CKD & Associated Flashcards

Question

Iron-based Phosphorous Binders - ferric citrate - sucroferric oxyhydroxide

Answer 1

Ferric Citrate - lowers phosphorous & treats iron deficiency !! Sucroferric Oxyhydroxide - lowers phophate - but does not work on IDA; still can increase iron studies and lower the need for IV iron or ESA use Precautions of these meds - discoloration of stool (bcuz iron) - drug interactions due to the iron - $$$$$

Answer 2

Calcium Acetate (**preferred agent of the two - Acetate= A+**) - more effective thatn carbonate - decreases phosphroud but increases calcium (watch thier orignial calcium levels!!! before giving) - more soluable and better absorbed at an alkaline pH Calcium Carbonate - decreases phosphrous, increases calcium - cheap, OTC - better in an acidic environment to absorb Caution Use - chronic use of calcium containing phosphate binders cane lead to an increase in calcifications in the vasculature and soft tissures = inc. CVD risk!! - titrate doses Q2-3 weeks do not use calcium containig meds if... - high calcium levels (ULN) - aterial calcifications - adynamic bone disease Drug-Drug INteractions - interfers with iron, zince and quinolone abx. **separate meds by 1-3 hours**

Answer 3

Aluminum Hydroxide - last line: only **short term therapy (4 weeks or less) if they are unresponsive to other oral treatments** - CNS toxicity with this - aluminum is renally eliminated = but kidneys arent working..... Magnesium containing antacds - effective, but diarrhea! and watch potassium levels

Answer 4

At initiation of treatment: watch phosphrous every 1-4 weeks when stable: watch phosphrous and calcium every 1-3 months *can monitor PTH too* **want to focus on the tredsn of thier corrected calcium, phosphrous and PTH levels**

Answer 5

patho - vit d comes from the sun, from food and supplements - it is biologically inactive then converted to calcidiol form in the liver, then converted to active form in the kidneys - active form = calcitriol (1, 25 dihydroxyvitamin D) - **the conversion to the active form can also happen outside the kidneys** CKD - all pts. with CKD: stages 1-5 are at risk for vitamin D deficiency - left untreated = leads to increase PTH levels and subsequent issues

Answer 6

1. assess vitamin D levels (calcidiol) - insufficient = 30-49 - deficiency = less than 30 **ensure the calcium and phosphate levels are normal or almost normal before supplementing the vit d (becuase those issues can precipiate a vit D deficiency)** Treatment - supplement with oral ergocalciferol (vit D2) or cholecaciferol (vit D3) - **normal goal: want calcidiol levels > 50** **the reason we can treat these people with inactive VitD is becuase although their kidnye function is not great, vit D synthesis can happen extra-renally thus the conversion process can still happen if they have only low VitD and not PTH**

Answer 7

**if calcidiol levels NORMAL, but PTH is elevated** they need the active form of Vit D ; they cannot convert anymore Meds - calcitriol (biologicallt active form of Vit D) - Vitamin d analog (doxercalciferol, paricalcitol) **always ensure the calcium and phosphate levels are normal or close to normal before starting vit D treatment**

Answer 8

**if on dialysis, AND PTH levels 2-9 times ULN = need to lower the PTH levels** lowering PTH via giving active vit D (calcitriol, doxercalciferol, dapicalcitol, cinacelcelt) for those with... - elevated PTH - normal calcium and phosphrous **give calcitriol, doxercalciferol or paricalcitol** for those with... - elevated PTH - elevated calcium - elevated phosphrous **give cinacalcet**

Answer 9

MOA - these are biologicall ACTIVE forms of Vit D - they bind to the vit D receptor on the parathyroid gland, intestine, bones and kidneys - this inhibits the suprresion of PTH (therefore stopping the signal that we need to conserve vit D) - this then allows greater absorbtion of clacium and phosphate from the GI tract & downregulation the PTH ADE - hypercalcemia - hyperphosphetemia - oversupressed PTH - adynamic bone disease - **all of these more likely to occur with calcitriol than the other anologs; the anologs bind better th PTH not the GI so less of the SE** Drug Interactions - Doxercalciferol: **pro-hormone: needs CYP3A4!!** cant use with inhibitors of CYP3A4 - paricalcitol: **MAJOR CYP3A4 SUBSTRATE: watch with inducers and inhibitors** - calcitriol and doxercalciferol: minor substrates at cyp3a4

Answer 10

Cinacalcet: used in CKD 5; dialysis with elevaetd PTH, calcium and phosphate (too much of everything!!) MOA: calcimimetic - increases how sensitive the calcium sensing receptors on the Parathyroid gland is: thus they sense the calcium and are about to reduce the secretion of PTH - they do not increase calcium and phophate absorbtion in the GI tract: a goo thing becuase there is already too much - **they actually can reduce calcium and phosphate levels: because they increase PTH receptors then stop the reabsorbtion of calcium and phosphate in the seurm** ADE - avoid in pts: low calcium and phosphate and those with seizure risk - N/V - hypocalcemia: paresthesias, myalgias, carmping, tetany, seizures Druge Intercations **many DD interactions** - major CYP2D6 substrate and inhibitor

Answer 11

- monitor PTH levels: avoid oversuprresion as that can lead to adynamic bone disease - monitor **PTH every month until stable, then every 3months** phosphorous and calcium levels - **get prior to starting meds - get within 1st week - then get everytime you get a PTH level**

Answer 12

Patho - there is a decrease in renally elimiated H+ and thereofer a build u = acidosis - accumulation of phosphate and anions lead to an elevated anion gap at a pH < 7.35.. - bone metabolism altered - decrease vit D effectiveness - protein catabolism (breakdown) occurs at pH , 7.2 - supressed heart contractiliy - caridaic arrythmias - hemodialysis needs to be started Management - treat underlying disorder - **give orla alkalinzing salt to replensih bicarb stores which are gone** salts - sodium bicarb tablets - bicitra & Shohl solution (sodium citrate and citric acid) - avoid citrates that contain potassium for risk of hyperkalemia

Answer 13

ADE: sodium bicarb tablets - volume overload: due to the sodium retention - exacerbation of heart faiure and HTN - gas, gastric disturbeances due to CO2 production when dissolivng - hypernatermia - metabolic alkalosis (if too aggressive with treatment) ADEs: Bicitra and Shohls solution - better tolerated than sodium bicarbs, less flatuence and overload risk - hypernatermia and alkalosis still possible

Answer 14

- dose dependent administration of medications based on weight & base deficit - administer loading dose, then maintenance dose Monitor - pH - bicarb - sodium (daily in inpt, weekly with dialysis in outpt.) DDI: wathc with citrate-containing products: can ehnace aluminum absoption!!

Answer 15

Patho - uremia = alters the ability of clotting factors = leads to hemorrhage risk - specifically alters platelet function and ability to aggregate (alters thromboxane production) - decreased vonwillbrad production, inability for platlets and the vessel wall to interact to clot properly - **this issue is made worse by anemia in CKD and medications that are preventing clotting** Management- Acute **Desmopression** DDAVP - increases the release of actor VIII (vonwills friend) - 1 hour onset of action, works for 8 hours - risk of tachyphlyaixis, flushing dizzy and HA - **cryoprecipitate** (blood products) - take 1 hour to work but risk of infection Management - Chronic - IV or PO estrogen (IV onset of action is quicker, lasts longer) - wathc hot flashes, fluid retention and HTN

Answer 16

First line: - dialysis = attempt to remove the uremic toxings causing the itch - manage phopsphate and protein intake Meds - antihistamines (hydroxyzine and diphenhydramine) Other Options - oils and emollients - oral charcol to bind to uremic toxins - gabapentin - zofran - naloxone - topical capsaicin - photothearpy

Answer 17

ESRD: hemodialysis - will ahve higher levels of AEK fat soluable ones and less of water soluable ones (thiamine, folic acid, riboflavin,etc.)

Answer 18

stages of CKD, mainly 3, 4, 5 and those on dialysis Dialysis - drug dosing dependent on the type of dialysis they are on and requires close monitoring of response to when to Dilyze - symptoms and signs due to kidney failure (serositis, acid-base issures, itchy) - inability to control volme or BP - deterioration in nutrtion - cognitive impairment - often beteen GFR 5-10