Dialysis

Question 1

Stage G1

Answer 1

> 90mL/min/1.73m^2

-Must have signs and symptoms

Question 2

Stage G2

Answer 2

• 60-89mL/min/1.73m^2

- Must have signs and symptoms

Question 3

Stage G3a

Answer 3

45-59mL/min/1.73m^2

Question 4

Stage G3b

Answer 4

30-44mL/min/1.73m^2

Question 5

Stage G4

Answer 5

15-29mL/min/1.73m^2

Question 6

Stage G5

Answer 6

<15mL/min/1.73m^2

Question 7

A1 (normal/mild)

Answer 7

-ACR or AER
<30mg/g (mg/24h)
-PCR or PER
<150 mg/g (mg/24h)

Question 8

A2 (moderate)

Answer 8

-ACR or AER
30-300mg/g (mg/24h)
-PCR or PER
150-500mg/g (mg/24h)

Question 9

A3 (high)

Answer 9

-ACR or AER
>300mg/g (mg/24h)
-PCR or PER
>500 mg/g (mg/24h)

Question 10

Drugs that will decrease proteinuria/albuminuria

Answer 10

• ACEi and ARBs
• Nondihydropyridine CCB (diltiazem, verapamil)
• Goals : decrease amount of protein in the urine, prevent progression from A2 to A3

Question 11

When to consider loop diuretics

Answer 11

When fluid overload is present in CKD patients

Question 12

Five reasons to dialyze someone

Answer 12

A- acidosis
E- electrolytes 
I- intoxication
O- fluid overload 
U- uremia

Question 13

Conventional (standard) Filter

Answer 13

• Small molecule

- Molecules < 500 Da

Question 14

High Flux Filter

Answer 14

• Large pores

- Molecules< 1500 Da

Question 15

Dialysate

Answer 15

• What you want the blood to be

- Has physiologic concentrations of electrolytes and glucose

Question 16

How dialysis works

Answer 16

a) Diffusion- high to low concentrations

b) Convection- machine makes a pressure difference (moves water)

Question 17

Access sites with highest infection risks

Answer 17

• Catheter > grafts > fistulas

- Use a fistula whenever possible

Question 18

Peritoneal Dialysis (PD)

Answer 18

• Can do from home
• Components
  1) Peritoneum- dialysis membrane
  2) Dialysate
  3) Access- Tenckoff catheter

Question 19

Different types of PD

Answer 19

1) CAPD- uses gravity to help with filtration

2) CCPD- automated, uses a machine to filter blood/dialysate, can be done while pt sleeps

Question 20

PD complications

Answer 20

• Catheter related infection

- Peritonitis; leading cause of morbidity

Question 21

Peritonitis

Answer 21

• Leading cause of morbidity in PD patients

- Signs/symptoms; cloudy dialysate, stomach pain, fever, nausea

Question 22

How to determine if a drug is dialyzable

Answer 22

1) Protein binding
2) Volume of distribution
3) Molecular weight
- Low protein binding
- Small volume of distribution
- Small molecular weight
- Drug is dialyzable

Question 23

Drug Dialyzability References

Answer 23

• Lexicomp
• Micromedex
• Handbook by Renal Pharmacy Consultants

Question 24

For dialysis pt do you still calculate GFR?

Answer 24

• Noooo
• Your answer will be jank
• If on dialysis assume that they are CKD stage 5

Question 25

Gabapentin dosing

Answer 25

• GFR 15 to 50mL/min = 300mg po q12-24h

- Dialysis pt = 100 to 300mg po qd

Question 26

Glyburide

Answer 26

• Do NOT give Glyburide to dialysis patients

- Glipizide is safe for dialysis patients

Question 27

Meperidine

Answer 27

• Has active metabolites

- Avoid this medication in CKD patients

Question 28

Definition of CKD

Answer 28

1) Structural abnormalities
- Albuminuria
- Hematuria
- RBC casts
- Electrolyte abnormalities
2) GFR < 60mL/min/1.73m^2

Question 29

Diabetes in CKD Patients

Answer 29

• Higher risk for hypoglycemia
• A1C < 7%
• Insulin is appropriate
• Glyburide is NOT
• Make sure pt’s are aware of hypoglycemic signs and symptoms

Question 30

Drugs that decrease albuminuria

Answer 30

• 1st line; ACEIs/ARBs
• 2nd line; Nondihydropyridine CCB
• Goals;
  a) decrease albumin levels in the urine
  b) prevent the progression from A2 to A3

Question 31

Monitoring of ACEI/ARBs

Answer 31

1) K+ levels
- 5 to 5.5mEq/L = decrease dose by 50%
- greater than 5.5 = d/c drug
2) GFR
- drop by 30 to 50% cut dose in half
- decrease greater than 50% d/c drug

Question 32

Blood pressure goals is CKD

Answer 32

• A1 <140/90

- A2 and A3 < 130/80

Question 33

Beta blockers

Answer 33

-Can mask the signs and symptoms of hypoglycemia

Question 34

Calcium Channel Blockers

Answer 34

-Nondihydropyridine CCB = good
ex verapamil, diltiazem
-Dihidropyridine CCB = bad
ex. Amlodipine (can lead to edema)

Question 35

Hypertension and proteinuria in CKD

Answer 35

• HTN leads to a faster decline in GFR

- Proteinuria also speeds up the decline of GFR

Question 36

Metformin dosing

Answer 36

• GFR < 45mL/min = 1g/day max

- GFR < 30 = d/c metformin

Question 37

Liraglutide

Answer 37

• Safe for CKD patients

- No dose adjusting required

Question 38

DPP4is

Answer 38

• Safe in CKD patients

- Dose adjusting is required

Question 39

Empagliflozin

Answer 39

-Contraindicated if GFR < 45mL/min