcium?

A

-CKD= 8.5-10.5 mg/dL (normal goal)
-ESRD= 8.4-9.5 mg/dL

39
Q

What is the goal lab values of PTH?

A

normal= 15-65 mg/L, in HD 2-9x upper limit of normal is the goal

40
Q

How often should calcium be monitored?

A

-stage 3= every 6-12 months
-stage 4= every 3-6 months
-stage 5= every 1-3 months

41
Q

How often should phosphorous be monitored?

A

-stage 3= every 6-12 months
-stage 4= every 3-6 months
-stage 5= every 1-3 months

42
Q

How often should PTH be monitored?

A

-stage 3= baseline
-stage 4= every 6-12 months
-stage 5= every 3-6 months

43
Q

How can phosphorous levels be decreases?

A

-dietary restrictions of phosphorous (800-1000 mg/day)
-phosphate binders

44
Q

What is the mechanism of action of phosphate binders?

A

binds dietary phosphate in the gut so must be taken with food

45
Q

What phosphate binder is generally avoided in all patients?

A

aluminum containing binders such as aluminum hydroxide or aluminum carbonate

46
Q

What phosphate binder is considered first-line?

A

calcium containing binder

47
Q

What are the products are calcium containing binders and dosing?

A

likely to cause hypercalcemia, no more than 2000 mg/day so be cautious of the amount of elemental calcium
-calcium carbonate= 1-2 tabs with meal, 45% elemental Ca
-calcium acetate= 2-3 tabs with meal, 25% elemental Ca

48
Q

What drug class is sevelamer?

A

phosphate binder

49
Q

What is the mechanism of action of sevelamer?

A

not absorbed into circulation, binds phosphorus in the gut so will also bind drugs in the gut (antiarrhythmics, antiepileptic, fluoroquinolones)

50
Q

What is the dosing of sevelamer?

A

initiate 800mg po with meals for phosphorous < 7.5 mg/dL, 1200-1600mg for >7.5mg/dL

51
Q

What are the contraindications of sevelamer?

A

bowel obstruction
DO NOT CRUSH OR CHEW= expands

52
Q

What drug class is lanthanum?

A

phosphate binder

53
Q

What is the contraindications of lanthanum?

A

PUD, ulcerative colitis, chron’s disease, bowel obstruction

54
Q

What are the adverse effects of lanthanum?

A

GI side effects

55
Q

What is the goal serum vitamin D of a patient with CKD?

A

30ng/mL +

56
Q

When should inactive vitamin D supplementation be initiated?

A

25(OH)D < 30 ng/mL

57
Q

What is the mechanism of action of inactive Vitamin D?

A

stimulate Ca absorption in gut, reabsorption in kidney- activated by kidney so pt must have remaining kidney function

58
Q

What are the adverse effects of inactive vitamin D supplementation?

A

hypercalcemia, headache, N/V

59
Q

What drugs are inactive vitamin D supplementation?

A

ergocalciferol, cholecalciferol

60
Q

What drugs are active vitamin D therapy?

A

calcitriol, doxercalciferol

61
Q

What vitamins must be repleted because they are removed during dialysis?

A

B vitamins, folic acid, and vitamin C

62
Q

What drugs are used during dialysis?

A

-anticoagulants= prevent clotting
-antibiotics= often administered post-dialysis to replace drug removed during dialysis
-Epoetin, iron, vit D= just simplifies patient regime

Therapeutics 1 (16 decks)

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