CKD Shepler Flashcards by Rehman Hameed

3 major causes of CKD

-diabetes mellitus
-hypertension
-glomerulonephritis

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GFR greater than or equal to 90 is what category of CKD?

G1 (normal or high)

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GFR between 60-89 is what category of CKD?

G2 (mildly decreased)

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GFR between 45-59 is what category of CKD?

G3a (mildly to moderately decreased)

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GFR between 30-44 is what category of CKD?

G3b (moderately to severely decreased)

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GFR between 15-29 is considered what category of CKD?

G4 (severely decreased)

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GFR less than 15 is considered what category of CKD?

G5 (kidney failure)

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what formula is used most commonly for estimation of creatinine clearance?

Cockcroft-Gault equation

Men: (140-age)IBW/(SCr * 72)
Women: CrCl * 0.85

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what is uremia?

build up of waste products in the blood (increase in BUN, pruritus, confusion, nausea, vomiting, anorexia)

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normal BUN levels

15 or less

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5 complications for kidney injury (from table; page 7)

-uremia
-fluid retention
-electrolyte imbalances
-mineral and bone disorder
-anemia

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fluid restriction is not generally necessary if _____ intake is controlled

sodium

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true or false: diuretics work in patients without functioning kidneys

false

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thiazides are ineffective when CrCl < ___ mL/min

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loop diuretics will work when CrCl < ___ mL/min

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what is the bioavailability of furosemide, bumetanide, and torsemide?

furosemide 10-100
bumetanide 80-100
torsemide 80-100

(since furosemide is lower, we would give higher dose of this compared to the other 2)

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as renal function declines, and the loop diuretic dose is maximized, a _____ may be added to the regimen to overcome diuretic resistance

thiazide

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for electrolyte imbalances, how much sodium per day should a patient get?

< 2 g of sodium/day or < 5 g NaCl per day

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for electrolyte imbalances, how much potassium should patients be restricted to?

3 gm/day (goal for ESRD patient is a pre-dialysis K conc of 4.5-5.5 mEq/L)

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which of the following diuretics is least likely to cause an allergic sulfa reaction?

a. furosemide
b. ethacrynic acid
c. torsemide
d. bumetanide

b. ethacrynic acid

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what organ activates vitamin D?

kidneys

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normal phos levels range

2.5-4.5 mg/dL

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true or false: phosphate binders must be taken with meals

true

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two calcium containing phosphate binders

calcium carbonate (Tums)
calcium acetate (PhosLo)

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calcium carbonate is what percent elemental calcium?

40%

calcium acetate is what percent elemental calcium?

25%

how much elemental calcium is in PhosLo?

169 mg

most common non-calcium containing phosphate binder?

sevelamer carbonate (Renvela)

if phos is 5.5-7.5, take _____ mg sevelemar tid; if phos is 7.5 or more, take _____ mg sevelemar tid

800; 1600

sevelamer increases/decreases uric acid levels

decreases

lanthanum carbonate (Fosrenol) is more efficacious at high or low pH?

low pH

lanthanum carbonate is elim in feces, has no long term accumulation, and does not cross _____

BBB (blood brain barrier)

what are the two non-calcium containing phosphate binders that contain iron?

Sucroferric oxyhydroxide (Velphoro) and Auryxia (ferric citrate) (Auryxia is for CKD patients on dialysis)

which of these has no effect on iron stores? a. sucroferric oxyhydroxide (Velphoro) b. Auryxia (ferric citrate)

a. sucroferric oxyhydroxide (Velphoro)

aluminum hydroxide (Amphojel) things to know (3)

-don't use -alum is elim in kidney so it can accumulate -no more than 4 weeks

drug class to treat hyperphosphotemia

phosphate binders

dietary phos intake should be restricted to 800 to 1000 mg per day if: phos > ___ (CKD stage 3 and 4) phos > ___ (CKD stage 5) ___ > target range for stage 3, 4, or 5

4.6; 5.5; PTH

Which of the following phosphate binders will affect the patient’s calcium serum concentrations? A. Renvela (sevelamer carbonate) B. Fosrenol (lanthanum carbonate) C. Velphoro (sucroferric oxyhydroxide) D. Tums (calcium carbonate)

D. Tums (calcium carbonate)

JT is a 78 year old male starting hemodialysis. His current lab values are: Ca 11 (H) Phos 6 (H) PTH 1200 (H) SCr 12 (H) Uric Acid 8 (H) Which of the following would be the best option for treating JT’s hyperphosphatemia? A. Renvela (sevelamer carbonate) B. Fosrenol (lanthanum carbonate) C. Velphoro (sucroferric oxyhydroxide) D. Tums (calcium carbonate)

A. Renvela (sevelamer carbonate) (dec uric acid; no tums bc already has high calcium)

Hyperphosphatemia and the kidneys inability to activate vitamin D lead to a subsequent decrease in _____ serum concentrations. This triggers the parathyroid gland to secrete more _____ to increase _____ mobilization from the bone.

calcium; PTH; calcium

vitamin D2 (ergocalciferol) and D3 (cholecalciferol) are given to what stage CKD patients?

stage 3 and 4

true of false: vitamin D2 and D3 don't require activation

false

vitamin D2 name

ergocalciferol

vitamin D3 name

cholecalciferol

what are the 3 activated vitamin D compounds we talked about (generic and brand names)?

calcitriol (Rocaltrol and Calcijex) paricalcitol (Zemplar) doxercalciferol (Hectorol)

paricalcitol causes ___ % reduction in iPTH

which of the three is a prodrug and needs to be activated by the liver? a. calcitriol b. paricalcitrol c. doxercalciferol

c. doxercalciferol

only calcimimetic drug

cinacalcet (sensipar); etelcalcetide (parsabiv) is IV (used to lower PTH conc)

cinacalcet MOA

mimics action of calcium by binding to calcium sensing receptor (CaR) and inducing conformational change to receptor, triggering PT gland to dec PTH secretion

sensipar is contraindicated in __________

hypocalcemia (if Ca is < 7.5 withhold drug until 8 or higher)

goals for calcium, phos, vitamin D, and intact PTH in CKD-MBD

calcium: 8.5-10.5 mg/dL phos: 2.5-4.5 mg/dL vit D: ~30 ng/mL (20-40) iPTH: non-dialysis 11-55 pg/mL, dialysis 100-500 pg/mL

Which of the following vitamin D products DOES NOT require activation by a body organ prior to activation? a. doxercalciferol b. ergocalciferol c. cholecalciferol d. calcitriol

d. calcitriol (a is prodrug, b and c need activation in kidney)

Mrs. Jenkins is an 82 year old hemodialysis patient who presented to the clinic today with persistent secondary hyperparathyroidism. Her most current labs are as follows: Ca 7.2 mg/dL (L) Phos 4.0 mg/dL PTH 1300 pg/mL (H) Vitamin D 35 ng/mL Which of the following medications should be recommended for treating her secondary hyperparathyroidism? A. cholecalciferol B. ergocalciferol C. cinacalcet (Sensipar) D. paricalcitol (Zemplar)

d. paricalcitol (Pt on hemodialysis so kidneys don't work, rule out A and B bc they need to be activated. Pt has low calcium so not C, only use sensipar for normal or little elevated)

erythoropoietin (EPO) function

promotes production of RBCs in bone marrow

4 mechanisms that cause anemia in ESRD pts

1. dec production of EPO 2. uremia caused by a dec life span of RBCs 3. vitamin losses during dialysis- folate, B12, B6 4. dialysis- loss of blood through dialyzer (hemolysis) (number 1 is main reason)

causes of microcytic anemia (2 of them)

-iron deficiency -aluminum toxicity

causes of macrocytic anemia (2 of them)

-folate deficiency -B12 deficiency

what is normocytic anemia?

less RBCs than normal, but their size is normal

causes of normocytic anemia (3 of them)

-anemia of chronic disease -GI bleed -EPO deficiency

MCV normal lab value range

80-96 um^3

RDW (red cell distribution width) normal lab value range

11.5-14.5%

diagnosis of anemia should be initiated at Hb less than what # in females and males?

Hb < 12 g/dL in females Hb < 13 g/dL in males

KDIGO suggests iron supp if TSAT < ___ % and serum ferritin is < ___ ng/mL

TSAT < 30 % ferritin < 500 (if > 30 % and > 500, don't give iron)

oral iron is best absorbed in a(n) _____ environment a. basic b. acidic

b. acidic

oral iron should be separated from any _____ by 2 hours

calcium

early CKD pts dose of oral iron = ___ mg of elemental iron per day at least

200 mg

how many mg elemental iron is in ferrous sulfate 325?

65 mg

common side effect of oral iron

stomach upset

heme iron things to know (3)

-greater absorption -different absorption site -not subject to 200 mg per day rule

IV iron is preferred route for which CKD pts?

CKD 5D (stage 5 on dialysis)

which IV iron agent interferes with MRIs?

ferumoxytol (Feraheme)

which IV iron requires a test dose?

iron dextran (inFed, Dexferrum) (due to anaphylactic rxns to dextran component)

5 IV iron agents

-iron dextran (InFed, Dexferrum) -sodium ferric gluconate (Ferrlicit) -iron sucrose (Venofer) -ferric carboxymaltose (Injectafer) -ferumoxytol (Feraheme)

what is Triferic (ferric pyrophosphate citrate)?

iron compound added to diasylate to give during dialysis

when to begin ESAs: CKD3-5ND -> Hb < ___ g/dL; Hb falling at rapid rate; needed to avoid blood transfusion CKD 5D -> start when Hb is between ___-___

10; 9-10 (as Hb inc, incidence of cerebrovascular AEs also inc, do not use ESA to push Hb above 11.5)

3 ESAs to know

-recombinant human EPO (rHuEPO, epoetin alfa, Epogen, Procrit, EPO) -darbepoetin alfa (Aranesp) -methoxy polyethylene glycol - epoetin beta (Mircera)

recombinant human EPO (Epogen) and darbepoetin alfa (Aranesp) function

stimulates erythroid progenitor cells

which has the longest half life? a. recombinant human EPO (Epogen) b. darbepoetin alfa (Aranesp) c. methoxy polyethylene glycol (Mircera)

c. methoxy polyethylene glycol (Mircera) (a. has the shortest half life)

ESA adverse effects (Epogen, Aranesp, Mircera)

Pure Red Cell Aplasia (PRCA) - antibodies develop to EPO; dc drug permanently

cause of ESA therapy failure (5)

lack of vitamins or iron (this is the main reason) alum toxicity active bleed drug induced bone marrow suppression acute inflammation or infection

drug that is a HIF-PHI

daprodustat (Jesduvroq)

daprodustat indication

treatment of anemia due to CKD in pts who have been on dialysis for at least 4 months