CKD Flashcards
First Line for HTN and CKD
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
Other HTN and CKD Agents
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)
Finerenone
-more potent anti-inflammatory and antifibrotic effects
AE:
-Hyperkalemia
-Hypotension
-Hyponatremia
DI: CYP3A4 inhibitors/inducers
Check serum K in 4 weeks
Sparsentan (Filspari)
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
Diabetes Management in CKD
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
SGLT2 Inhibitor Considerations
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
Additional Medications to Treat Diabetes (after starting Metformin and SGLT2 inhibitor)
Weight loss/HF/ASCVD: GLP1RA
egfr < 15 or dialysis: DPP4I, insulin, TZD
Avoid hypo: GLP1RA, DPP4I, TZD
Glucose lowering: GLP1RA, insulin
GLP1 RA Dosing in CKD
-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
Dyslipidemia in CKD
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)
Anemia in CKD
Goals
-HGB 9.5-11, rise 1-2 per month
-TSAT 20-50%
-Ferritin 100-500
> 200 dialysis dependent, > 100 non dep
Oral Iron Supplementation
-200 mg iron per day
AE: constipation, nausea, abd cramping
*empty stomach
DI: AA, H2RA, PPI, quinolones
Intravenous Iron Products
-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
Erythropoietin-Stimulating Agents
- 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
Bone Disease, Tx Algorithm
- Control phosphorus
-Dietary restriction (if elevated)
*chocholate, dark cola, PB, ice cream
-Binders - Replace Vitamin D
-Check 25OH level, replete VD
-iPTH elevated + check alk phos: active vitamin D replacement
Phosphate Binders
- Sevelamer (1st) (also lowers chol/LDL)
- Lanthanum carbonate (1st)
- Calcium based binders
- 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”
Bone Disease Goals
