CKD Shepler Flashcards

1
Q

3 major causes of CKD

A

-diabetes mellitus
-hypertension
-glomerulonephritis

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2
Q

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

A

G1 (normal or high)

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3
Q

GFR between 60-89 is what category of CKD?

A

G2 (mildly decreased)

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4
Q

GFR between 45-59 is what category of CKD?

A

G3a (mildly to moderately decreased)

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5
Q

GFR between 30-44 is what category of CKD?

A

G3b (moderately to severely decreased)

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6
Q

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

A

G4 (severely decreased)

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7
Q

GFR less than 15 is considered what category of CKD?

A

G5 (kidney failure)

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8
Q

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

A

Cockcroft-Gault equation

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

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9
Q

what is uremia?

A

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

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10
Q

normal BUN levels

A

15 or less

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11
Q

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

A

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

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12
Q

fluid restriction is not generally necessary if _____ intake is controlled

A

sodium

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13
Q

true or false: diuretics work in patients without functioning kidneys

A

false

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14
Q

thiazides are ineffective when CrCl < ___ mL/min

A

30

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15
Q

loop diuretics will work when CrCl < ___ mL/min

A

30

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16
Q

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

A

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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17
Q

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

A

thiazide

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18
Q

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

A

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

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19
Q

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

A

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

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20
Q

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

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

A

b. ethacrynic acid

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21
Q

what organ activates vitamin D?

A

kidneys

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22
Q

normal phos levels range

A

2.5-4.5 mg/dL

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23
Q

true or false: phosphate binders must be taken with meals

A

true

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24
Q

two calcium containing phosphate binders

A

calcium carbonate (Tums)
calcium acetate (PhosLo)

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25
Q

calcium carbonate is what percent elemental calcium?

A

40%

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26
Q

calcium acetate is what percent elemental calcium?

A

25%

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27
Q

how much elemental calcium is in PhosLo?

A

169 mg

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28
Q

most common non-calcium containing phosphate binder?

A

sevelamer carbonate (Renvela)

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29
Q

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

A

800; 1600

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30
Q

sevelamer increases/decreases uric acid levels

A

decreases

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31
Q

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

A

low pH

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32
Q

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

A

BBB (blood brain barrier)

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33
Q

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

A

Sucroferric oxyhydroxide (Velphoro) and Auryxia (ferric citrate)

(Auryxia is for CKD patients on dialysis)

34
Q

which of these has no effect on iron stores?

a. sucroferric oxyhydroxide (Velphoro)
b. Auryxia (ferric citrate)

A

a. sucroferric oxyhydroxide (Velphoro)

35
Q

aluminum hydroxide (Amphojel) things to know (3)

A

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

36
Q

drug class to treat hyperphosphotemia

A

phosphate binders

37
Q

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

A

4.6; 5.5; PTH

38
Q

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)

A

D. Tums (calcium carbonate)

39
Q

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

A. Renvela (sevelamer carbonate)

(dec uric acid; no tums bc already has high calcium)

40
Q

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.

A

calcium; PTH; calcium

41
Q

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

A

stage 3 and 4

42
Q

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

A

false

43
Q

vitamin D2 name

A

ergocalciferol

44
Q

vitamin D3 name

A

cholecalciferol

45
Q

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

A

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

46
Q

paricalcitol causes ___ % reduction in iPTH

A

30

47
Q

which of the three is a prodrug and needs to be activated by the liver?

a. calcitriol
b. paricalcitrol
c. doxercalciferol

A

c. doxercalciferol

48
Q

only calcimimetic drug

A

cinacalcet (sensipar); etelcalcetide (parsabiv) is IV

(used to lower PTH conc)

49
Q

cinacalcet MOA

A

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

50
Q

sensipar is contraindicated in __________

A

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

51
Q

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

A

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

52
Q

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

A

d. calcitriol

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

53
Q

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)

A

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)

54
Q

erythoropoietin (EPO) function

A

promotes production of RBCs in bone marrow

55
Q

4 mechanisms that cause anemia in ESRD pts

A
  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)

56
Q

causes of microcytic anemia (2 of them)

A

-iron deficiency
-aluminum toxicity

57
Q

causes of macrocytic anemia (2 of them)

A

-folate deficiency
-B12 deficiency

58
Q

what is normocytic anemia?

A

less RBCs than normal, but their size is normal

59
Q

causes of normocytic anemia (3 of them)

A

-anemia of chronic disease
-GI bleed
-EPO deficiency

60
Q

MCV normal lab value range

A

80-96 um^3

61
Q

RDW (red cell distribution width) normal lab value range

A

11.5-14.5%

62
Q

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

A

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

63
Q

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

A

TSAT < 30 %
ferritin < 500

(if > 30 % and > 500, don’t give iron)

64
Q

oral iron is best absorbed in a(n) _____ environment

a. basic
b. acidic

A

b. acidic

65
Q

oral iron should be separated from any _____ by 2 hours

A

calcium

66
Q

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

A

200 mg

67
Q

how many mg elemental iron is in ferrous sulfate 325?

A

65 mg

68
Q

common side effect of oral iron

A

stomach upset

69
Q

heme iron things to know (3)

A

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

70
Q

IV iron is preferred route for which CKD pts?

A

CKD 5D (stage 5 on dialysis)

71
Q

which IV iron agent interferes with MRIs?

A

ferumoxytol (Feraheme)

72
Q

which IV iron requires a test dose?

A

iron dextran (inFed, Dexferrum)

(due to anaphylactic rxns to dextran component)

73
Q

5 IV iron agents

A

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

74
Q

what is Triferic (ferric pyrophosphate citrate)?

A

iron compound added to diasylate to give during dialysis

75
Q

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 ___-___

A

10; 9-10

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

76
Q

3 ESAs to know

A

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

77
Q

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

A

stimulates erythroid progenitor cells

78
Q

which has the longest half life?

a. recombinant human EPO (Epogen)
b. darbepoetin alfa (Aranesp)
c. methoxy polyethylene glycol (Mircera)

A

c. methoxy polyethylene glycol (Mircera)

(a. has the shortest half life)

79
Q

ESA adverse effects (Epogen, Aranesp, Mircera)

A

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

80
Q

cause of ESA therapy failure (5)

A

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

81
Q

drug that is a HIF-PHI

A

daprodustat (Jesduvroq)

82
Q

daprodustat indication

A

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