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PHRM 844 > Lecture 5: CKD > Flashcards

Lecture 5: CKD Flashcards

1
Q

Lab Values - Kidney Function

SCr

A

males: 0.6-1.2 mg/dL
females: 0.5-1.1 mg/dL

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2
Q

Lab Values - Kidney Function

BUN

A

10-20 mg/dL

“normal BUN is 15 or less”

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3
Q

Lab Values - Kidney Function

CrCl

A

males: 110-150 mL/min
females: 100-130 mL/min

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4
Q

Lab Values - Kidney Function

eGFR

A

greater than or equal to 90 mL/min/1.73 m^2

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5
Q

Lab Values - Mineral and Bone Disorder

Phos

A

2.5-4.5 mg/dL

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6
Q

Lab Values - Mineral and Bone Disorder

Ca

A

8.5-10.5 mg/dL

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7
Q

Lab Values - Mineral and Bone Disorder

Vitamin D

A

~ 30 ng/mL

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8
Q

Lab Values - Mineral and Bone Disorder

PTH

A

non-dialysis: 11-54 pg/mL
dialysis: 100-500 pg/mL

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9
Q

Lab Values - Anemia of CKD

anemic Hb levels

A

females: Hb < 12 g/dL
males: Hb < 13 g/dL

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10
Q

Lab Values - Anemia of CKD

TSAT

A

20-30%

if < 30% AND ferritin is < 500 ng/mL, do iron supp

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11
Q

Lab Values - Anemia of CKDLab Values - Anemia of CKD

Ferritin

A

100-500 ng/mL

if < 30% AND ferritin is < 500 ng/mL, do iron supp

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12
Q

Lab Values - Anemia of CKDLab Values - Anemia of CKD

MCV

Mean Corpuscular Volume

A

80-96 mcm^3

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13
Q

Lab Values - Anemia of CKDLab Values - Anemia of CKD

RDW

red cell distribution width

A

11.5-14.5%

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14
Q

3 major causes of CKD

A
  1. DM
  2. HTN
  3. glomerulonephritis

other causes:
- polycystic kidney disease (PKD)
- HIV nephropathy

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15
Q

CKD is classified on (3)

A
  • cause
  • GFR
  • albuminuria
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16
Q

Stage 3 CKD, eGFR range of ___ , is where we get concerned

A

45-59 mL/min/1.73 m^2

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17
Q

Estimating Kidney Function (Creatinine Clearance)

Cockroft and Gault formula

A

M: CrCl = [(140-age) x IBW]/(SCr x 72)
F: that x 0.85

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18
Q

Estimating Kidney Function (Creatinine Clearance)

Cockroft and Gault
- accurate for pts with ___ kidney functions (don’t want to use with ___ )
- good predictor of ___
- tends to ___ renal function in moderat-severe kidney impairment

A
  • stable, AKI
  • GFR
  • overestimate

AKI levels typically not stable

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19
Q

What equation is most accurate in estimating GFR?

A

Modification of Diet in Renal Disease (MDRD)

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20
Q

IBW equation

A

M: 50 kg + (2.3 x inches over 60)
F: 45.5 kg + (2.3 x inches over 60)

use AjBW if ABW > 130% IBW

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21
Q

Complications Associated with CKD - Uremia

Uremia - accumulation of waste molecules such as ___ , ammonia, bilirubin, and ___ ) in the blood that are normally removed by the kidenys.
- monitor ___

A
  • urea, uric acid
  • BUN
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22
Q

Complications Associated with CKD - Uremia

Effects on the Body
- CNS: encephalopathy
- EENT: uremic ___
- Pulmonary: non-cardiogenic ___ from volume overload
- GI: ___ , NV, constipation, ___ taste
- Musculoskeletal: ___ and ___ disorder, restless ___ syndrome
- Anemia: ___ deficient
- skin: uremic ___

A
  • fetor
  • edema
  • anorexia, metallic
  • mineral, bone, leg
  • EPO
  • frost

fetor = breath smells like urine

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23
Q

Complications Associated with CKD - Fluid Retention

Fluid Retention - pitting and/or pulmonary edema. ___ will increase
- should we restict how much fluid the pt is drinking?
- Diuretics will not work in a pt without functioning ___ . Used to treat volume overload and HTN in patients with renal ___ or those producing some ___

A
  • blood pressure
  • not generally necessary if Na intake is controlled. H2O will follow Na
  • kidneys
  • insufficiency, urine
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24
Q

Complications Associated with CKD - Fluid Retention

T or F: all loop diuretics are similar, therefore a poor response to one means a poor response to all

A

T; next step is to add a thiazide to trear resistance

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25
Q

Complications Associated with CKD - Fluid Retention

Considerations when using diuretics:
- thiazides are ineffective when CrCl < ___ mL/min
- loops will work when CrCl < ___ mL/min
- ___ bioavailability (10-100%) is usually about ___ % therefore PO dose may be ___ the IV dose
- avoid ___ diuretics
- as renal function declines, loop dose is maximized, a ___ may be added to overcome diuretic ___

A
  • 30 mL/min
  • 30 mL/min
  • furosemide, 50%, twice
  • K sparing
  • thiazide, resistance
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26
Q

Complications Associated with CKD - Electrolyte Imbalances

Na - no need to severely sodium restrict pts beyond a ____ diet unless needed for HTN and edema
- < ___ g Na/day or < ___ g NaCl/day
- used saline containing IV bags with __
- make outpatients aware of hidden high sodium containing foods ( ___ and ___)

A
  • “no-salt-added”
  • 2, 5
  • caution
  • canned soups, hotdogs
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27
Q

Complications Associated with CKD - Electrolyte Imbalances

K - restrict to ___ g/day (goal for ESRD pt is pre-dialysis K concentration of ___ mEq/L)
- avoid high K foods (tomatoes, ____ , and salt substitutes)
- treatment for hyperkalmeia (___)

A
  • 3
  • 4.5-5.5
  • fruits (dried and fresh)
  • C A BIG K DROP
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28
Q

Which of the following diuretics is least likely to cause an allergic sulfa reaction?

A) furosemide
B) ethacrynic acid
C) torsemide
D) bumetanide

A

ethancrynic acid

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29
Q

The oral bioavailabilites of 3 loop diuretics are listed below:
- furosemide 10-100%
- bumetanide 80-100%
- torsemide 80-100%

how would a pharmacist use this info in a clinic when treating a pt for edema?

A

Furosemide would require a higher dose in order to have the same effect as bumetanide or torsemide. About 50% of the drug is lost when taken orally.

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30
Q

Complications Associated with CKD - Mineral and Bone Disorder

Hyperphosphatemia - nearly a problem for all ESRD pts. Nearly all pts receive phosphate binders.
- Normal range: ___ mg/dL
- ___ phosphate is bound and chelate is pooped out

A
  • 2.5-4.5 mg/dL
  • dietary

must take with food for them to work

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31
Q

Phosphate Binders

Calcium carbonate ( ___ )
- ___% elemental Ca
- Dose: ___ mg (as elemental Ca) TID with ___
- SE: ___
- DO NOT exceed ___ mg/day of elemental Ca (some of the Ca will get absorbed into the blood and add to ___ problem)

A

Tums
- 40%
- 500 mg, meals
- constipation
- 1500 mg/day, soft tissue calcification

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32
Q

Phosphate Binders

Calcium acetate (___)
- ___ % elemental Ca
- Dose: ___ tabs TID with ___
- DO NOT exceed: ___ mg/day
- may produce fewer ___ events compared to tums

A
  • PhosLo
  • 25%
  • 2-3, meals
  • 1500 mg/day
  • hypercalcemic
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33
Q

Phosphate Binders

T or F: when given at the same elemental dose, calcium carbonate will bind twice as much phosphate compared to calcium acetate

A

F: when given at the same elemental dose, calcium acetate will bind twice as much phosphate compared to calcium carbonate

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34
Q

Non-calcium containing phosphate binders

Sevelamer carbonate (___)
- can be used in conjunction with ___
- Dose: Phos = 5.5-7.5 mg/dL: ___ mg TID with ___
- Dose: Phos > 7.5 mg/dL ___ mg TID with ___
- SE: GI ___ , NV, diarrhea
- decreases ___ by 15-30%
- decreases ___

dont have to worry about Ca potentially being absorbed :)

A
  • Renvela
  • tums
  • 800 mg, meals
  • 1600 mg, meals
  • upset
  • LDL
  • uric acid

max dose studied: 14g/day; no ADRs (pretty safe)

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35
Q

Non-calcium containing phosphate binders

Lanthanum carbonate (___)
- ___ tab
- Dose: ___ mg TID with ___
- may titrate to ___ mg/day
- unlike Ca phosphate binders, this is more efficacious in ___ environments but overall has ___ efficacy range
- eliminated in the ___
- no long term ___
- does not cross ___
- SE: mild ___

A
  • Fosrenol
  • chewable
  • 250-750 mg, meals
  • 1500-3000 mg/day
  • acidic, broad
  • feces
  • accumulation
  • BBB
  • GI
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36
Q

Non-calcium containing phosphate binders

Sucroferric oxyhydroxide (___)
- ___ containing phospahte binder
- Dose: ___ mg ___ tab TID with ___
- titrate by ___ tab per day each week
- may cause ___ stools

A
  • Velphoro
  • iron
  • 500, chewable, meals
  • 1 tab
  • black
37
Q

Non-calcium containing phosphate binders

Auryxia (___)
- for CKD pts on ___
- Dose: ___ tabs TID with ___
- each tab has ___ g ferric citrate
- may cause dark stools

significant effect on iron stores

A
  • ferric citrate
  • dialysis
  • 2 tabs, meals
  • 1 g
38
Q

Non-calcium containing phosphate binders

Aluminum hydroxide (___)
- DONT USE
- Dose: ___ mg TID with meals
- ___ eliminated through the kidneys
- extra toxicity
- if necessity to use… no more than ___ weeks

A
  • Amphojel
  • 300-600 mg
  • aluminum
  • 4 weks
39
Q

Non-calcium containing phosphate binders

Magnesium carbonate (___)
- ___ approved
- Dose: ___ tabs TID with ___

A
  • Mag-Carb
  • non-FDA
  • 1-3 tabs, meals
40
Q

Non-calcium containing phosphate binders

nicotinic acid and nicotinamide arent really used bc

A

SE are terrible, causes facical flushing

41
Q

Hyperphosphatemia

Dietary Restrictions - intake should be restricted to ___ mg per day if:
- Phos > ___ mg/dL (CKD stage 3 and 4)
- Phos > ___ mg/dL (CKD stage 5)
- ___ > target range for 3, 4, or 5

A
  • 800-1000
  • 4.6
  • 5.5
  • PTH
42
Q

Which of the following phosphate binders will affect the pt’s calcium serum concentrations?

A) Renvela (sevelamer carbonate)
B) Fosrenol (lanthanum carbonate)
C) Velphoro (sucroferric oxyhydroxide)
D) Tums (calcium carbonate)

A

Tums

it’s the only one that has calcium

43
Q

JT is a 78 YOM starting hemodialysis. His current lab values are:
Ca: 11 (H)
Phos: 6 (H)
PTH: 1200 (H)
SCr: 12 (H)
Uric Acid: 8 (H)

Which of the following would be the best option for treating JT’s hyperphosphatemia?

A) Renvela (sevelamer carbonate)
B) Fosrenol (lanthanum carbonate)
C) Velphoro (sucreoferric oxyhydroxide)
D) Tums (calcium carbonate)

A

Renvela (sevelamer carbonate)

decreases phosphate and uric acid

44
Q

Complications Associated with CKD - Mineral and Bone Disorder

Vitamin D and Secondary Hyperparathyroidism (SHPT)
- hyperphosphatemia and kidneys inability to activate vit D lead to decrease in serum ___
- this triggers the ___ gland to produce ___ to mobilize Ca from the bone
- Vit D stops PTH production through ___
- if pts has working kidneys (stage 3-4), unactivated vit D like ___ is used.
- if no kidney function (stage 5) must use ___ forms

A
  • Ca
  • parathyroid, PTH
  • negative feedback
  • cholecalciferol or ergocalciferol
  • activated
45
Q

what enzyme in the kidney converts unactivated Vit D to activated

A

1-alpha-hydroxylase

46
Q

Which Vit D are unactivated

A

ergocalciferol and cholecalciferol

47
Q

Vit D and SHPT (unactivated)

Ergocalciferol (___)
- Vit D___
- Dose: one ___ IU cap per ___
- for CKD stage ___ and ___

Cholecalciferol
- Vit D___
- Dose: ___ IU PO daily
- for CKD stage ___ and ___

A
  • calciferol
  • D2
  • 50,000
  • 3, 4
  • D3
  • 1000
  • 3, 4
48
Q

T or F: it is always best to give unactive form of Vit D if we think the pt has kidney activity bc the body will activate the Vit D when it is needed.

A

T

49
Q

Vit D and SHPT (activated)

Calcitriol ( ___ or ___ )
- 1,25(OH)2D3
- Dose: ___ - 0.25 mcg po d or q other d; may increase every 4-8 weeks
- Dose: ___ - 0.5mcg/day ___ TIW

Monitor:
- signs and symptoms of ___ (fatigue, weakness, headache, NV, muscle pain, constipation)

  • approved for ___ use
  • greatest risk of ___
  • not good for pts with high ___
  • cheapest
A

Rocaltrol, Calcijex
- Rocaltrol
- Calcijex, IV
- hypercalcemia
- pediatric
- hypercalcemia
- Ca

50
Q

Vit D and SHPT (activated)

Paricalcitol (___)
- 19-nor-1-a-25(OH)2D2
- IV Dose: ___ mcg/kg 2-3 times per week
- PO Dose: PTH less than or equal to ___ pg/mL; 1 mcg d or 2 mcg q other day
- PO Dose: PTH greater than ___ pg/mL; 2 mcg d or 4 mcg q other day
- > ___ % reduction in iPTH
- most ___ ADE profile
- less ___ activity compared to calcitriol
- Monitor: ___ and __

A

Zemplar
- 0.04-0.10 mcg/kg
- 500
- 500
- 30
- favoraable
- calcemic
- Ca and iPTH

51
Q

Vit D and SHPT (activated)

Doxercalciferol (___)
- if ___, DO NOT USE
- 1-a-OHD2
- Dose: ___ mcg PO or IV ___ times per week
- ___ that requires activation by the liver
- lower incidence of ___ compared to calcitriol
- higher incidence of ___

A

Hectorol
- multiple organ failure
- 2.5-10, 2-3x
- prodrug
- hypercalcemia
- hyperphosphatemia

52
Q

Calcium homeostasis and SHPT - calcimimetics

Cinacalcet (___) - a type II calcimimetic agent
- MOA: mimics the action of Ca by binding to Ca receptor and inducing a ___ change to the receptor, triggering the parathyroid gland to ___ PTH secretion
- Dose: ___ mg once daily PO, increase dose to achieve desired PTH levels
- MAX: ___ mg
- Contraindicated in ___
- withhold until Ca is > ___ mg/dL

A

Senispar
- conformational, decrease
- 30 mg
- 180 mg
- hypocalcemia
- 8 mg/dL

53
Q

Calcium homeostasis and SHPT - calcimimetics

Etelcalcetide (___)
- same as cinacalcet but it’s the ___ route
- Dose: ___ mg three times ___ after ___ session
- Contraindicated in ___.
- withhold until Ca > ___ mg/dL

A

Parsabiv
- IV
- 5 mg, weekly, hemodialysis
- hypocalcemia
- 8 mg/dL

54
Q

Monitoring Parameters for CKD-MBD - Goal Ranges

Ca: ___
Phos: ___
25(OH)D: ___
PTH (dialysis and non-dislysis): ___ and ___

A
  • 8.5-10.5 mg/dL
  • 2.5-4.5 mg/dL
  • ~30 ng/dL
  • 100-500 pg/mL, 11-54 pg/mL
55
Q

Which of the following Vit D products DOES NOT require activation by a body organ prior to activation?

A) calcitriol
B) doxercalciferol
C) cholecalciferol
D) ergocalciferol

A

calcitriol

doxercalciferol requires liver to activate (prodrug)

56
Q

Mrs. Jenkins is an 82 yo hemodialysis pt who presents to the clinic with SHPT. Her labs are below:
Ca: 7.2 mg/dL
Phos: 4.0 mg/dL
PTH: 1300 pg/mL
Vit D: 35 ng/mL

Which of the following medications should be recommended for treating her SHPT?

A) cholecalciferol
B) ergocalciferol
C) cinacalcet
D) paricalcitol

A

paricalcitol (Zemplar)

Not A or B due to kidney activation, not C due to low Ca

57
Q

Anemia

Erythropoietin EPO - promotes production of mature ___ in the bone marrow. More RBCs in circulation leads to increased oxygenation and lower levels of ___ factor, suppressing EPO production

A

RBC, hypoxia-inducible

58
Q

Anemia

Iron is necessary as well for RBC production. Its absorption and transport are promoted by ___ factor

A

hypoxia-inducible

59
Q

Anemia

Hypoxia-inducible factor- degrades under conditions of normal oxygen tension. But in anemia or hypoxia, it promotes gene transcription of ___

A

EPO

60
Q

Anemia

Nearly all ESRD pts will develop anemia by one or more of the following mechanisms:
1) decreased production of ___
2) ___ causes a decreased life span of RBC
3) ___ losses during dialysis
4) loss of blood through ___

A
  • EPO
  • uremia
  • vitamin (folate, B12, B6)
  • dialysis (hemolysis)
61
Q

anemia

What is MCV

A

mean corpuscular volume - how big your blood cells are

80-96 mm^3

62
Q

Normal lab value range for MCV

A

80-96 mm^3

63
Q

What is RDW and what is the normal lab value

A

Red cell Distribution Width

11.5-14.5%

64
Q

what does microcytic iron deficiency look like on a graph?

A
65
Q

What does Macrocyctic B12, folate deficiency look like on a graph?

A
66
Q

What does normal MCV and increased RDW look like on a graph?

A
67
Q

If you are at the lower end of the MCV graph, you might have ___ deficiency or ___ toxicity

A

iron, aluminum

68
Q

If you are at the middle of the MCV graph but youre not building RBCs fast enough you might have anemia of ___, ___ bleed, or ___ deficiency

A
  • chronic disease
  • GI
  • Erythropoietin
69
Q

if you are at the high end of the MCV graph, you might have ___ or ___ deficiencies

A

folate, B12

70
Q

Anemia

Monitoring parameters:
___ is best assessment parameter for anemia due to increased stability
- should be monitored ___ in CKD 3, ___ a year on CKD 4-5ND, and q ___ in CKD 5D
- if existing anemia, monitor fo CKD 3-5ND q ___ and CKD 5D ___

A

Hb
- annually, twice, 3 months
- 3 months, monthly

71
Q

Anemia

anemic Hb level for males and females

A

F: Hb < 12 g/dL
M: Hb < 13 g/dL

72
Q

Anemia Treatment

Iron Therapy
- you need iron for ___
- if a pt is receiving erythropoietin, they need adequate iron stores to prevent deficiency
- KDIGO suggests iron supplementation if TSAT < ___ % and serum ferritin in < ___ ng/mL

A
  • erythropoiesis
  • 30%, 500 ng/mL
73
Q

Anemia Treatment

  • Monitor TSAT and ferritin at least q ___.
  • there is no longer a specific range for targeting ___ and ___
  • KDIGO says iron shou;d not be given if TSAT > ___% and/or ferritin is > ___ ng/mL
A
  • 3 months
  • TSAT, ferritin
  • 30%, 500 ng/mL
74
Q

Oral Iron

will not likely be sufficient for correcting and maintaining iron stores for ____ pts
- may be used for CKD pts or ___ pts
- drugs: ___ salts (sulfate, gluconate, and fumerate)
- Dose = ___ mg of ___ iron per day at least
- SE: ___ upset
- best absorbed in ___ environments; take with ___
- ___ coated iron is not ideal
- watch out for medications that might affect stomach pH: ___ and ___
- separate from Ca by ___

A

hemodialysis
- peritoneal dialysis
- ferrous
- 200 mg, elemental
- stomach
- acidic (stomach), orange juice
- enteric
- PPIs, H2RAs
- 2 hrs

75
Q

IV Iron - CKD 5D

Iron dextran (InFed, ___ )
- 25 mg ___ dose
- 100 mg IV every hemodialysis session x 10
- cheap

A

Dexferrum
- test

anaphylaxis to dextran component

76
Q

IV Iron - CKD 5D

Sodium ferric gluconate (___)
- ___ mg IV every hemodialysis session x8-10 doses

Iron sucrose (___)
- 100 mg IV every hemodialysis session x 10
- ___ mg IV push x 5 doses for __ CKD

A

Ferrlicit
- 125

Venofer
- 200, ND

77
Q

IV Iron - CKD 5D

Ferric carboxymaltose (___)
- ___ mg IV dose once, repeat in 7 days

Ferumoxytol (___)
- ___ mg IV once, repeat in 3-8 days
- interferes with ___ for up to 3 months after 2nd injection

A

Injectafer
- 750 mg

Feraheme
- 510 mg
- MRI

78
Q

Other Iron

Triferic (ferric pyrophosphate citrate)
- iron compound added to ___ during dialysis

A

dialysate

79
Q

Erythropoiesis stimulating agents (ESAs)

used after all other correctable causes of anemia have been adressed

When to start ESA:
- CKD3-5ND: Hb < ___ g/dL; Hb falling at rapid rate; needed to avoid blood transfusion
- CKD 5D: Hb between ___ and ___ g/dL
- NEVER go above Hb of ___

A
  • 10 g/dL
  • 9-10 g/dL
  • 11.5 g/dL
80
Q

T or F: although quality of life increases as Hb increases, the incidence of cerebrovascular adverse events also increases

A

T; do not use ESA to push Hb above 11.5 g/dL

81
Q

ESA drugs

recombinant human erythropoietin (rHuEPO, epoetin alfa, Epogen, Procrit, EPO) - stimulate ___ progenitor cells.
- Dose: 120-180 unit/kg/week IV divided up into 3 doses
- Dose: 80-120 units/kg/week SC divided up into 2-3 doses
- Preferred route: ___ bc IV is more expensive

Darbepoetin alfa (___ )
- 3 fold longer half life than epoetin alfa
- dosed once per week IV or SC
- starting dose 0.45 mcg/kg - titrate to maintain Hb in the ___ g/dL range

Methoxy polyethylene glycol - epoetin beta (___)
- extended ___
- dosed one every ___ weeks
- starting dose ___ mcg/kg

in order of increasing ___

A

erythroid
- SC

Aranesp
- 10-11

Mircera
- half life
- 2 weeks
- 0.6 mcg/kg

82
Q

ESA adverse effects

Epogen, Aranesp, and Mircera
- Pure Red Cell Aplasia (PRCA): ___ develop to erythropoietin; DC drug permanently
- HTN: ___ % of pts will develop increased BP

Causes of ESA therapy failure
- lack of vitamins or ___
- ___ toxicity
- active bleed
- drug induced bone ___ suppression
- acute inflammation or ___

A
  • antibodies
  • 23%
  • iron
  • aluminum
  • marrow
83
Q

New Therapy for Anemia of Chronic Kidney Disease

Hypoxia inducible factor-Prolyl Hydroxylase (HIF-PHI)
Daprodustat (___)
- must be on ___
- indication: for treatment of anemia due to CKD in pts who have been on dialysis for at least ___ months
- dosing: once daily PO

A

Jesduvroq
- dialysis
- 4 months

84
Q

HIF-PHI - Daprodustat (Jesduvroq)

  • must discontinue drug if Hb is greater than ___ g/dL
  • decrease dose by 1/2 pt has ___ impairment
  • do not give with strong CYP___ inhibitors (gemfibrozil)
A
  • 12 g/dL
  • hepatic
  • 2C8
85
Q

which of the following IV iron products requires a test dose first time it is administered?
A) iron sucrose
B) iron dextran
C) sodium ferric gluconate
D) ferrous sulfate

A

iron dextran

86
Q

JB is a 77 YOM hemodialysis pt reporting to the clininc today feeling tired and lethargic. He is evaluated by nephrologist for his anemia.
Current meds: Aranesp, iron sucrose, and calcium carbonate.
Labs: Hb 9.1 g/dL, TSAT 35%, Ferritin 525 ng/mL
Which is the appropriate recommendation?

A) no changes needed
B) increase iron sucrose
C) decrease iron sucrose
D) increase Aranesp dose

A

increase Aranesp dose

plenty of iron for the ESA to work

87
Q

Nutrition

protein and energy requirements (ESRD vs CKD)
- ___ kcal/kg/day
- Protein: ___ g/kg/day if GFR < 30 mL/min
- Protein: ___ g/kg/day ESKD
- water soluble vitamin replacement: ___ and ___
- we dont want to eat a lot of protein bc the ___ in it makes pts feel sicker and increase ___

A
  • 60-65
  • 0.8
  • 1.2
  • B and C
  • nitrogen, BUN
88
Q
A

PHRM 844 (52 decks)

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