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Therapeutics II > CKD/Hemodialysis > Flashcards

CKD/Hemodialysis Flashcards

1
Q

Major causes of kidney disease

A

-Diabetes mellitus
-Hypertension
-Glomerulonephritis

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2
Q

Physiologic functions of the kidney

A

-Excrete waste products of metabolism from the blood (i.e., urea, ammonia, bilirubin, uric acid etc.)
-Regulates body’s concentration of water and salt
-Maintains acid balance of plasma (secretes H+ ions)
-Synthesizes calcitriol (active from of vitamin D)
-Secretes hormones (erythropoietin, rennin, PGAs)

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3
Q

Complications associated with CKD and ESRD

A

-Uremia
-Fluid retention
-Electrolyte imbalances
-Mineral and bone disorder
-Anemia

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4
Q

Considerations when using diuretics

A

-Diuretics will not work in patients with no kidney function
-Thiazides are ineffective when CrCl < 30 ml/min
-Loops will work when CrCl < 30 ml/min
-Avoid potassium-sparing diuretics
-Thiazide may be added to loop diuretic as renal function declines to overcome diuretic resistance

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5
Q

Sodium considerations/counseling for CKD patients

A

-No salt diet
-Use saline containing IV solutions
-Make outpatients aware of hidden high-sodium-content foods
-Less than 2g sodium/day or 5g NaCl

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6
Q

Potassium considerations/counseling for CKD patients

A

-Restrict to 3 gm/day
-Goal for ESRD patient is a pre-dialysis K concentration of 4.5 – 5.5 mEq/L
-Avoid high potassium foods

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7
Q

Mechanism of action for phosphate binders

A

These agents bind dietary phosphate which is ingested in the food and the chelate is eliminated in the feces
MUST BE GIVEN WITH EVERY MEAL

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8
Q

Tums drug class

A

Calcium containing phosphate binder
(Calcium carbonate)

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9
Q

PhosLo drug class

A

Calcium containing phosphate binder
(Calcium acetate)

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10
Q

Main difference between Tums and PhosLo

A

Calcium acetate will bind twice as much phosphate compared to calcium carbonate. Calcium acetate may produce fewer hypercalcemic events when compared to calcium carbonate

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11
Q

Renvela drug class

A

Non-calcium containing phosphate binder
(Sevelamer carbonate)

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12
Q

Fosrenol drug class

A

Non-calcium containing phosphate binder
(Lanthanum carbonate)

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13
Q

Velphoro drug class

A

Non-calcium containing phosphate binder
(Sucroferric oxyhydroxide)

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14
Q

Auryxia drug class

A

Non-calcium containing phosphate binder
(Ferric citrate)

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15
Q

Renvela considerations/counseling

A

-Side effects: mild GI upset, nausea, vomiting, diarrhea
-Decreases LDL 15-30%
-Not absorbed
-Decreases uric acid
-Very hard to overdose

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16
Q

Fosrenol considerations/counseling

A

-Binds very well in acidic pH
-Excreted in feces
-No long term accumulation
-Does not cross BBB
-Mild GI upset

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17
Q

Difference between Velphoro and Auryxia

A

Auryxia increases iron levels while Velphoro does not

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18
Q

When should Amphojel (aluminum hydroxide) be used?

A

Never

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19
Q

Dietary restrictions for patients with hyperphosphatemia

A

Dietary phosphorous should be restricted to 800 to 1000 mg per day if:
-Phos >4.6 mg/dL (CKD stage 3 and 4)
-Phos >5.5 mg/dL (CKD stage 5)
-PTH > 55

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20
Q

Inactive form of vitamin D in the body

A

25-hydroxyvitamin D [25(OH)D]

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21
Q

Active form of vitamin D created by the kidney

A

1,25-dihydroxyvitamin D [1,25(OH)2D3]

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22
Q

Enzyme in the kidney that converts inactive vitamin D to active form

A

1-alpha-hydroxylase

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23
Q

Calciferol drug class

A

Inactive vitamin D compound
(Ergocalciferol)
(Vitamin D2)

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24
Q

Cholecalciferol drug class

A

Inactive vitamin D compound
(Vitamin D3)

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25
Q

Rocaltrol/Calcijex drug class

A

Activated vitamin D compound
(Calcitriol)

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26
Q

Zemplar drug class

A

Activated vitamin D compound
(Paricalcitol)

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27
Q

Hectorol Drug class

A

Activated vitamin D compound
(doxercalciferol)

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28
Q

Sensipar drug class

A

Type II calcimimetic agent
(Cinacalcet)

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29
Q

Parsabiv drug class

A

Type II calcimimetic agent
(Etelcalcetide)

30
Q

Inactive calcium vs. active calcium

A

-Inactive vitamin D is used for patients with stage 3 and 4 CKD while active vitamin D is used for patients with stage 5 CKD
-Inactive is better to use than activated

31
Q

Difference between Rocaltrol and Calcijex

A

Rocaltrol is oral and calcijex is IV

32
Q

Calcitriol considerations/counseling

A

-Monitor signs and symptoms of hypercalcemia
-Approved for pediatric use
-Greatest risk of hypercalcemia

33
Q

Paricalcitol considerations/counseling

A

-30% reduction in iPTH
-Most favorable adverse drug reaction profile
-Less calcemic activity compared to calcitriol
-Monitor signs and symptoms of hypercalcemia

34
Q

Doxercalciferol considerations/counseling

A

-Produces a more even serum concentration than calcitriol
-30% reduction of iPTH
-Lower incidence of hypercalcemia compared to calcitriol
-Higher incidence of hyperphosphatemia
-Prodrug and must be activated by the liver

35
Q

What are calcimimetics contraindicated in?

A

Hypocalcemia (Ca <7.5 mg/dL, withhold cinacalcet/etelcalcetide until Ca is = or > 8 mg/dL)

36
Q

Mechanism of action of calcimimetics

A

Mimics the action of calcium but does so by binding to the calcium sensing receptor and inducing a conformational change to the receptor, triggering the parathyroid gland to decrease PTH secretion

37
Q

The four ways ESRD patients can develop anemia

A

-Decreased production of erythropoietin
-Uremia causes a decreased life span of red blood cells
-Vitamin losses during dialysis – folate, B12, B6
-Dialysis – loss of blood through dialyzer

38
Q

Low MCV

A

Microcystic

39
Q

Increased MCV

A

Macrocystic

40
Q

MCV is normal but RDW is increased

A

Normocystic

41
Q

Characteristics of microcystic

A

-Iron deficiency
-Aluminum toxicity

42
Q

Characteristics of normocystic

A

-Anemia of chronic disease
-Gastrointestinal bleed
-Erythropoietin deficiency

43
Q

Characteristics of macrocystic

A

-Folate deficiency
-B12 deficiency

44
Q

When to use oral iron vs iv iron

A

Oral iron cannot be absorbed by patients on hemodialysis

45
Q

Oral iron considerations/counseling

A

-causes upset stomach
-Best absorbed in acidic environment
-Take with orange juice to increase absorption
-Will not work as well on patients taking meds that lower pH
-Separate from calcium by 2 hours

46
Q

InFed or Dexferrum drug class

A

IV Iron
(Iron dextran)

47
Q

Ferriclit drug class

A

IV Iron
(Sodium ferric gluconate)

48
Q

Venofer drug class

A

IV Iron
(Venofer)

49
Q

Injectafer drug class

A

IV Iron
(Ferric carboxymaltose)

50
Q

Feraheme drug class

A

IV Iron
(Ferumoxytol)

51
Q

IV Iron considerations/counseling

A

-Preferred route for CKD 5D patients
-Straight iron can kill the patient
-Flushing, dizziness, hypotension are possible with IV iron products

52
Q

InFed, Dexferrum considerations/counseling

A

-Can be allergic to dextran
-Requires 25mg test dose
-Oldest and cheapest

53
Q

Venofer considerations/counseling

A

Can be used on patients not on dialysis

54
Q

Feraheme considerations/counseling

A

Feraheme interferes with magnetic resonance imaging for up to 3 months after the second injection. MR imaging should be completed prior to starting Feraheme

55
Q

Order the three ESAs from shortest to longest half life
-Aranesp
-rHuEPO, epoetin alfa, Epogen, Procrit, EPO
-Micera

A

-Recombinant human erythropoietin (Procrit)
-Darbepoetin alfa (Aranesp)
-Methoxy polyethylene glycol (Mircera)

56
Q

Causes of ESA therapy failure

A

-Lack of vitamins or iron
-Aluminum toxicity
-Active bleed

57
Q

New therapy for anemia of chronic kidney disease

A

Hypoxia inducible factor (HIF) Prolyl hydroxylase inhibitors (PHI) or HIF-PHIs:
-Daprodustat (Jesduvroq)
-Indication: for the treatment of anemia due to chronic kidney disease in patients who have been on dialysis for at least 4 months

58
Q

Indications for RRT

A

-Acid/base balance
-Electrolyte disturbances
-Intoxication
-Overload of fluid
-Uremia

59
Q

Goals of dialysis

A

-General rule is to initiate when BUN >100, SCr >10

60
Q

AV fistula access

A

-Longest survival rates
-Fewer complications
-Takes 1-2 months to mature
-No needle sticks or blood pressure cuffs on access arm
-Using catheter can increase infection rate by 30x

61
Q

AV graft access

A

-Synthetic
-Shorter survival (foreign object in body)
-Increased infection rates
-2-3 weeks to mature

62
Q

What substances are not removed by dialysis?

A

-High Vd
-High lipophilicity
-High hydrophilicity
-Large molecular weight
-Highly protein bound

63
Q

How do you measure effectiveness of a dialysis session?

A

-Kt/V
-Urea reduction rate (URR)

64
Q

Complications caused by hemodialysis

A

-Hypotension
-Puritus
-Muscle cramps

65
Q

Peritoneal Dialysis

A

-Uses patients peritoneal membranes as dialysis membrane
-Mostly reserved for pediatrics or ESRD patients already receiving PD
-Rarely used for acute renal failure (ARF) except in children
-Not as effective as hemodialysis, but is a continuous therapy
-Residual renal function is preserved so kidneys will continue to work
-Best used on patients with large bellies

66
Q

Continuous ambulatory peritoneal dialysis (CAPD)

A

Replaces bag every 4 hours in the day then leaves fluid in at night to then replace in the morning

67
Q

Continuous cyclic peritoneal dialysis (CCPD)

A

Leaves fluid in during the day then at night a machine takes the fluid in and out

68
Q

Nocturnal intermittent peritoneal dialysis (NIPD)

A

No fluid is in the peritoneum during the day but then at night a machine preforms very rapid exchanges

69
Q

Tidal peritoneal dialysis (TPD)

A

Puts in half of the fluid into the peritoneum then exchanges the other half throughout the night

70
Q

What is continuous renal replacement therapy used for?

A

-It is primarily used for acute renal failure
-Continuous renal replacement therapies were developed for those patients who could not tolerate regular hemodialysis sessions

Therapeutics II (33 decks)

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