Kidney Flashcards
What are the key drugs that should be decreased in dose or increased in interval in patients with CKD?
- aminoglycosides
- beta-lactam antibiotics (most)
- fluconazol
- quinolones (except moxi)
- vancomycin
- LMWH
- rivaroxaban (for afib)
- H2RAs (famotidine, ranitidine)
- metoclopramide
- biphosphonates
- lithium
Which key drug is contraindicated in CrCl < 60 mL/min?
nitrofurantoin
Which key drug is contraindicated in CrCl < 50 mL/min?
- tenofovir disoproxil fumurate containing products
- Stribild: CI in current patients at this CrCl; if patient is new to this rx, CI in CrCl < 70
- voriconazole IV
Which key drug is contraindicated in CrCl < 30 mL/min?
- tenofovir alafenamide containing products
- NSAIDs
- dabigatran (DVT/PE)
- rivaroxaban (DVT/PE)
Which key drug is contraindicated in GFR < 30 mL/min/1.73m^2?
- SGLT2 inhibitors
- metformin
What is a key drug to take into consideration with renal issues?
meperidine; no specifics in naplex book
What are the classes of phosphate binders?
- aluminum based
- calcium based
- aluminum and calcium free
Which class of phosphate binders is used as first line?
calcium based
What is the aluminum based phosphate binder?
aluminum hydroxide suspension
aluminum hydroxide pearls
- 300-600mg TID with meals
- rarely used b/c risk of aluminum accumulation -> nervous system and bone toxicity*
- limit to 4 weeks
- dialysis dementia*
What are the calcium based phosphate binders?
- Phoslyra, PhosLo (calcium acetate)
- Tums (calcium carbonate)
calcium acetate dosing (not underlined)
- 1334mg PO TID with meals
- titrate based on PO4 levels
- tablet, capsule, solution
calcium carbonate dosing (not underlined)
- 500mg PO TID with meals
- titrate based on PO4 levels
- tablet, chewable tablet
calcium based phosphate binder pearls
- total daily calcium should < 2g
- hypercalcemia*, constipation, nausea
- increased Ca w/ use of vit D*
What are the calcium free and aluminum free phosphate binders?
- Velphoro (sucroferric oxyhydroxide)
- Auryxia (ferric citrate)
- Fosrenol (lanthanum carbonate)
- Renvela (sevelamer carbonate)
- Renagel (sevelamer hydrochloride)
Which calcium free and aluminum free phosphate binders are not systemically absorbed?
sevelamer
Calcium free and aluminum free phosphate binders (that are systemically absorbed) pearls
- iron absorption with ferric citrate
- N/V/D, constipation
- must Fosrenol chew tablet thoroughly
Calcium free and aluminum free phosphate binders (that are systemically NOT absorbed) pearls
- N/V/D
- can lower total and LDL cholesterol by 15-30%
- can maintain bicarbonate concentrations
- can reduce absorption of some vitamins
Where does loop diuretics work and MOA?
- ascending limb of loop of henle
- inhibit Na/K pump
- cause less Ca reabsorption
Where does thiazide diuretics work and MOA?
- distal convoluted tubule
- inhibit Na/Cl pump
- increases Ca reabsorption
Where does aldosterone antagonists work and MOA?
- collecting duct & distal convoluted tubule
- inhibit aldosterone
- under normal conditions, aldosterone increase Na and water reabsorption and decrease K reabsorption
After initiating ACEi or ARB, baseline SCr can increase by how much?
30%
ACEi or ARB MOA
- inhibit renin-angiotensin-aldosterone system (RAAS) causing efferent arteriolar dilation
- this reduces pressure in glomerulus which decreases albuminuria
phosphate binder drug interactions
separate administration from levothyroxine and antibiotics that chelate
How is secondary hyperparathyroidism treated?
- vitamin D
- calcimimetic
What are the vitamin D analogs?
- Rocaltrol (calcitriol)
- Rayaldee (calficediol)
- Hectorol (doxercalciferol)
- Zemplar (paricalcitol)
vitamin D analogs pearls
ADE: hypercalcemia
What are the calcimimetics?
- Sensipar (cinacalcet)
- Parsabiv (etelcalcetide)
calcimimetics pearls
- hypocalcemia
- Parsabiv (etelcalcetide): muscle spasms, paresthesia
anemia is hbg level of what?
< 13 g/dL
What are the erythropoiesis stimulating agents (ESA)?
- epoetin alfa: Procrit, Epogen, Retacrit
- darbepoetin alfra (Aranesp)
ESA risks
- HTN
- thrombosis
When should you use ESA in anemia?
- when hbg < 10 g/dL
- D/C when hbg > 11 g/dL
What effect does insulin have on potassium?
shifts potassium into the cell
What are symptoms of high K levels?
- muscle weakness
- bradycardia
- fatal arrhythmias
key drugs that increase K levels
- ACEi/ARBs
- aldosterone antagonist
- aliskiren
- canagliflozein
- drospirenone-containing oral contraceptive
- bactrim
- cyclosporine
- everolimus
- tacrolimus
What are the steps to treating hyperkalemia?
- stabilize heart
- shift K intracellularly
- enhance K elimination
Hyperkalemia: which drug stabilizes the heart?
calcium gluconate
Hyperkalemia: which drugs shifts K intracellularly?
- regular insulin
- dextrose
- sodium bicarbonate
- albuterol
Hyperkalemia: enhances K elimination?
- furosemide
- sodium polystyrene sulfonate
- patiromer
- sodium zirconium cyclosilicate
- HD
sodium polystyrene sulfonate pearls
- can bind to other oral medications
- do not use oral for emergency; can use rectal for emergency
patiromer pearls
- hypomagnesemia
- can bind to oral drugs; separate by 3 hours
- ADE: constipation
- delayed onset (7h) -> do not use in emergency
sodium zirconium cyclosilicate pearls
- can bind to oral drugs; separate by 2 hours
- delayed onset (1h) -> do not use in emergency
bicarbonate in relation to CKD progression
- ability to reabsorb bicarbonate decreases as CKD progresses
- leads to metabolic acidosis
- treatment initiated when bicarb serum < 22 mEq/L
