Exam 1 lecture 6 Flashcards
What things should we check when deciding treatment for low phosphorous
Calcium levels
uric acid levels
Does the pt have kidney disease?
what is SHPT? what is it caused by?
(secondary hyperparathyroidism) caused when phosphate is high, calcium is low and vit D is low
Why is SHPT called secondary
because there is nothing wrong with the gland, just being affected by phos, ca, vit D
Unactivated vit D name
cholecalciferol (D2)-sun
ergocalciferol (D3)-food
how are cholecalciferol and ergocalciferol activated in the body
activation happens in kidney by 1-alpha-hydroxylase in kidney
How does activated vit D affect parathyroid gland
activated vit D affects parathyroid gland, causing it to slow production of PTH
What stages of CKD are ergocalciferol and cholecalciferol used in?
Stages 3 and 4
why are ergocalciferol and cholecalciferol not able to be used in patients on hemodialysis (stage 5)
kidney can no longer convert to vit D. only active form can be given to patients
what are some activated vit D cpds for stage 5 pts
calcitrol (rocalcitrol & calcijex)
paracalcitrol(zemplar)
doxercalciferol (hectorol)
what is iPTH
PTH
which activated vit D drug has greatest risk of hypercalcemia
calcitrol (rocalcitrol & calcijex)
other name for calcitrol
calcijex/rocalcitrol
Things to monitor when giving calcitrol
serum calcium
paracalcitrol other name
zemplar
things to monitor when giving paracalcitrol?
K and iPTH
what 3 things about paracalcitrol that we should know
most favorable ADE profile (adverse drug effect)
less calcemic activity than calcitrol
>30% reduction in iPTH
doxercalciferol other name
hectorol
compare doxercalciferol to calcitrol
produces more even serum concentration than calcitrol
lower incidence of hypercalcemia
higher incidence of hyperphosphatemia
what is the logic behind calcimimetics
Decrease in calcium causes a rise in parathyroid hormone. If we can fool parathyroid gland into thinking we have a lot of calcium it will reduce the PTH.
calcimimetics fool calcium sensing receptors into thinking calcium is there by binding and inducing conformational change
what are two calcimimetics
Cinacalcet (sensipar)
etelcalcitide (parasabir)- IV version
when are calcimimetics contraindicated
hypocalcemia
what levels of calcium should we withhold calcimimetics
If calcium is <7.5 withhold cinacalcet/etelcalcitide until = or > than 8
what factor affects rise in PTH the most
rise in phos. address hyperphosphatemis first
correction, what are 3 factors causing rise in PTH
increased phos, decreased ca and vit d
why can’t hemodialysis pts use cholecalciferol and ergocalciferol
they can not be converted invivo
kidney makes a hormone called
Erythropoietin
What does erythropoietin do?
Works on bone marrow and causes RBC to be produced
3 components of RBC
Hemoglobin
iron
oxygen
What element is needed for erythrogenesis
iron
erythrogenesis is an iron consuming process
What lab value do we look at to see if someone has anemia or not
Hemoglobin
MCV
RDW
TSAT
Ferritin
What causes kidney patients to be low energy
anemia
Which lab value tells us how bad anemia is?
Hemoglobin
nearly all ESRD pts will develop anemia via one of these 3 causes
Decerased production of erythropoiesis (main reason)
Uremia causes decreased life span of RBC
Vitamin losses during dialysis
signs and symptoms of anemia
Headache
palor (white-ish appearence)
decreased cognition
fatigue
what is MCV
Mean corpuscular value
what does MCV measure
How big your RBC are
What is a normal MCV
80-96 mm^3
what is decreased MCV mean
Microcytic anemia
What does increased MCV mean
macrocytic anemia
Microcytic anemia causes
iron deficiency
aluminum toxicity
Macrocytic anemia causes
Folate and B12 deficiency
What is normocytic anemia
nothing wrong with size of cells, we just do not have enough
what is normocytic anemia caused by
Bleeding
erythropoietin deficiency
RDW meanning
red cell distribution width
RDW range
11.5-14.5
diagnosis of anemia in males vs females
males- hb<12
females<13
how many steps are there before blood transfusion in anemia treatment
2
what are the two steps before blood transfusion to treat anemia
Iron therapy
ESA
WHat is TSAT and ferritin
TSAT- transferrin saturation
transferrin- delivery truck for iron
ferritin- storage house for iron
What does a low TSAT mean? low ferritin?
If TSAT is low, we can not get iron to where it needs to go.
If ferritin is low we need to give the pt more iron
TSAT normal levels
10-30%
ferritin normal levels
100-500
is oral iron good for CKD? ESKD?
Oral iron is good for CKD, but not ESKD/dialysis pts due to reduced efficacy.
What are some side effects of oral iron?
Stomach upset
What environment is iron best absorbed in the body? How does this affect the way we take the meidcation?
Iron is best absorbed in acidic environment. Take with food or OJ.
Also be aware of meds that can make the stomach less acidic (H2 blockers-pepcid, ppi-omeprazole)
how many mg of elemental iron a day is recommended? what should we be cautious of when taking iron?
200 mg, separate from calcium by 2 hours.
difference between oral iron and heme irons
Heme irons have greater absorption because they go through different absorption site.
examples of heme iron? Are heme irons subject to 200 mg/day rule
Proferrin ES
Proferrin forte
why cant oral iron be absorbed in ESRD pts
Ferroportin helps iron be absorbed from stomach to blood. When kidney disease happens over time, it causes more and more inflammation, which causes a bad molecule called hepcidin to be secreted. Hepcidin blocks ferroportin.
Iron source for ESRD pts that start dialysis
IV iron
what are the names of the 5 IV iron products
Iron dextran
Sodium ferric gluconate (ferrlicit)
Venofer (iron sucrose)
Ferumoxytol (feraheme)
Triferic
which is the only IV iron product that requires a test dose, why is there a test dose?
Iron dextran (25 mg test dose), potential dextran allergy.
Which IV iron product can also be used for nD-CKD (non-dialysis CKD) pts
Venofer (iron sucrose)
which Iron IV product is very magnetic? WHat effects could that have?
Ferumoxytol (faraheme), could interfere with MRI
Which iron IV product can be added during dialysis
Triferic
When do we start using ESA
CKD stage 3-5 ND (non dialysis)
HB<10, Hb falling rapidly, needed to avoid blood transfusion
CKD 5D(dialysis)
start when hb is between 9-10
although quality of life increases as the Hb increases, the incidence of ___________ increase
Cerebrovasular adverse events, so do not use ESA to go above 11.5
What should we be cautious about when giving ESAs
do not use ESA to push Hb above 11.5, only 10-11
when should we reduce or interrupt ESA in CKD 3-5 ND (non-dialysis) patients
Hb>10,
Initiale if less than 10,
reduce or interrupt when approaching 10-11
What are the name of the 3 ESA drugs
-Recombinant human erythropoietin (rHUEPO, epoietin alfa, epogen)
-darbepoietin alfa (aranesp)
-methoxy polyethylene glycol-epoietin beta (mircera)
Which ESA has shortest half life
recombinant human erythropoietin
Which ESA has longest half life
methoxy polyethylene glycol
how are the ESA drugs administered
SubQ or IV
Adverse effect of ESA
23% develop high BP
Cause of ESA therapy failure
not enough Iron
What is the name of the new drug therapy for anemia
Hypoxia induced factor prolyl hydroxylase inhibitor (HIF-PHI)
What is the name of the only HIF-PHI drug
Daprodustat (jesduvroq)
When is daprudostat (jesduvroq) indicated
indicated in treatment of anemia due to CKD in pts who have been on dialysis for atleast 4 months
what does hypoxia induced factor (HIF) do?
when there is low O2 in blood HIF causes the kidney and other areas of the body to start pumping out erythropoietin.
what do proleohydroxylase do?
when O2 levels in blood return to normal, the enzyme proleohydroxylase comes and chops HIF. PHI(proleohydroxylase inhibitors) stop the chopping of HIF so it can increase EPO.
How many times a day is Daprodustat (jesduvroq) taken
1 tab a day
when to dx daprodustat (jesduvroq)
When Hb >12
What to do with daprodustat (jesduvroq) when pt has hepatic issues
decrease dose by 1/2
Never give daprodustat (jesduvroq) with
CYP-2C8 inhibitors (gemfibrazil)
If patient is concerned about soft tissue calcification what do we do?
Dx tums and start sevelamir/lanthanum carbonate
Does CRCL matter anymore in pts on hemodilaysis?
No
What is removed from blood in dialysis that we need to replace
Water soluble vitamins (B&C)
what drugs should be given to replace vit B and C that were lost during dialysis
Nephrocaps, Nephron FA
