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PHM601 AKI/CKD > CKD - MBD > Flashcards

CKD - MBD Flashcards

1
Q

What does stimulation of the PTH gland do?

A

Increases serum calcium and phosphorus

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2
Q

What causes MBD in CKD

A

secondary hyperparathyroidism

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3
Q

Hyperparathyroidism directly leads to what

A

phosphate retention
decreased vitamin D activation

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4
Q

Phosphate retention and decreased Vit D activation lead to what?

A

Hypocalcemia

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5
Q

True or False

As GFR declines, CKD-MBD worsens

A

True

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6
Q

Clinical Presentation pf CKD-MBD

A

Usually asymptomatic so monitor labs
Consequences are significant when severe/uncontrolled

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7
Q

When should you monitor Calcium and Phosphorus

A

CKD Stage 3 - Every 6 - 12 months
CKD Stage 4 - Every 3 - 6 months
CKD Stage 5 - every 1 - 3 months

***Calcium with ALbumin

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8
Q

When should you monitor iPTH

A

CKD Stage 3 - every 12 months
CKD Stage 4 - every 3 - 12 months
CKD Stage 5 - every 3 - 6 months

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9
Q

When should you monitor 25-OH Vitamin D

A

at baseline

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10
Q

What is alkaline phosphatase/Bone -specific
(ALP/BALP)?

A

Bone specific ALP; reflects biosynthetic activity of osteoblasts

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11
Q

Equation for Corrected Calcium

A

= Measured Ca + 0.8(4- albumin)

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12
Q

Calcium normal range

A

8.5 - 10.2

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13
Q

Consequences of CKD-MBD

A
  • Bone disease
  • CV disease (#1 cause of ESRD death)
  • Calciphylaxis (CUA)
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14
Q

Consequences of secondary hyperparathyroidism

A
  • ESA resistance
  • Left ventricular hypertrophy
  • Parathyroid Hyperplasia
  • Myocardial fibrosis
  • Immune dysfunction
  • Lipid metabolism (HyperTG)
  • Renal Osteodystrophy
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15
Q

What happens if you undertreat HyperPTH

A

Ostetitis fibrosa

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16
Q

What happens if you overtreat HyperPTH

A

Adynamic bone disease
Osteomalacia

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17
Q

Goals of CKD-MBD Treatment

A
  • Prevent cardio/extravascular calcification
  • Prevent development of HyperPTH and Renal Osteodystrophy
  • Maintain critical biochemical parameters in range (Calcium, Phosphorus, iPTH)
  • Prevent mortality
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18
Q

General Approach to CKD-MBD Treatment

A

1st step: Phosphate Binders (w/dietary control)
2nd step: Activated Vitamin D
3rd step: Calcimimetics

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19
Q

How to give phosphate binders

A

Check serum Calcium

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20
Q

Low serum Ca, give what phosphate binder?

A

Calcium based phosphate binder

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21
Q

Normal serum Ca, give what phosphate binder

A

Non-Ca based phosphate binder

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22
Q

High serum Ca, give what phosphate binder?

A

Non- Ca based phosphate binder

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23
Q

What are your calcium based phosphate binders?

A

Calcium carbonate
Calcium acetate

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24
Q

Calcium acetate specifications

A

Expensive
Only available Rx
Less Ca

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25
Q

Calcium carbonate specifications

A

OTC (Tums)
More Ca
Less expensive
Requires acidic pH

26
Q

What are your non-Ca based phosphate binders?

A

Sevelamer carbonate
Lanthanum carbonate
Ferric citrate
Sucroferric oxyhydroxide

27
Q

1st line non-Ca based Phos Biinder?

A

Sevelamer carbonate

***may improve metabolic acidosis

28
Q

When should you use Lanthanum carbonate

A

when you cannot use Renvela
OR
when you need a chewable formulation

***worsens metabolic acidosis

29
Q

After Phosphate binders, what should you do to lower PTH

A

Activated Vitamin D/analogs
OR Calcimimetic

30
Q

When should you use Activated Vitamin D/analogs

A

Serum Calcium is normal - low

31
Q

When should you use Calcimetic

A

Serum calcium normal - high

32
Q

Goals of treatment for secondary hyperparathyroidism

A

Avoid hypercalcemia (asymptomatic hypoCa is okay)
Phosphate towards normal range: 2.7 - 4.6, 3.5-5.5
iPTH 2- 9 x ULN (150 - 600)

33
Q

What are your Activated Vitamin D & analogs

A
  • Calcitriol (Rectorol)
  • Paracalcitol (Zemplor)
  • Doxercalciferol (Hectorol)
34
Q

Activated Vitamin D vs Analaogs

A

Analogs have less risk of hypercalcemia

35
Q

What are your calcimimetics

A

Cinacalcet (Sensipar) - PO
Etelcalcitide (Parsabiv) - IV

36
Q

How should you take Phosphate binders?

37
Q

Adverse effects of Ca based phosphate binders

A

Abdominal Discomfort
Nephrolithiasis
Calciphylaxis

38
Q

Ca based Phos binders dosinh

A

Carbonate 1250 mg TID w/ food
Acetate 1334 mg TID W/ food

***Note TID w/ food

39
Q

Ca based phosphate binders DDI

A

Fluroquinolones
Levothyroxine
Iron

***other meds, separate by 2 hrs

40
Q

Sevelamer dosing

A

Based on serum phosphate levels

5.5 - 7.5 800 mg TID
7.5 - 9 1200 - 1600 mg TID
>9 1600 mg TID

41
Q

Sevelamer Adverse effects

A

GI and Diarrhea

42
Q

Iron based phosphate binders

A

Ferric citrate (PO TID)
- iron deficiency anemia
Sucroferric oxyhydroxide (chewable)
- lower pill burden

43
Q

Ferric citrate adverse effetcs

A

iron overload
stool discoloration
Gi
diarrhea

44
Q

Sucroferric oxyhydroxide adverse effects

A

Gi
diarrhea

45
Q

Al based phosphate binder

A

Last line
Risk of Al toxicity
ADEs: Gi, CNS toxicity
Use short term

46
Q

Phosphorus and Mortality

A

Every 1 mg/dl increase in Phos above normal is 18% increase in mortality risk

47
Q

True or False

You cannot combine Calcium and non-Calcium based Phosphate binders

48
Q

What is activated Vitamin D

A

Calcitriol

49
Q

When should Calcitriol or its analogs be used

A

When iPTH is still elevated w/ Calcium and Phosphate at goal
OR
Persistent HypoCa and HyperPhos

50
Q

When should Calcitriol and its analogs not be used

A

HyperCa AND HyperPhos

51
Q

What is vitamin D2 and its dosing

A

Ergocalciferol
50,000IU weekly/monthly

52
Q

What is Vitamin D3?

A

Cholecalciferol
>1000IU daily

53
Q

What are your Vitamin D analogs?

A

Ergocalciferol and Cholecalciferol

***Recommended in CKD and ESRD for Vit D deficiency

54
Q

What is Calcifediol?

A

Prohormone of calcitriol (calcidiol)

55
Q

Calcifediol dosing

A

30 mcg PO QHS

56
Q

Calcifediol specifications

A

Only use in CKD Stage 3 and 4
***NOT ESRD
Serum Ca must be <9.8 and Serum Phos <5.5

57
Q

Side effects of Calcifediol

A

HyperCalcemia
HyperPhosphatemia

58
Q

Cinacalcet

A

Oral Calcimimetic that increases sensitivity of PTH gland to increase Calcium affinity and reduce PTH secretion

59
Q

Cinacalcet dosing

A

30 mg/day w/ food (titrate up)
- Requires acidic pH

60
Q

Cinacalcet Adverse effects

A
  • GI (N/V)
  • QTc Prolongation
  • Ventricular Arrythmia
  • Hypocalcemia (paresthesias, cramping)

***All are dose limiting

61
Q

What is Etelcalcitide

A

IV Calcimimetic dosed at hemodialysis

62
Q

Etelcalcetide Adverse effetcs

A
  • QTc Prolongation
  • Hypocalcemia
  • Less GI effects vs PO form

PHM601 AKI/CKD (5 decks)

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