Kidney Disease Flashcards
SGLT2 inhibitors inhibit glucose reabsorption in the…
proximal tubule
Loop diuretics inhibit the Na-K-Cl pump, causing more excretion and less Na and Ca reabsorption in the…
ascending loop of henle (25% of Na is reabsorbed here)
Thiazide diuretics inhibit the Na-Cl pump, causing less Na reabsorption, and increase Ca reabsorption at the Ca pump in the…
distal convoluted tubule (DCT)
Aldosterone works in the DCT and collecting duct to increase Na/water reabsorption and…
decrease K reabsorption
Aldosterone antagonists block aldosterone so more Na/water is excreted in the urine and serum K…
increases
Drugs that cause kidney disease include…
aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAIDs, polymyxins, radiographic contrast dye, tacrolimus, vancomycin
Risk factors for drug-induced kidney disease include…
taking multiple kidney toxic drugs, existing kidney disease, decreased blood flow to the kidneys, elderly age
CKD is defined as a GFR…
<60 mL/min
Albuminuria is defined as an ACR greater than or equal to…
30
C/I (CrCl <60 mL/min)
Nitrofurantoin
C/I (CrCl <50 mL/min)
TDF-containing products (e.g. Stribild, Complera, Atripla, Symfi, Symfi Lo), voriconazole IV (due to vehicle)
C/I (CrCl <30 mL/min)
TAF-containing products, NSAIDs, dabigatran, rivaroxaban
C/I (CrCl <30 mL/min)
SGLT2 inhibitors, metformin, meperidine
C/I (CrCl <30 mL/min): Others
Avanafil, bisphosphonates, duloxetine, fondaparinux, K-sparing diuretics, tadalafil, tramadol ER, dofetilide, edoxaban, glyburide, sotalol
Complications of CKD include:
Increased PO4 (phosphate), decreased vitamin D and calcium, decreased EPO
Hyperphosphatemia must be treated and leads to chronically elevated…
parathyroid hormone (PTH) levels
Three types of phosphate binders include:
1) Aluminum-based
2) Calcium-based (first-line)
3) Aluminum-free, calcium-free drugs
Vitamin D cannot be activated by the kidney, causing dietary calcium absorption to decrease. Ca is pulled from the bone, causing…
bone demineralization and increased fractures
Treatment for hyperphosphatemia includes restricting dietary phosphate (e.g. dairy products, cola, chocolate, nuts) and using…
phosphate binders. Counsel patients to take doses right before or with meals.
Phosphate binders interact with many drugs including…
levothyroxine, quinolones, tetracyclines, oral bisphosphonates, others
Healthy kidneys hydroxylate vitamin D to its active form…
1,25- dihydroxy vitamin D
In CKD patients, anemia can be treated using…
Erythropoietin stimulating agents (ESAs) and iron
ESAs have risks and should only be used when…
Hbg <10 g/dL
ESAs are only effective if…
adequate iron is available to make Hbg (supplement if needed)
A normal K level is…
3.5-5 mEq/L. Higher than this may lead no symptoms, or muscle weakness, bradycardia, and fatal arrhythmias.
Drugs that may raise K levels include…
ACE inhibitors, aldosterone receptor antagonists, ARBs, aliskiren, canagliflozin, drospirenone-containing COCs (Yaz), K-containing IV fluids, K supplements, SMX/TMP, transplant drugs (cyclosporine, everolimus, tacrolimus), glycopyrrolate, heparin, NSAIDs, pentamidine
Risk factors for hyperkalemia include:
diabetes (insulin deficiency reduces the ability to shift K into the cells) and hospitalized patients
Steps for treating severe hyperkalemia:
1) Stabilize the heart to prevent arrhythmias (IV Calcium gluconate)
2) Move K intracellularly with IV regular insulin + IV dextrose, IV Na bicarb, if metabolic acidosis is present, and nebulized albuterol.
3) Remove K using IV furosemide, rectal SPS, patiromer, sodium zirconium cyclosilicate, HD.
As CKD progresses, bicarbonate reabsorption decreases, leading to..
metabolic acidosis
When serum HCO3 < 22 mEq/L, treat metabolic acidosis using…
sodium bicarbonate, sodium citrate/citric acid solution. Monitor sodium levels.
Which factors affect drug removal during dialysis?
1) MW/size: smaller molecules are more readily removed
2) Vd: drugs with a large Vd are less likely to be removed
3) Protein-binding: highly protein-bound drugs are less likely to be removed by dialysis
4) Dialysis membrane: high-flux and high-efficiency HD filers remove more substances
5) Blood flow rate: higher dialysis blood flow rates increase drug removal over a given time
JS has been using famotidine 20 mg BID for 5 years. His renal function has worsened over time from 78 mL/min to 26 mL/min. Which statement is true regarding his famotidine use?
Famotidine could accumulate and cause adverse effects. Same is true of other drugs that are renally cleared.
Where would bumetanide exert it’s MOA?
thick ascending limb of the loop of Henle
Which drugs can require a decrease in dose or an increase in dosing interval with impaired renal function?
Antibiotics 1) Aminoglycosides (increase interval) 2) Beta-lactams (except antistaph pencillins and ceftriaxone) 3) Fluconazole 4) Quinolones (except moxifloxacin) 5) Vancomycin CV drugs 1) LMWHs (enoxaparin) 2) rivaroxaban, apixaban, dabigatran GI drugs 1) H2RAs (famotidine, ranitidine) 2) Metoclopramide Others: bisphosphonates, lithium, topiramate
Which drugs can require a decrease in dose or an increase in dosing interval with impaired renal function? (continued)
Antibiotics 6) amphotericin B 7) anti-TB meds (ethambutol, pyrazinamide) 8) antivirals (acyclovir, valacylovir, ganciclovir, valganciclovir, oseltamivir) 9) aztreonam 10) NRTIs, including tenofovir 11) polymyxins 12) SMX/TMP CV drugs 3) antiarrhythmics (digoxin, disopyramide, dofetilide, procainamide, sotalol) 4) most statins Pain/Gout 1) allopurinol 2) colchicine 3) gabapentin, pregabalin 4) morphine, codeine 5) tramadol ER Transplant 1) cyclosporine 2) tacrolimus
What is the primary dietary source of vitamin D?
Vitamin D2 (ergocalciferol)
Calcitriol (Rocaltrol) is the active form of vitamin D3. Tri= 3. Newer vitamin D analogs, like paricalcitol and doxercalciferol, are associated with less…
hypercalcemia than calcitriol
CrCl (mL/min) =
[140- (patient age)]/(72 x SCr)* weight (kg) * 0.85 (if female)
SC has lupus-related renal disease. Her serum creatinine today is 2.7 g/dL and the K is 6.2 mEq/L. In order to reduce the potassium, the physician has prescribed SPS. When can the physician expect the effects to start?
hours to days
Aluminum hydroxide, suspension
Al-based phosphate binder, rarely used due to risk of accumulation (expect short term).
S/E: Al intoxication, “dialysis dementia”, osteomalacia, constipation, nausea
Monitoring: Ca, PO4, PTH, ss of Al toxicity
Calcium-based phosphate binders: first-line.
1) Calcium acetate (Phoslyra, PhosLo)
2) Calcium carbonate (Tums)
S/Es: hypercalcemia, constipation, nausea
Monitor: Ca, PO4, PTH
Total daily dose of elemental Ca be <2,000 mg (from diet and supplements)
Note: Calcium acetate binds dietary phosphorus on an elemental calcium basis than Tums
Hypercalcium is especially problematic with concomitant use of vitamin D (due to increased calcium absorption)
Al and Ca- free binders: more $.
1) Sucroferric oxyhydroxide (Velphoro), chewable tablet.
2) Ferric citrate (Auryxia), tablet.
Warnings: iron absorption occurs with ferric citrate; dosage reduction of IV iron may be necessary; store out of reach of children to prevent accidental OD.
S/Es: diarrhea, constipation, discolored (black) feces
Monitoring: iron, ferritin, TSAT (only with ferric citrate), PO4, PTH
Notes: Absorption is minimal with sucroferric oxyhydroxide
All phosphate binders should be divided TID and taken…
with meals
Lanthanum carbonate (Fosrenol); chewable tablet, powder
C/Is: GI obstruction, fecal impaction, ileus
S/Es: N/V/D, constipation, abdominal pain
*Must chew tablet thoroughly to reduce risk of severe GI adverse effects. Use powder if unable to chew.
Monitoring: Ca, PO4, PTH
sevelamer carbonate (Renvela); sevelamer HCl (Renagel)
*Not systemically absorbed
C/I: bowel obstruction
Warnings: can reduce dietary absorption of vitamins D, E, K and folic acid (consider supplementation)
Tablets can cause dysphagia and get stuck in the esophagus; consider powder if unable to swallow.
S/Es: N/V/D (all >20%), dyspepsia, constipation, abdominal pain, flatulence
Monitoring: Ca, PO4, HCO3, Cl, PTH
Notes: can lower total cholesterol and LDL by 15-30%. Sevelamer carbonate can maintain bicarbonate concentrations.
Separate phosphate binders from…
levothyroxine and antibiotics that chelate (e.g. quinolones, tetracycline)
Vitamin D analogs: increase intestinal absorption of Ca, which provide negative feedback to parathyroid
1) calcitriol (Rocaltrol)
2) calcifediol (Rayaldee), ER capsule (prodrug of calcitriol). Taken with food or after a meal.
3) doxercalciferol (Hectorol)
4) paricalcitol (Zemplar)
C/Is: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
S/Es: hypercalcemia, hyperphosphatemia, N/V/D (<10%)
Monitor: Ca, PO4, PTH, 25-hydroxy vitamin D
Calcimimetics:
Cinacalcet (Sensipar); etelcalcetide (Parsabiv) IV only
*Only use in dialysis patients
MOA: Increases sensitivity of the calcium-sensing receptor on the parathyroid gland, which causes decreased PTC, Ca, PO4
C/Is: hypocalcemia
Warnings: caution in patients with seizure history
S/Es: hypocalcemia, N/V/D, paresthesia, HA, fatigue, depression, anorexia, constipation, bone fracture, weakness, arthralgia, myalgia, limb pain, URTIs
Sodium polystyrene sulfonate (SPS, Kayexalate);
powder, oral suspension, rectal suspension
Warnings: electrolyte disturbances (hypernatremia, hypokalemia, hypomagnesemia, hypocalcemia, fecal impaction, GI necrosis (increased risk when given with sorbitol; do not use together) Can bind other oral meds (separate)
S/Es: N/V, constipation or diarrhea
Monitoring: K, Mg, Na, Ca
Notes: do not mix oral products with fruit juices containing K
Patiromer (Veltassa); powder for oral suspension
Instructions: measure 1/3 cup of water and pour half into an empty cup; empty packet contents into the water and stir well; add the remaining water and stir well; drink the mixture right away.
Warnings: can worsen GI motility, hypomagnesemia
Binds to many oral drugs; separate by at least 3 hours before or after
Monitor: K, Mg
Notes: delayed onset of action (~7 hours); not for emergencies
Store powder in fridge (must be used within 3 months if stored at room temperature)
Sodium zirconium cyclosilicate (Lokelma); powder for oral suspension
Instructions: empty packet contents into a cup with at least 3 tablespoons of water; stir well and drink immediately (if powder remains in the cup, add additional water and drink; repeat as needed)
Warnings: can worsen GI motility, edema, contains sodium (may need to adjust dietary Na intake.
S/Es: peripheral edema
Notes: Can bind other drugs; separate by at least 2 hours before or after
Delayed action (~1 hour); not for emergency use
Store at room temperature
Metabolic acidosis; treat when serum bicarbonate <22 mEq/L. Drugs to replace bicarb are:
1) Sodium bicarbonate (Neut). Monitor Na, can cause fluid retention
2) Sodium citrate/citric acid solution (Cytra-2, Oracit, Shohl’s solution). Note: metabolized to bicarb b the liver; may not be effective in patients with liver failure. Monitor Na.
