CKD

Question 1

First Line for HTN and CKD

Answer 1

1st line: ACEI and ARB
-indicated in pts with proteinuria

AE:
-30% rise in Scr within first 2 months
-Hyperkalemia
-Hypotension
-Anemia

CI: CKD 5, pregnancy

Question 2

Other HTN and CKD Agents

Answer 2

CCB (dilate afferent arteriole)
-NON DHP CCD = anti proteinuria effects (diltiazem and verapamil)
-DO NOT USE ALONE without ACEI or ARB in proteinuria pts (can worsen proteinuria)

Question 3

Finerenone

Answer 3

-more potent anti-inflammatory and antifibrotic effects

AE:
-Hyperkalemia
-Hypotension
-Hyponatremia

DI: CYP3A4 inhibitors/inducers

Check serum K in 4 weeks

Question 4

Sparsentan (Filspari)

Answer 4

Indicated to reduce proteinuria in adults with primary immunoglobulin A nephropathy (IgAN)

-DC RAAS agents before starting
-Dose: 200 mg for 2 weeks, then 400 mg daily
-CI in pregnancy (needs negative pregnancy test) = REMS program med (hepa/tera)
-RR24

AE:
-edema, hypotension, dizzy, hyperkalemia, anemia, hepatoxicity (HHHEAD)

DI: CYP3A4 inhibitors, AA, H2RAs, PPIs(CHAP)

SPARRR24 CHAP just wants HHHEAD

Question 5

Diabetes Management in CKD

Answer 5

Goal:
-PRE 90-130
-POST <180
-A1C: 6.5 for Stage 2-3, 8 for Stage 4-5 (or pts with repeated hypoglycemia)

Preferably SGLTI
or GLP1RA with CVD benefit
then add other agent

Question 6

SGLT2 Inhibitor Considerations

Answer 6

Potential CI:
-genital infection risk, ketoacidosis, foot ulcers, immunosuppression

Cana 100, Dapa or Empa 10
-300 of Cana not rec for cod

Consider hypoglycemia and volume depletion risk

Question 7

Additional Medications to Treat Diabetes (after starting Metformin and SGLT2 inhibitor)

Answer 7

Weight loss/HF/ASCVD: GLP1RA

egfr < 15 or dialysis: DPP4I, insulin, TZD

Avoid hypo: GLP1RA, DPP4I, TZD

Glucose lowering: GLP1RA, insulin

Question 8

GLP1 RA Dosing in CKD

Answer 8

-Lira: 1.2-1.8 mg once daily

-Dula: 0.75-1.5 mg once a week

-Sema: 0.5-1 mg once a week
*oral 3, 7, 14 mg daily

Question 9

Dyslipidemia in CKD

Answer 9

Most patients will require a moderate intensity statin
* DOC: HMG Co-A reductase inhibitors

DI: CCB (diltiazem, amlodipine)

High dose ROSUvastatin = worsen proteinuria

Avoid fibrates (risk of myopathies)

Question 10

Anemia in CKD

Answer 10

Goals
-HGB 9.5-11, rise 1-2 per month
-TSAT 20-50%
-Ferritin 100-500
> 200 dialysis dependent, > 100 non dep

Question 11

Oral Iron Supplementation

Answer 11

-200 mg iron per day

AE: constipation, nausea, abd cramping
*empty stomach

DI: AA, H2RA, PPI, quinolones

Question 12

Intravenous Iron Products

Answer 12

-dextran = anaphylaxis, test dose of 25

-dialysis dep: sucrose (100) and gluconate (125) are more rapid
-non dialysis dep: sucrose 500, ferumoxytol 510
*cause hypotension, large doses not by IV

Do not recheck iron indices for at least 2 weeks following loading dose

iron therapy associated with worsening infections

Question 13

Erythropoietin-Stimulating Agents

Answer 13

• Epoetin alfa and darbepoetin
  *Darbepoetin has a longer half life, less frequent dosing

-Dialysis dep: epoetin alfa 3x week

-Non dia dep: epoetin alfa 1x month (can increase to 1x week)

AE: flu like sx, risk of malignancy, hypertension

BBW increased mortality, CV and TE events, tumor progression

Question 14

Bone Disease, Tx Algorithm

Answer 14

1. Control phosphorus
   -Dietary restriction (if elevated)
   *chocholate, dark cola, PB, ice cream
   -Binders
2. Replace Vitamin D
   -Check 25OH level, replete VD
   -iPTH elevated + check alk phos: active vitamin D replacement

Question 15

Phosphate Binders

Answer 15

1. Sevelamer (1st) (also lowers chol/LDL)
2. Lanthanum carbonate (1st)
3. Calcium based binders
4. Aluminum hydroxide
   AE: encephalopathy, anemia, bone disease
   -limit to 4 weeks (4ABE)

Counseling
* Take at the start of the meal
* Carry a small pill box in case of unplanned “snacks or small meals”

Question 16

Newer Phosphate Binders

Answer 16

• Ferric Citrate (Auryxia)
  -AE: NVD, constipation, abd pain
  -210 mg, 1-2 tabs 3x day
• Sucroferric Oxyhydroxide (Velphoro)
  -AE: ND, stool discoloration
  -500 mg, 1 tab 3x day, chewable

Question 17

Active Vitamin D Analogs

Answer 17

should be reserved for CKD stage 4- 5 with severe and progressive hyperparathyroidism

3 analogs
-calcitriol, 0.25 mcg
-paricalcitol, 1 mcg
-doxercalciferol, 1 mcg

*empty stomach, pulse dosing 3x week has less hypercalcemia than daily dosing

AE: hypercalcemia, hyperphosphatemia, dynamic bone disease

DI: cholestyramine, paricalcitol = 3A4 inhibitors

Question 18

Calcimimetics - Cinacalcet

Answer 18

Used when there is hypercalcemia and high PTH

AE: NV, hypocalcemia

DI: CYP2D6 inhibitors

Dosing: 30-180 po daily with food

Question 19

Bone Disease Goals

Answer 19

Question 20

Metabolic Acidosis

Answer 20

-Correct pH and bicarb > 22

-Na Bicarb tabs 7.7 mEq, 650 mg tab
*1-2 tabs po daily then TID

-Bictra solution, 30 ml po daily to TID
*avoid admin with aluminum antacids

AE: GI distress

Question 21

Pt Ed

Answer 21

-Avoid nephrotoxins (NSAIDs, herbals)

-Sick: fluids, hold BP meds, hold ACEI if volume depleted

-Increased risk of hypoglycemia (15)

-No orange juice for CKD pts

-REC vaccinations (covid, flu, pneu, hepB)

Question 22

GFR STAGING OF CKD

Answer 22

G1 >90

G2 60-89

G3a 45-59

G3b 30-44

G4 15-29

G5 <15