Exam 1 lecture 6 Flashcards by Matti Daniel

What things should we check when deciding treatment for low phosphorous

Calcium levels
uric acid levels
Does the pt have kidney disease?

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what is SHPT? what is it caused by?

(secondary hyperparathyroidism) caused when phosphate is high, calcium is low and vit D is low

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Why is SHPT called secondary

because there is nothing wrong with the gland, just being affected by phos, ca, vit D

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Unactivated vit D name

cholecalciferol (D2)-sun
ergocalciferol (D3)-food

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how are cholecalciferol and ergocalciferol activated in the body

activation happens in kidney by 1-alpha-hydroxylase in kidney

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How does activated vit D affect parathyroid gland

activated vit D affects parathyroid gland, causing it to slow production of PTH

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What stages of CKD are ergocalciferol and cholecalciferol used in?

Stages 3 and 4

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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

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what are some activated vit D cpds for stage 5 pts

calcitrol (rocalcitrol & calcijex)
paracalcitrol(zemplar)
doxercalciferol (hectorol)

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what is iPTH

PTH

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which activated vit D drug has greatest risk of hypercalcemia

calcitrol (rocalcitrol & calcijex)

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other name for calcitrol

calcijex/rocalcitrol

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Things to monitor when giving calcitrol

serum calcium

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paracalcitrol other name

zemplar

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things to monitor when giving paracalcitrol?

K and iPTH

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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

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doxercalciferol other name

hectorol

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compare doxercalciferol to calcitrol

produces more even serum concentration than calcitrol
lower incidence of hypercalcemia
higher incidence of hyperphosphatemia

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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

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what are two calcimimetics

Cinacalcet (sensipar)
etelcalcitide (parasabir)- IV version

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when are calcimimetics contraindicated

hypocalcemia

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what levels of calcium should we withhold calcimimetics

If calcium is <7.5 withhold cinacalcet/etelcalcitide until = or > than 8

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what factor affects rise in PTH the most

rise in phos. address hyperphosphatemis first

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correction, what are 3 factors causing rise in PTH

increased phos, decreased ca and vit d

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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

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?

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