CKD Flashcards
How does secondary hyperparathyroidism occur in CKD?
Describe what happens to calcium, phosphate, vitamin D and PTH.
Phosphate rises as it cannot be excreted by the kidneys.
Vitamin D drops as it cannot be hydroxylated by the kidneys.
Calcium drops as it cannot be absorbed due to low vitamin D.
PTH rises in response to try and increase calcium and lower phosphate.
How does tertiary hyperparathyroidism occur in CKD?
Describe what happens to calcium, phosphate, vitamin D and PTH.
Secondary hyperparathyroid leads to parathyroid hyperplasia
- initially Ca low, PO4 high, Vit D low, PTH high.
Hyperplasia leads to even higher PTH which can normalise or even overshoot the desired calcium level:
- Ca normal/high, PO4 normal/low, Vit D normal/low, PTH very high
Hyperparathyroidism can cause the following bone diseases in CKD: Ostetits fibrosa cystica Adynamic bone disease Osteomalacia Osteosclerosis Osteoperosis
What is the management to prevent these bone diseases in CKD?
Target is to reduce phosphate and PTH via:
- Phosphate binders - calcium-based therapy or Sevelamer
- Vitamin D supplementation - alfacalcidiol, calciterol
- Parathyroidectomy
How is anaemia in CKD managed?
Erythropoetin or Darbeporetin
Must always check iron levels prior to initiating therapy, as they will not work if iron is low.
What are side effects of calcium-based phosphate binders in CKD?
Hypercalcaemia
Vascular calcification
What are the added benefits of Sevelamer phosphate binder in CKD?
Reduces uric acid and improves lipid profile.
CKD can cause hypertension.
How is this managed?
ACEi - 30% rise in creatinine permitted after initiation
Furosemide (if eGFR <45)
How is proteinuria quantified in CKD?
Albumin:Creatinine ratio
How is the test to measure Albumin:Creatinine ratio performed?
What are normal and abnormal results?
When may the test need to be repeated, based on the result?
A first-pass morning sample or urine is collected
If >3 mg/mmol
Repeated if the first measurement is between 3-70 mg/mmol, if the second result is also >3, it is considered clinically significant.
- note, there is no need to repeat initial test if it was >70 mg/mmol
How is proteinuria managed in CKD?
What are the indications for initiating treatment?
ACEi or ARB
Initiate if hypertensive and > 30 mg/mmol
OR
Initiate if normotensive and >70 mg/mmol
What are 5 drugs/drug types that need to be stopped/cannot be used in CKD?
Tetracyclines Nitrofurantoin NSAIDs Lithium Metformin
What is the preferred opioid to use in CKD?
Oxycodone (10-50 eGFR)
Alfentanil, fentanyl or buprenorphine in severe CKD (<10 eGFR)
Is warfarin ok to use in CKD?
Yes
