CKD anemia Flashcards
what alterations in RBC indices are expected for CKD of anemia
RBC decreased
Hgb decreased
MCV normal
MCHC normal
reticulocyte count decreased
what is the primary cause of CKD anemia
decreased erythropoietin production
goal level for Hgb in CKD
10-11.5
when is PRBC transfusion indicated
Hgb<7
when is ESA indicated
Hgb<10 or 9-10 on dialysis
when is iron supplementation indicated
Tsat <30%
serum ferritin <500
(peds: Tsat <20%, serum ferritin <100)
when to give PO vs IV iron
IV: patient on ESA, or PO iron inadequate
PO: patient not on ESA
definition of anemia
Males: Hgb<13
females: Hgb<12
CKD anemia is _____ and ______ anemia
normocytic, normochromic
(cells are normal in size and color)
counseling for PO iron supplements
absorption is improved when taken on an EMPTY stomach
when to administer IV iron products
after dialysis session
monitor for ~30 mins for infusion reaction
when to monitor iron therapy
1-3 months
discontinue when iron stores are consistently above goal:
TSat>30%
Serum ferritin >500
what are the actions of the erythropoiesis stimulating agents (ESAs)
stimulate division & differentiation of erythroid progenitor cells; increase release of reticulocytes from bone marrow into blood stream
black box warning for ESAs
for CKD: increased risk of death and CV events with Hgb target> 11 g/dL- USE LOWEST DOSE POSSIBLE
what are the ESA names?
Epoetin alfa (Epogen, Procrit)
Epoetin alfa-epbx (biosimilar- Retacrit)
Darbepoetin alfa (Aranesp)
Methoxy PEG-epoetin beta (Mircera)
ALL ARE EQUALLY EFFECTIVE THEY JUST HAVE DIFFERENT ADMINISTRATION
when to monitor ESA therapy?
1 month
might take 4-6 weeks to see complete response
if iron stores are adequate, Hgb increases by 0.2-0.5 per week
HOLD ESAS WHEN HGB> 11.5
what are hypoxia-inducible factor (HIF-PH) inhibitors?
HIF is a transcription factor for EPO production, produced in response to hypoxia. HIF is degraded by enzyme HIF-prolyl-hydroxylase 2.
Daprodustat (Jesduvroq) inhibits this enzyme to stabilize HIF so effects are increased Hgb, physiologic EPO levels, improves iron absorption and improves iron deficiency
when is daprodustat indicated and what are the black box warnings
indications: anemia of CKD in adults receiving dialysis for >4 months
boxed warnings: thrombosis and CV events; targeting Hgb > 11 increases death and arterial thrombosis- use lowest dose possible
what are the hormones involved in calcium and phosphorus regulation
parathyroid hormone
vitamin D
fibroblast growth factor-23
effects on calcium and phosphorus regulation when GFR<60 in CKD?
Net effects: Phos levels can be maintained initially, Ca levels usually decrease
effects on calcium and phosphorus regulation when GFR<30 in CKD?
net effects: Ca levels decrease, Phos levels increase
what is the effect of hyperparathyroidism in CKD
BONE DISEASE!
osteomalacia
low burn turnover with low bone mineralization
adynamic bone disease
very low bone turnover
osteitis fibrosa cystica
high bone turnover
what happens as phosphorus continues to rise, that impacts the heart?
phosphorus likes to bind to calcium: calcification in the heart
goals for phosphorus Stages G3-G5D
near normal (2.5-5)
goals for calcium Stages G3-G5D
avoid hypercalcemia
goals for PTH G5D
2-9x normal
(cannot get it down to normal)
options for management of hyperphosphatemia in CKD
Non pharm: dietary phos restriction (dairy, dark cola, chocolate)
Dialysis
Pharmacologic: Phosphate binders
-Non-calcium containing
-Iron containing
-Calcium containing
-Aluminum and magnesium containing
-
general actions of phosphate binders
decrease phos
decrease pth
no effect on vitamin d
counseling for all phosphate binders (def exam question)
give just before or with meals
(phos comes from food!)
what are the non-calcium containing phosphate binders and their pros/cons
first line agents; best for hypercalcemia or soft tissue calcifications
Sevelamer/sevelamer carbonate: also has favorable effect on cholesterol. carbonate preparation also has effect on bicarb. CONS being may require high doses. ADEs are nausea vomiting diarrhea
lanthanum carbonate: PRO being few reported drug interactions. CONS are palatability, cost, GI effects
what are the iron containing phosphate binders and their pros/cons
can be first line; best for concomitant anemia
Sucroferric oxyhydroxide– PROS: insoluble form of iron, lower pill burden. CONS: GI effects, can’t take with Synthroid, take 1 hr after doxycycline and alendronate.
Ferric citrate– PROS: each tab contains 210 mg iron so good for iron deficiency, can increase serum ferritin and TSAT levels. CONS: GI EFFECTS, constipation
what are the calcium containing phosphate binders and their pros/cons
calcium carbonate: 40% of tablet strength is calcium; 20-30% calcium absorbed may require high doses
calcium acetate: less calcium absorption than calcium carbonate; binds twice as much phosphorus.
PROS: cheap, lots of products available
CONS: constipation, disrupts calcium balance in CKD
current guidelines: restrict dose of calcium-containing phosphate binders
what are the aluminum and magnesium containing phosphate binders and their pros/cons?
very limited role in CKD; best agents for AKI
Aluminum hydroxide– PROS: increased phosphorus binding capacity compared to calcium products. CONS: aluminum toxicity, constipation, bone mineral effects
Magnesium carbonate– PROS: increased phosphorus binding capacity compared to calcium products. CONS: increased magnesium accumulation; should only be used in CKD patients receiving hemodialysis, ADEs are hypermagnesemia and diarrhea.
what are the options for management of hyperparathyroidism in CKD
- phosphate binders (elevated phos stimulates the parathyroid glands to release PTH)
- vitamin D analogs
- calcimimetics
- vitamin d supplementation
indications for vitamin D analogs and what are the options
To inhibit PTH release in patients with evidence of bone disease. Calcium and phosphorus must be at goal before starting vitamin D analogs.
Calcitriol, paricalcitol, doxercalciferol
what are the calcimimetics
cinacalcet
etelcalcetide
can cause hypocalcemia; do not start if corrected Ca<8.4
