CKD Flashcards
CKD is classified based on what 3 things?
- Cause of kidney disease
- assessment of GFR
- extent of proteinuria
What are frequent complications of advanced CKD?
- altered Na and water balance
- hyperkalemia
- metabolic acidosis
- anemia
- CKD related mineral and bone disorder (CKD-MBD)
- cardiovascular disease
What is the 1st, 2nd, and 3rd leading causes of CKD leading to ESRD?
- DM
- HTN
- Glomerulonephritis
Besides the top 3 (DM, HTN, and glomerulonephritis), what other 4 diseases cause CKD?
- Polycystic Kidney Disease
- Wegener’s granulomatosis
- Vascular Diseases
- HIV nephropathy
1st line therapy for CKD caused by DM?
ACEI or ARB
Tx for CKD caused by DM:
-
ACEI or ARB
- Dose is usually increased until what 3 things happen?
- Albuminuria is reduced by 30-50% (1st goal!)
- Significant drop in eGFR
- Hyperkalemia
Therapy for CKD caused by HTN?
ACEI and ARB
(effect on renal hemodynamic and reduction of BP)
Deficiency in the production of endogenous erythropoietin by the kidney (iron deficiency as a contributing factor)
Anemia
2 ways to manage anemia
- erythropoietic stimulating agents (ESAs) (epoetin alfa, darbepoetin alfa)
- Regular iron supplementation (oral or IV administration)
What are the “administartion limits” of treating anemia? (2)
- Higher risk of cardiovascular events
- When hemoglobin is targeted to greater than 11 g/dL
At which stage of CKD should you send to nephrology based on the GFR?
Stage 2 CKD (mildly decreased) = 60-89
At what stage of CKD do you need adjust dose?
Stage 3 CKD, GFR of 50-60
(most common GFR is at 30)
What stage of CKD is ESRD?
Stage 5
KDIGO recommendations for initiation of Erythropoiesis Stimulating Agents and Iron in Anemia of CKD
- If Hb is <___ g/dL, consider the ____ of Hb prior to initiating ESA.
- DO NOT initiate if Hb is ___g/dL or greater
- 10 / rate of fall
- 10
- Do not use ESAs to intentionally increase Hb above ___ g/dL
- Do not use ESAs to maintain Hb above ___g/dL
- 13
- 11.5
Initiate Iron therapy when TSat is ___% or less and ferritin is ___ or less
- 30
- 500
Use ESAs to avoid drop in Hb to <9 by starting an ESA when Hb is between ___ and ___ g/dL
9 and 10
What are the 3 Erythropoiesis-Stimulating Agents in CKD?
- Epoetin alfa
- Darbepoetin alfa
- Methoxy PEG-epoetin beta
Which ESA?
- Adults: 50-100 units 3x/week
Epoetin alfa
Which ESA?
- Once every 4 weeks
Darbepoetin alfa
Which ESA?
- Every 2 weeks, once Hb stabilizes, double the dose and administer monthly
Methoxy PEG-epoetin beta
MOA of which drug?
- Induces erythropoiesis by stimulating the division of differentiation of committed erythroid progenitor cells
- Induces release of reticulocytes from the bone marrow into the blood stream
Erythropoetin Stimulating Agents (ESA)
2 clinical indications for ESAs
- Anemia due to myelosuppression
- Anemia due to CKD
ESA half lives
- Are half lives longer in IV or SQ?
SQ
3 Adverse Effects of ESAs
- Boxed warning: increased CV and CKD events w/ Hb >11 g/dL
- Cancer
- Increase risk of DVT
What is the Hb goal / change for management of anemia in adults?
1-2g/dL in 4 weeks
What are the 6 abnormalities in Chronic Kidney Disease-Mineral & Bone Disorder?
- Parathyroid hormone (PTH)
- Calcium, phosphorus
- The calcium-phosphorus product
- Vit D
Bone turnover - Soft tissue calcifications
What effect does PTH have in regards to CKD-MBD?
- Serum Ca increased**
- Serum Phosphate decreased**
(Net effect on serum levels)
What effect does Vit D have in regards to CKD-MBD?
- Serum Ca increased*
- Phosphate increased*
(net effect on serum levels)
What effect does FGF23 have in regards to CKD-MBD?
- Decreased serum phosphate*
(Net effect on serum levels)
4 ways to manage CKD-MBD?
- Dietary phosphorus restriction
- Phosphate-binding agents
- Vit D supplementation
- Calcimimetic therapy
Give examples of foods high in phosphorus
- Pumpkin seeds
- Ground mustard seeds
- Parmesan cheese
- Brazil nuts
- Cocoa powder
- Edamame
- Baker’s yeast
- Bacon
- Beef liver
- Canned sardines
What 2 drugs are Calcium Based Binders used to tx Hyperphosphatemia in CKD patients?
- Calcium acetate (PhosLo)
- Calcium carbonate (Tums)
What 2 drugs are Iron-based binders used to tx Hyperphosphatemia in CKD?
- Ferric citrate (Auryxia)
- Sucroferric oxyhydroxide (Velphoro)
What are 2 Resin binders used to tx Hyperphosphatemia in CKD pts?
- Sevelamer carbonate (Renvela)
- Sevelamer hydrochloride (Renagel)
What are 2 “other elemental binders” used to tx hyperphosphatemia in CKD pts?
- Lanthanum carbonate (Fosrenol)
- Aluminum hydroxide (AlternaGel)
Which drug?
- MOA: Binds w/ dietary phosphate to form insoluble calcium phosphate: excreted in feces
- Clinical indication: CKD hyper-phosphatemia
Calcium Based Phosphate-Binding Agents for tx of Hyperphosphatemia in CKD pts.
- Calcium acetate (PhosLo)
- Calcium carbonate (Tums)
Adverse effects of which drug?
- Hypercalciumia
- Hypophosphatemia
- Milk-alkali syndrome
Calcium Based Phosphate-Binding Agents for tx of Hyperphosphatemia in CKD pts.
- Calcium acetate (PhosLo)
- Calcium carbonate (Tums)
These sxs are apart of which adverse effect for which drug?
- HA
- Nausea
- Irritability
- Weakness or Alkalosis
- Hypercalciumia
- Renal impairment
Milk-Alkali Syndrome
(from Calcium based Phosphate Binding agents for tx of hyperphosphatemia in CKD pts)
- Calcium acetate (PhosLo)
- Calcium carbonate (Tums)
Which drug?
- MOA: binds phosphate within intestinal lumen limiting absorption and decreasing serum phosphate concentrations
- Clinical indications: Hyperphosphatmia tx, lowers low-density lipoprotein cholesterol, consider in pts at risk for “extraskeletal calcification”
Sevelamer Hydrochloride (Renagel)
(Resin Binder to tx hyperphosphatemia)
Adverse effects of which drug?
- Metabolic acidosis (greater in children)
- N/V/D
- Dyspepsia
Sevelamer hydrochloride (Renagel)
(Resin Binder to tx Hyperphosphatemia)
Which drug?
- MOA: binds dietary phosphate resulting in insoluble lanthanum phosphate complexes with net decreases in phosphate and Ca levels
- Clinical indications: hyperphosphatemia tx, bone half life is 2 - 3.6 yrs, potential for accumulation of lanthanum
Lanthanum carbonate (Fosrenol)
“other elemental binder)
Adverse Effects of which drug?
- N/V
- Abd pain
- Bowel obstruction
- Constipation
- Dyspepsia
- Fecal impaction
- Ileus
Lanthanum carbonate (Fosrenol) to tx hyperphosphatemia
“other elemental binders”
Which drug?
- MOA: binds phosphate in GI tract preventing absorption of phosphate
- Clinical indications: not a first line agent, reserve for short term use (4 weeks) in pts w/ hyperphosphatemia not responding to other binders
Aluminum Hydroxide (AlternaGel)
Used to tx hyperphosphatemia in CKD
“Other elemental binders”
Which drug?
- Risk of aluminum toxicity
- Constipation, fecal impaction
- Hypomagnesemia
- Hypophosphatemia
Aluminum hydroxide (AlternaGel)
Used to tx hyperphosphatemia in CKD
“Other elemental binders”
What are the 2 “nutritional Vitamin D” drugs?
- Ergocalciferol (Drisdol)
- Cholecalciferol
What are the 3 “Vitamin D & Analogs?”
- Calcitrol (Rocaltrol)
- Doxercalciferol (Hectorol) - analogs
- Paricalcitol (Zemplar) - analogs
Production of Vitamin D requires what?
Conversion of 7-dehydrocholesterol to cholecalciferaol (vit D3) by sunlight
- The first hydroxylation step of Vitamin D occurs where?
- The final conversion step of Vitamin D occurs where?
- 1st: Liver, to form 25-hydroxyvitamin D3
- Final: Kidney, to form 1,25-dihydroxyvitamin D3 or calcitriol
Recommendations for CKD
- Adjust med doses for kidney function
- Seek pharmacist or medical advice before using OTC meds / nutritional supplements
- Are herbal medicines recommended?
- ___ is suggested for pts at risk for atherosclerotic events unless there is an increased bleeding risk
- Avoid ______ in people w/ a GFR <60 or in those known to be at risk of phosphate nephropathy
- Herbal meds NOT recommended
- ASA
- oral phosphate-containing bowel preparations
