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830 > CKD + Bone Mineral Disease (Exam 1 Cut Off) > Flashcards

CKD + Bone Mineral Disease (Exam 1 Cut Off) Flashcards

1
Q

Goals of Therapy

A
  • Prevent secondary hyperparathyroidism
  • Prevent CKD BMD: bone pain, bone fractures, bone deformities
  • Prevent soft tissue calcification
  • Prevent morbidity and mortality associated with sHPT and CKD-MBD
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2
Q

Managing CKD-MBD

A
  • Lowering high serum phosphorus and maintaining serum calcium
  • Treating abnormal PTH levels
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3
Q

Lab Reference Values - BMD

A
  • P: 2.3-5.6 mg/dL
  • Ca: 8.4-10.4 mg/dL
  • PTH: 18-84 pg/mL
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4
Q

What do you assess first?

A

Phosphorus

Limit/Avoid high phosphorus foods

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5
Q

Guidelines for CKD 3a-5

A
  • Treatment should be based on serial assessments of phosphate, calcium, and PTH levels (consider TOGETHER)
  • We suggest lowering elevated phosphate levels toward the normal range and treat overt hyperphosphatemia
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6
Q

CKD 3a/b Monitoring/Goals

A

Serum Ca

  • Monitor: Every 6-12 months
  • Goal: Maintain within normal range

Serum Phosphorus

  • Monitor: Every 6-12 months
  • Goal: Maintain within normal range

Intact PTH

  • Monitor based on baseline level and CKD progression
  • Goal: normal range
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7
Q

CKD 4 Monitoring and Goals

A

Serum Ca

  • Monitor: Every 3-6 months
  • Goal: Maintain within normal range

Serum Phosphorus

  • Monitor: Every 3-6 months
  • Goal: Maintain within normal range

Intact PTH

  • Monitor: every 6-12 months
  • Goal: normal range
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8
Q

CKD 5ND Monitoring and Goals

A

Serum Ca

  • Monitor: Every 1-3 months
  • Goal: Maintain within normal range

Serum Phosphorus

  • Monitor: Every 1-3 months
  • Goal: Maintain within normal range

Intact PTH

  • Monitor: every 306 months
  • Goal: normal range
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9
Q

CKD 5D Monitoring and Goals

A

Serum Ca

  • Monitor: Every 1-3 months
  • Goal: Maintain within normal range

Serum Phosphorus

  • Monitor: Every 1-3 months
  • Goal: Maintain towards normal range

Intact PTH

  • Monitor: every 3-6 months
  • Goal: 2-9 times the upper limit of normal
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10
Q

Phosphate Binders

A
  • Prevents absorption of phosphorus from the diet
  • Only for the gut
  • Administer with meals
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11
Q

Calcium Salt Options

A
  • Calcium Carbonate
  • Calcium Acetate
  • Calcium Citrate
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12
Q

Calcium Carbonate

A
  • OsCal, Tums, etc.
  • 40% elemental calcium
  • Inexpensive, OTC
  • Wide variety of products/availability
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13
Q

Calcium Acetate

A
  • PhosLo 667 mg
  • 25% elemental calcium
  • Expensive, Rx only
  • Similar phosphorus binding efficacy as calcium carbonate
  • First line agent for hyperphosphotemia
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14
Q

Calcium Citrate

A
  • AVOID

- Thought to increase Al absorption: Al toxicity

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15
Q

Calcium Salt AE/Initial Dosing

A

AE

  • Constipation
  • HYPERCALCEMIA

Initial Dose

  • 250-500 mg of elemental Ca TID with meals
  • Titrate to serum phosphorus concentrations
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16
Q

Calcium Salt Guideline Recommendations

A
  • We suggest avoiding with hypercalcemia
  • Restrict dose of calcium-based phosphate binders
  • Limit elemental calcium from binders to 1500 mg/day
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17
Q

[Calcium] + Hypoalbuminemic

A
  • Total serum calcium concentration corrected for low serum albumin
  • Better reflection of free [Ca]
  • Corrected CA = Measured + 0.8*[4-serum albumin]
  • *If serum albumin >4, don’t correct the calcium level**
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18
Q

Sevelamer

A
  • Renvela
  • Nonadsorbed phosphate-binding polymer: anion-exchange resin
  • Free of metal ions
  • Decreases TC and LDL by 15-30%
  • Formulations: 800 mg tablets or 800/2400mg powder packets
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19
Q

Sevelamer AE

A
  • N/V
  • Diarrhea
  • Dyspepsia
  • Bowel Obstruction
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20
Q

Sevelamer Dosing

A
  • Start at 800-1600 mg TID with meals depending on severity of hyperphosphatemia
  • Titrate dose up or down based on effect
21
Q

Sevelamer Place in Therapy

A
  • First line, more expensive than calcium salts
  • Preferred for those with hypercalcemia or extraskeletal calcification
  • For patients who remain hyperphosphatemic on monotherapy, use combo therapy
22
Q

Fosrenol

A
  • Lanthanum Carbonate
  • 500, 750, 1000 mg chewable tablets
  • AE: N/V, abdominal pain
  • Dosing: 500 mg PO TID with meals
  • Costly
  • Consider when hypercalcemia is an issue
  • No long-term safety data and limited drug interaction information
23
Q

Aluminum Salt

A
  • Aluminum hydroxide
  • Alternagel: 600 mg/5 mL susp
  • Amphojel: 300/600 mg tablet, 320 mg/5 mL suspension
  • High phosphate binding toicity
  • AE: aluminum toxicity, constipation/impaction
  • Dose: 300-600 mg PO TID with meals
24
Q

Guidelines + Aluminum Salt

A
  • AVOID LONG TERM USE

- Limit to 4 weeks only

25
Q

Aluminum Disease

A
  • Dementia/neurotoxicity
  • Anemia
  • Renal osteodystrophy
26
Q

Iron Salts Options

A
  • Sucroferric Oxyhydroxide

- Ferric Citrate

27
Q

Velphoro

A
  • Sucroferric oxyhydroxide
  • Dose: 1 tab chewed TID with meals (max of 6 tabs/day)
  • ADE: diarrhea, discolored feces, nausea
  • Available: 500 mg chewable iron tablet
28
Q

Auryxia

A
  • Ferric Citrate
  • Dose: 2 tabs TID with meals (max 12 tabs/day
  • ADE: diarrhea, constipation, nausea, discolored feces
  • Available: tablet containing 210 mg iron
29
Q

Phosphate Binders: Drug Interactions

A
  • Ca, Al, Lanthanum, Sevelamer, Fe
  • Interfere with absorption with other drugs like quinolones, levothyroxine
  • Known interaction with Ca salts and PO iron
  • Space administration timing with all of the above
30
Q

Guidelines + Abnormal PTH Levels

A
  • Optimal PTH levels are not known for 3a-5
  • However, if their lab values are rising or persistently above upper normal limit, assess for modifiable factors
  • Factors include hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency
31
Q

Vitamin D Indications/AE

A
  • Indication: enahnce Ca+ and P+ absorption from the gut

- AE: hyperphosphatemia and hypercalcemia

32
Q

Inactive Vitamin D

A
  • Ergocalciferol (D2) and Cholecalciferol (D3)
  • If CKD 3/4 + Elevated iPTH, measure vitamin D level: give inactive Vitamin D if < 30 ng/mL
  • Stage 4 CKD + Elevated iPTH: measure vitamin D level: give active Vitamin D if > 30 ng/mL
33
Q

Vitamin D Dosing

A
  • Vitamin D < 5 ng/dL: severe deficiency requiring 50,000 IU/week PO x 12 weeks, then qmo x 6 mo
  • Vitamin D 5-15 ng/dL: mimld deficiency, 50,000 IU/week PO x 4 weeks, then qmo x 6 mo
  • Vitamin D 16-30 ng/dL, vitamin D insufficiency requiring 50,000 IU/mo PO x 6 mo
34
Q

Cholecalciferol

A
  • No dosing recommendations for guideline
  • Clinic Example: 1000 IU PO daily
  • Titrate to 4000 IU PO daily as required to replenish vitamin D stores and decrease iPTH
35
Q

Guidelines + Active Vitamin D/Analogs

A
  • Dont use for 3a-5ND routinely

- Reserve calcitriol and vitamin D analogs for CKD 4-5 patients with severe/progressive hyperparathyroidism

36
Q

Active Vitamin D

A
  • Calcitriol
  • Most active form
  • PO: 0.25 or 0.5 ug capsule
  • 1 ug/mL solution
  • IV form: Calcijex
  • Risk of hypercalcemia and hyperphosphatemia
  • Daily or TID weekly dosing
37
Q

Paricalcitol

A
  • Zemplar
  • Vitamin D Analog
  • 1, 2, and 4 ug capsules or IV form
  • 19-nor-1,25-dihydroxyvitamin D2
  • Associated with decreased incidence of hypercalcemia and hyperphosphatemia than calcitriol
38
Q

Doxercalciferol

A
  • Hectorol
  • Vitamin D Analog
  • 1-alpha-hydroxyvitamin D2
  • 0.5, 1, and 2.5 ug capsules and IV form
  • Associated with decreased incidence of hypercalcemia and hyperphosphatemia than calcitriol
39
Q

Calcifediol

A
  • Rayaldee
  • Vitamin D Analog
  • 25-hydroxyvitamin D3
  • ER 30 mcg cap
  • Indicated for CKD 3 or 4 with vitamin D levels <30 ng/mL
  • Monitor for hypercalcemia and hyperphosphotemia
40
Q

Guidelines + PTH in Dialysis

A
  • Maintain iPTH levels in the hrange of approximately 2-9 times the upper limit of normal
  • In patients with CKD 5D requiring PTH lowering therapy, use calcimimetics, calcitriol, or vitamin D analogs, or a combination of both
41
Q

Cinacalcet MoA

A
  1. Cinacalcet bind to the CaR and increases its sensitivity to Ca
  2. When Ca binds to CaR, the receptor is activated
    - PTH release is inhibited
42
Q

Cinacalcet

A
  • Calcimimetic
  • 30, 60, 90 mg tablets
  • Dose: 30-180 mg daily with meals
  • Useful in patients with high calcium and/or phosphate levels with elevated iPTH
43
Q

Cincalcet AE

A
  • Hypocalcemia: avoid if Ca <8.4 mg/dL
  • Paresthesia, myalgias, cramping, seizures
  • GI: N/V, diarrhea
44
Q

Cincalcet Drug Interactions

A
  • Inhibits CYP 2D6 (antiarrhythmics, psych meds)

- CYP 3A4 substrate

45
Q

Cinacalcet Monitoring

A
  • Serum Ca and P within 1 week of starting/changing dose
  • iPTH within 1-4 weeks of starting/changing dose
  • If Ca decreases under 7.5 mg/dL or patient is symptomatic, HOLD cincacalcet and restart a lower dose when Ca > 8 mg/dL
  • If Ca 7.5-8.4 mg/dL, start Ca-based phosphate binder or vitamin D (if appropriate)
46
Q

Managing Therapy for Renal Osteohystrophy and sHPT: Step 1

A
  • Assess for hyperphosphatemia: if present, initiate phosphate binder (Ca based or sevelamer) and monitor calcium levels to avoid hypercalcemia
  • *Use corrected calcium formula**
  • Can use combinations
47
Q

Managing Therapy for Renal Osteohystrophy and sHPT: Step 2

A
  • Consider Vitamin D
  • Stage 3/4 with elevated iPTH: inactive if vitamin D, 30 ng/mL
  • Stage 4 + elevated iPTH + Vit. D > 30 ng/dL: use active vitamin D or analog
  • Stage 5 + elevated iPTH: active vitamin D or Vitamin D analog
  • Ensure Ca and P well controlled before starting
  • HOLD all forms of vit. D when corrected Ca levels are elevated
48
Q

Managing Therapy for Renal Osteohystrophy and sHPT: Step 3

A
  • Assess need for calcimimetic

- Only Stage 5D

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