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CKD anemia Flashcards

1
Q

what alterations in RBC indices are expected for CKD of anemia

A

RBC decreased
Hgb decreased
MCV normal
MCHC normal
reticulocyte count decreased

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2
Q

what is the primary cause of CKD anemia

A

decreased erythropoietin production

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3
Q

goal level for Hgb in CKD

A

10-11.5

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4
Q

when is PRBC transfusion indicated

A

Hgb<7

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5
Q

when is ESA indicated

A

Hgb<10 or 9-10 on dialysis

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6
Q

when is iron supplementation indicated

A

Tsat <30%
serum ferritin <500

(peds: Tsat <20%, serum ferritin <100)

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7
Q

when to give PO vs IV iron

A

IV: patient on ESA, or PO iron inadequate
PO: patient not on ESA

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8
Q

definition of anemia

A

Males: Hgb<13
females: Hgb<12

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9
Q

CKD anemia is _____ and ______ anemia

A

normocytic, normochromic
(cells are normal in size and color)

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10
Q

counseling for PO iron supplements

A

absorption is improved when taken on an EMPTY stomach

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11
Q

when to administer IV iron products

A

after dialysis session
monitor for ~30 mins for infusion reaction

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12
Q

when to monitor iron therapy

A

1-3 months
discontinue when iron stores are consistently above goal:
TSat>30%
Serum ferritin >500

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13
Q

what are the actions of the erythropoiesis stimulating agents (ESAs)

A

stimulate division & differentiation of erythroid progenitor cells; increase release of reticulocytes from bone marrow into blood stream

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14
Q

black box warning for ESAs

A

for CKD: increased risk of death and CV events with Hgb target> 11 g/dL- USE LOWEST DOSE POSSIBLE

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15
Q

what are the ESA names?

A

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

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16
Q

when to monitor ESA therapy?

A

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

17
Q

what are hypoxia-inducible factor (HIF-PH) inhibitors?

A

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

18
Q

when is daprodustat indicated and what are the black box warnings

A

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

19
Q

what are the hormones involved in calcium and phosphorus regulation

A

parathyroid hormone
vitamin D
fibroblast growth factor-23

20
Q

effects on calcium and phosphorus regulation when GFR<60 in CKD?

A

Net effects: Phos levels can be maintained initially, Ca levels usually decrease

21
Q

effects on calcium and phosphorus regulation when GFR<30 in CKD?

A

net effects: Ca levels decrease, Phos levels increase

22
Q

what is the effect of hyperparathyroidism in CKD

A

BONE DISEASE!

23
Q

osteomalacia

A

low burn turnover with low bone mineralization

24
Q

adynamic bone disease

A

very low bone turnover

25
Q

osteitis fibrosa cystica

A

high bone turnover

26
Q

what happens as phosphorus continues to rise, that impacts the heart?

A

phosphorus likes to bind to calcium: calcification in the heart

27
Q

goals for phosphorus Stages G3-G5D

A

near normal (2.5-5)

28
Q

goals for calcium Stages G3-G5D

A

avoid hypercalcemia

29
Q

goals for PTH G5D

A

2-9x normal
(cannot get it down to normal)

30
Q

options for management of hyperphosphatemia in CKD

A

Non pharm: dietary phos restriction (dairy, dark cola, chocolate)
Dialysis
Pharmacologic: Phosphate binders
-Non-calcium containing
-Iron containing
-Calcium containing
-Aluminum and magnesium containing
-

31
Q

general actions of phosphate binders

A

decrease phos
decrease pth
no effect on vitamin d

32
Q

counseling for all phosphate binders (def exam question)

A

give just before or with meals
(phos comes from food!)

33
Q

what are the non-calcium containing phosphate binders and their pros/cons

A

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

34
Q

what are the iron containing phosphate binders and their pros/cons

A

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

35
Q

what are the calcium containing phosphate binders and their pros/cons

A

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

36
Q

what are the aluminum and magnesium containing phosphate binders and their pros/cons?

A

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.

37
Q

what are the options for management of hyperparathyroidism in CKD

A
  1. phosphate binders (elevated phos stimulates the parathyroid glands to release PTH)
  2. vitamin D analogs
  3. calcimimetics
  4. vitamin d supplementation
38
Q

indications for vitamin D analogs and what are the options

A

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

39
Q

what are the calcimimetics

A

cinacalcet
etelcalcetide
can cause hypocalcemia; do not start if corrected Ca<8.4

advanced nephrology (7 decks)

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