CKD Progression Flashcards
Note, this has all the ACE’s/Arbs listed, so for the most important/common ones that Dr. Meaney pointed out) there’ll be cards but for the rest its basic drug info to keep the list shorter
:)
How is CKD Staged/Classified?
(CGA–> Cause, GFR, and Albuminuria)
1.)By CKD-Epi eGFR (NOT CrCl!) and level of Albuminuria
-For eGFR: it’s CKD-EPI, not MDRD
-For eGFR: G1-5 (G5 being ESRD/renal failure, and g3 having a and b categories)
For Albuminuria: A A1,A2, and A3 (worst) for albuminuria level
ie G2A1 or G3bA3
What are the cutoffs of CKD stages?
For eGFR (ml/min/1.73m^2): Stage G1: GFR>=90ml/min/1.73M2 G2: GFR 60-89 G3a: 45-59 G3b: 30-44 G4: 15-29 G5<15 For Albuminuria: A1 is < 30mg albumin/g creatine A2 is 30-300mg/g A3 is over 300mg/g
is CKD a silent disease? If so when is it normally caught?
Up to 3a is normally a silent disease, in part due to the intact nephron hypothesis
Can CKD be stopped/treated?
No, the progression can only be slowed!
Often a stepwise progression (large/small injury without a full recovery and this process repeats)
What are the Modifiable Risk Factors of CKD?
1.) Diabetes,
2.) HTN
3.) Proteinuria
4.)Hyperlipidemia
5.) Tobacco use, are the big 5
then there’s systemic inflammation and environmental exposures like heavy metals
What are the non modifiable risk factors of CKD?
Older age,
African or Native American ethnicity
Genetics (fmaily hx)
And Gender?- is not totally elucidated but men seem to be at higher AKI risk
What’s the MOST IMPORTNANT predictor of CKD progression (thus the most important to treat)?
Management/treatment of the UNDERLYING CAUSE
along with maintaining QOL and preventing/managing complications
Role of blood glucose control (for diabetics I;m gussing?)
Best to have strict A1C goals< 7%
-Can be less strict as kidney gets near or during ESRD (stages 4 or 5) because the damage is already done
What’s the main goal of CKD treatment? (clinically)
Slowing the progression of CKD
Blood pressure goals/HTN treatment in CKD?
130/80 regardless of albuminuria, if they’re over this, treat it! (It’s also the goal)
What medication is first line for HTN in CKD?
ACE’s/ARB’s
HTN treatment/BP Control in CKD
1st. ) Ace/ARB
2nd. ) Thiazide diuretic
- - Loop diuretic if they have clinically evident edema
3rd. ) CCB’s:
- -Non DHP (diltiazem preferred) for albuminuria lowering and DHP for bp lowering
A Note About about CCB’s for HTN/albuminuria control management in those with CKD?
What about CCB’s for HTN/albuminuria control management in those with CKD?
When to use CCB’s for HTN in CKD
(NOTE- DHP CCB’s aren’t 2nd line, just general info here, and Non-DHPs can be 2nd line (or additions) but for their albumin control, not 2nd line for BP)
Use Diltiazem (or verapamil if no other option) IF:
1.) Patient is ACE/ARB intolerant OR
2.) Patient is on MAX TOLERATED DOSE of ACE/ARB and still has albuminuria
-BUT can’t use these with Beta-Blockers and they have many DDI’s, so if you can’t use one then
DHP CCB: NOT 2nd line
1.) For improved BP control only BUT ACE/ARB + DHP CCB > ACE/ARB alone for renal function so it still helps
What are the Lifestyle changes recommended for CKD:
- Limit sodium intake to <2g/day
- ) Moderate exercise 30mins/5x per week
- ) Weight loss to BMI 20-25
- ) Limit alcohol to 1 drink/day for females and 2 for males
Statin use in CKD?
Generally same dosing, they do have some benefits in NON-Dialysis patients
- So add a statin for non-dialysis patients, if they’re already on one its okay to keep them on it once they get on dialysis too.
- Still use it during ACS events in dialysis patients
When does proteinuria happen with regards to measured kidney fx?
Proteinurua happens before GFR declines!
What is the desired Albuminuria reducing goals?
Hopefully to reduce albuminuria by 30-50%
What’s the treatment for CKD?
ACE/ARB are first line for all patients with CKD AND ALBUMINURIA (X>30mg/day)
Main ACE-inhibitors?
Enalapril and Lisinopril
For CKD, All ACEi’s are daily dosing EXCEPT which ones?
Captopril (capoten) is TID and Enalapril (vasotec) is BID to start then moves to QD (can still be BID at target dose, it’s BID and QD with QD more common)
What is the brand name of Enalapril and Lisinopril?
Enalapril-EV/ElectroVehicle- Vasotec is brand name
Lisinopril- LZ/LandingZone- Zestril (or prinivil) is the brand name
Pneumonic devices for other ACEs/brand names
Benzepril-BL/BorderLands=Lotensin Captopril-CC/CC you in an email- Capoten Fosinopril-FM/FM radio-Monopril Moexipril-MU/Mu (μ)-Univasc Quinapril-QAc/Qac like a duck- Accupril Ramipril-RA/RAmp-Altace Trandolopril-TM-TradeMark-Mavik
What’s the ACEi that contains magnesium?
Quinapril
What’s the Starting and maximum/target? CKD dose of 1st.) Enalapril and 2nd.) Lisinopril?
Enalapril=2.5mg QD to start to 20mg QD (or 10 BID)
Lisinopril=5mg QD to start to 80mg QD
What’s the elimination route of enalapril and lisinopril?
Enalapril= RENAL (94% renal) Lisinopril= RENAL (ALL 100% RENAL)
Most common/important ARBs
Irbesartan, Losartan, and valsartan
What dosing regimen do all ARBs have in common?
They’re all daily/QD!
Fill this in:
The Starting dose of Irbesartan /Avapro is _________ mg QD and it’s max is ________mg QD
75-150mg QD and 300mg QD
75/150-300mg QD
Fill this in:
The Starting dose of Losartan/Coozar is _________ mg QD and it’s max is ________mg QD
25/50mg QD and 100/150mg QD
25/50-100/150mg QD
Fill this in:
The Starting dose of Valsartan/Diovan is _________ mg QD and it’s max is ________mg QD
- 25mg QD and 20mg QD
1. 25-20mg QD
The elimination of 1.) Irbesartan/Avapro, 2.) Losartan/Coozar, and 3.) Valsartan/Diovan are:
- ) HEPATIC (80% hep/20% renal)
- ) FECES (60 feces/40 urine)
- ) Almost ALL FECES (83 Feces/13% urine)
Dual Raas inhibition?
Is a no no!
What’s Aliskerin/Tekturna?
It’s a DRI/Direct renin inhibitor that’s dosed at 150-300mg QD
-Same effect on CKD progression as an ace/arb
What are the ABSOLUTE Contraindications to RAAS drugs?:
- ) Pregnancy
- ) Bi-BILATERAL…BIIIIIIIIILATERAL Renal artery stenosis
- ) History of ACE/ARB angioedema (if with ace can try an arb under supervision but if react to an ARB then can’t get an ACE or ARB)
What circumstances should you use RAAS drugs with caution but aren’t total Contraindications?
- UNI-UNIlateral renal artery stenosis
- Hyperkalemia
- Dehydration/hypovolemia
- hypotension
- Kidney Dysfunction (SCr>3.0, eGFR<30)
RAAS Drug monitoring and adjustment:
Labs, vitals, symptoms,
THIS SLIDE INCLUDES ACE/ARB AE’s
Labs: K+ and SCr within 1-2 weeks
BP and HR qd if possible
AE’s/Symptoms to watch for: Orthostasis, Angioedema, Cough (more with ACE’s, females, and African Americans)
What to do with SCr changes:
Expect a decline in GFR and increasein K+
(note if only for HTN it’s a 35% decrease cutoff for stopping the drug- no middle ground in that situation)
If GFR decreases by <30%, no change is needed
If GFR decreases by 30-50%, cut the dose in half
If GFR decreases by over 50%, that’s AKI-Stop the drug and restart when Kidney funtion is stable at a lower dose
What to do with K+ changes?
If K>5 recommend dietary changes
K>6 give a loop + SPS
If K>6,5, hold the drug and adress hyperkalemia then resume the drug with a better regimen
DDI;s in CKD
Avoid with:
-NSAIDS–> AKI more likely (HEMODYNAMIC)
-Potassium supplements –> hyperkalemia
-Dual RAAS inhib –> AKI and hyperkalemia
Use with Caution:
-Aldosterone antags/K+sparing diuretics–> Hyperkalemia
-Lithium–> higher lithium concentrations
-Quinalipril has magnesium–> Avoid with fluoroquinolones and tetracyclines
pears of RAAS inhibitors
Start low and go slow if worried about hyperkalemia- could start at 1/2 dose or 1/2 the dose of their diuretic for a little bit
- Could tell patients to increase salt intake just for a few weeks
- Use in all patients with CKD regardless of BP if have albuminuria and unless contraindicated
- No CI for renal dysfunction
- Mortality benefit in HFrEF
SGLT2 inhibitors?
Have benefit in CKD progression for even NON-Diabetic patients!
Affgerent arteriole vasoconstriction decreases glomerular pressure
-Weak diuretic effect
Possible side effects with SGLT2 inhibs in (* in CKD)
AKI*
Euglycemic DKA
UTI’s/genital mycotic infections
Lower Limb Amputations
What if a patient has gout? What’s the uric acid goal and drug dosing?
Want uric acid<7mg/dl –> can use allopurinol or febuxostat
Allopurinol dosing: 1.5 x eGFR
—AE’s include rash/fever/ SJS and other hypersensitivity reactions- get help ASAP if start having these
— Screen (genotyping test) Asians for a particular HLA that predispposes them to this reaction
What acid base disorder is common in ckd patients and how to treat it?
Chronic metabolic acidosis is common–> Treat when Serum bicarb gets below 20 using 1950-2600mg oral alkali/day (Split BID so, 975mg-1300mg BID)
What are the lifestyle modifications recommended for CKD?
As CKD worsens limit protein to (at CKD3-4) <0.8g/kg/day
Limit salt to <2g sodium or <5g table salt per day
Limit alcohol to 1 (female) to 2 (male) drinks/day
Try to STOP SMOKING!
Lastly: Weight loss strategies including exercise to a goal BMI of <25kg/m^2
Sick day management! What do you do?
Stop your RAAS drugs, metformin, DIURETICS, DIGOXIN, lithium, and AVOID NSAIDS
Should we ever recommend herbals?
Oh yes, herbals are totally great
aka always recommend AGAINST using them, even if they’re doctor may have recommended something
