Chronic Kidney Disease (CKD) Flashcards by Kathryn Cannaday

What are the therapeutic goals of CKD?

-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

How well did you know this?

Not at all

Perfectly

What is the function of the kidneys?

-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

How well did you know this?

Not at all

Perfectly

Define: Chronic Kidney Disease (CKD)

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

How well did you know this?

Not at all

Perfectly

How is kidney damage assessed using proteinuria?

How well did you know this?

Not at all

Perfectly

What is the GFR value for G1 CKD Staging?

90+ mL/min/m2

How well did you know this?

Not at all

Perfectly

What is the GFR value for G2 CKD Staging?

60-89 mL/min/m2

How well did you know this?

Not at all

Perfectly

What is the GFR value for G3a CKD Staging?

45-59 mL/min/m2

How well did you know this?

Not at all

Perfectly

What is the GFR value for G3b CKD Staging?

30-44 mL/min/m2

How well did you know this?

Not at all

Perfectly

What is the GFR value for G4 CKD Staging?

15-29 mL/min/m2

How well did you know this?

Not at all

Perfectly

What is the GFR value for G5 CKD Staging?

<15 mL/min/m2

How well did you know this?

Not at all

Perfectly

What are the risk factors for CKD?

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

How well did you know this?

Not at all

Perfectly

What are the risk factors for initiation of CKD?

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

How well did you know this?

Not at all

Perfectly

What are the risk factors for the progression of CKD?

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

How well did you know this?

Not at all

Perfectly

What are the complications of CKD?

-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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

<30%

How well did you know this?

Not at all

Perfectly

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

< 500 ng/mL

How well did you know this?

Not at all

Perfectly

When should a patient’s hemoglobin be monitored?

-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

How well did you know this?

Not at all

Perfectly

When would oral iron be used?

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

How well did you know this?

Not at all

Perfectly

What is the recommended daily dose of elemental iron?

200mg

How well did you know this?

Not at all

Perfectly

What are the adverse effects of oral iron?

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

How well did you know this?

Not at all

Perfectly

What are the drug interactions of oral iron?

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

How well did you know this?

Not at all

Perfectly

What dose of IV Iron is needed for repletion?

1000mg

How well did you know this?

Not at all

Perfectly

What is the maintenance dose of IV Iron?

25-125mg/weekly

How well did you know this?

Not at all

Perfectly

What IV Iron product requires a test dose?

Iron dextran

What are important points regarding IV Iron?

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

What are the common side effects of IV Iron?

-hypotension -dizziness -N/V

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

deferoxamine

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

-angioedema -cardiovascular shock -dyspnea and diaphoresis

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

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

What is the goal of ESAs therapy?

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

When would ESA therapy be considered for a patient?

*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

What are the monitoring parameters for ESA therapy?

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

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

-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

What is the BLACK BOX warning of ESAs?

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

What are the signs/symptoms of hyperparathyroidism?

-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

What is the goal lab values of phosphorus?

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

What is the goal lab values of calcium?

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

What is the goal lab values of PTH?

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

How often should calcium be monitored?

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

How often should phosphorous be monitored?

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

How often should PTH be monitored?

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

How can phosphorous levels be decreases?

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

What is the mechanism of action of phosphate binders?

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

What phosphate binder is generally avoided in all patients?

aluminum containing binders such as aluminum hydroxide or aluminum carbonate

What phosphate binder is considered first-line?

calcium containing binder

What are the products are calcium containing binders and dosing?

*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

What drug class is sevelamer?

phosphate binder

What is the mechanism of action of sevelamer?

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

What is the dosing of sevelamer?

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

What are the contraindications of sevelamer?

bowel obstruction *DO NOT CRUSH OR CHEW= expands*

What drug class is lanthanum?

phosphate binder

What is the contraindications of lanthanum?

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

What are the adverse effects of lanthanum?

GI side effects

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

30ng/mL +

When should inactive vitamin D supplementation be initiated?

25(OH)D < 30 ng/mL

What is the mechanism of action of inactive Vitamin D?

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

What are the adverse effects of inactive vitamin D supplementation?

hypercalcemia, headache, N/V

What drugs are inactive vitamin D supplementation?

ergocalciferol, cholecalciferol

What drugs are active vitamin D therapy?

calcitriol, doxercalciferol

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

B vitamins, folic acid, and vitamin C

What drugs are used during dialysis?

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