Chronic kidney disease part 2

Question 1

treatment of reversible causes

Answer 1

give fluids to correct hypovolemia

Discontinue or minimize nephrotoxic medications

Relieve obstruction

Question 2

prevention or delay progression

Answer 2

Primary goals are lowering of blood pressure and proteinuria

Glycemic control

Correction of metabolic acidosis

Smoking cessation

Question 3

elevated blood pressure: pathogenesis

Answer 3

↑ sodium retention

↑ renin-angiotensin system activity

↑ sympathetic nervous system activity

Question 4

elevated blood pressure: management

Answer 4

With proteinuria, ACE inhibitor or ARB

With volume overload, diuretic

Question 5

the presence or absence of diabetes does not does not affect

Answer 5

KDIGO recommendations for how to treat your patient with CKD.

Question 6

elevated blood pressure: goals, 1st line, additional
proteinuric
volume overload 
non volume overload 
non-proteinuric 
volume overload 
non volume overload

Answer 6

proteinuric
< or equal to 130/80 mmHg, ace or arb, Diuretic then
Non-dihydropyridine CCB (IN ORDER)
< or equal to 130/80 mmHg, ace or arb, Non-dihydropyridine CCB (IN ORDER)
non-proteinuric
< or equal to 140/90 mmHg, diuretic, then ACEi or ARB or
Dihydropyridine CCB (NO SPECIFIC ORDER)
< or equal to 140/90 mmHg, ACEi or ARB or
Dihydropyridine CCB (NO SPECIFIC ORDER)

Question 7

cutoff for considering someone proteinuric

Answer 7

30 mg/day

Question 8

Non-dihydropyridine CCB examples

Answer 8

diltiazem and verapamil

Question 9

proteinuria

Answer 9

Goal PCR 500 to 1000 mg/g

ACE inhibitor or ARB as for elevated blood pressure (G3-G5D)

Protein restriction < 0.8 g/kg/day (G4-G5)

Question 10

control hyperglycemia to prevent CKD

Answer 10

Goal HbA1C ~7%

With type 2 diabetes, SGLT2 inhibitors

Question 11

metabolic acidosis

Answer 11

Sodium bicarbonate or sodium citrate

Question 12

anemia

Answer 12

Erythropoiesis-stimulating agents

• SQ without dialysis
• IV with dialysis

iron therapies

red blood cells
lower limit 10 g/dl without dialysis, 9 g/dl with dialysis

Question 13

increased parathyroid hormone

Answer 13

increased P, decreased Na and calcitriol. will help counteract P and Na level dysfunction. but this increased level can become pathologic

Question 14

CaR

Answer 14

calcium sensing receptor senses hypercalcemia. downregulates secretion of PTH in the setting of excess calcium.

Question 15

when PTH is released

Answer 15

it works to promote activity of osteoclasts. breaks down bone in order to mobilize calcium into body.
so when you experience hypocalcemia, pth helps to mobilize calcium from bone.

Question 16

patients who had mild to moderate CKD

Answer 16

P was not elevated, but calcitriol was decreased.

Question 17

fibroblast growth factor (FGF23)

Answer 17

molecule released in response to increasing phosphate, PTH, or calcitriol levels. improves release of phosphate by kidneys and decreases PTH and calcitriol levels. KLOTHO is needed.

Question 18

in CKD, klotho is decreased so less ability for

Answer 18

fgf23 to bind to PTH and to act. therefore, excessive levels of PTH.

Question 19

CKD-Mineral and Bone Disorder: Goals
goal 1
goal 2
goal 3

Answer 19

Goal 1/2: lower elevated phosphate towards normal range, avoid hypercalcemia (G3a-G5D)

Goal 3: reserve PTH-directed pharmacotherapy for severe and progressive secondary hyperparathyroidism (G3a-G5D)

Question 20

patients with severe and progressive secondary hypoparathyroidism (g4/g5)
pth therapies

Answer 20

(before dialysis) calcitriol, vitamin D

(during dialysis) calcimimetics

Question 21

treatment of hypoparathyroidism

Cinacalcet

Answer 21

Initiate 30 mg po qday and titrate to max 180 mg po qday

Administer with or shortly after meal

Question 22

treatment of hypoparathyroidism/lowers calcium

Etelcalcitide

Answer 22

Initiate 5 mg iv push thrice weekly and titrate from min 2.5 to max 15 mg iv push three times weekly
Administer post-dialysis