Lecture 5: CKD Flashcards
Lab Values - Kidney Function
SCr
males: 0.6-1.2 mg/dL
females: 0.5-1.1 mg/dL
Lab Values - Kidney Function
BUN
10-20 mg/dL
“normal BUN is 15 or less”
Lab Values - Kidney Function
CrCl
males: 110-150 mL/min
females: 100-130 mL/min
Lab Values - Kidney Function
eGFR
greater than or equal to 90 mL/min/1.73 m^2
Lab Values - Mineral and Bone Disorder
Phos
2.5-4.5 mg/dL
Lab Values - Mineral and Bone Disorder
Ca
8.5-10.5 mg/dL
Lab Values - Mineral and Bone Disorder
Vitamin D
~ 30 ng/mL
Lab Values - Mineral and Bone Disorder
PTH
non-dialysis: 11-54 pg/mL
dialysis: 100-500 pg/mL
Lab Values - Anemia of CKD
anemic Hb levels
females: Hb < 12 g/dL
males: Hb < 13 g/dL
Lab Values - Anemia of CKD
TSAT
20-30%
if < 30% AND ferritin is < 500 ng/mL, do iron supp
Lab Values - Anemia of CKDLab Values - Anemia of CKD
Ferritin
100-500 ng/mL
if < 30% AND ferritin is < 500 ng/mL, do iron supp
Lab Values - Anemia of CKDLab Values - Anemia of CKD
MCV
Mean Corpuscular Volume
80-96 mcm^3
Lab Values - Anemia of CKDLab Values - Anemia of CKD
RDW
red cell distribution width
11.5-14.5%
3 major causes of CKD
- DM
- HTN
- glomerulonephritis
other causes:
- polycystic kidney disease (PKD)
- HIV nephropathy
CKD is classified on (3)
- cause
- GFR
- albuminuria
Stage 3 CKD, eGFR range of ___ , is where we get concerned
45-59 mL/min/1.73 m^2
Estimating Kidney Function (Creatinine Clearance)
Cockroft and Gault formula
M: CrCl = [(140-age) x IBW]/(SCr x 72)
F: that x 0.85
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
- stable, AKI
- GFR
- overestimate
AKI levels typically not stable
What equation is most accurate in estimating GFR?
Modification of Diet in Renal Disease (MDRD)
IBW equation
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
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 ___
- urea, uric acid
- BUN
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 ___
- fetor
- edema
- anorexia, metallic
- mineral, bone, leg
- EPO
- frost
fetor = breath smells like urine
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 ___
- blood pressure
- not generally necessary if Na intake is controlled. H2O will follow Na
- kidneys
- insufficiency, urine
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
T; next step is to add a thiazide to trear resistance
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 ___
- 30 mL/min
- 30 mL/min
- furosemide, 50%, twice
- K sparing
- thiazide, resistance
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 ___)
- “no-salt-added”
- 2, 5
- caution
- canned soups, hotdogs
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 (___)
- 3
- 4.5-5.5
- fruits (dried and fresh)
- C A BIG K DROP
Which of the following diuretics is least likely to cause an allergic sulfa reaction?
A) furosemide
B) ethacrynic acid
C) torsemide
D) bumetanide
ethancrynic acid
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?
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.
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
- 2.5-4.5 mg/dL
- dietary
must take with food for them to work
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)
Tums
- 40%
- 500 mg, meals
- constipation
- 1500 mg/day, soft tissue calcification
Phosphate Binders
Calcium acetate (___)
- ___ % elemental Ca
- Dose: ___ tabs TID with ___
- DO NOT exceed: ___ mg/day
- may produce fewer ___ events compared to tums
- PhosLo
- 25%
- 2-3, meals
- 1500 mg/day
- hypercalcemic
Phosphate Binders
T or F: when given at the same elemental dose, calcium carbonate will bind twice as much phosphate compared to calcium acetate
F: when given at the same elemental dose, calcium acetate will bind twice as much phosphate compared to calcium carbonate
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 :)
- Renvela
- tums
- 800 mg, meals
- 1600 mg, meals
- upset
- LDL
- uric acid
max dose studied: 14g/day; no ADRs (pretty safe)
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 ___
- Fosrenol
- chewable
- 250-750 mg, meals
- 1500-3000 mg/day
- acidic, broad
- feces
- accumulation
- BBB
- GI
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
- Velphoro
- iron
- 500, chewable, meals
- 1 tab
- black
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
- ferric citrate
- dialysis
- 2 tabs, meals
- 1 g
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
- Amphojel
- 300-600 mg
- aluminum
- 4 weks
Non-calcium containing phosphate binders
Magnesium carbonate (___)
- ___ approved
- Dose: ___ tabs TID with ___
- Mag-Carb
- non-FDA
- 1-3 tabs, meals
Non-calcium containing phosphate binders
nicotinic acid and nicotinamide arent really used bc
SE are terrible, causes facical flushing
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
- 800-1000
- 4.6
- 5.5
- PTH
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)
Tums
it’s the only one that has calcium
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)
Renvela (sevelamer carbonate)
decreases phosphate and uric acid
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
- Ca
- parathyroid, PTH
- negative feedback
- cholecalciferol or ergocalciferol
- activated
what enzyme in the kidney converts unactivated Vit D to activated
1-alpha-hydroxylase
Which Vit D are unactivated
ergocalciferol and cholecalciferol
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 ___
- calciferol
- D2
- 50,000
- 3, 4
- D3
- 1000
- 3, 4
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.
T
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
Rocaltrol, Calcijex
- Rocaltrol
- Calcijex, IV
- hypercalcemia
- pediatric
- hypercalcemia
- Ca
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 __
Zemplar
- 0.04-0.10 mcg/kg
- 500
- 500
- 30
- favoraable
- calcemic
- Ca and iPTH
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 ___
Hectorol
- multiple organ failure
- 2.5-10, 2-3x
- prodrug
- hypercalcemia
- hyperphosphatemia
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
Senispar
- conformational, decrease
- 30 mg
- 180 mg
- hypocalcemia
- 8 mg/dL
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
Parsabiv
- IV
- 5 mg, weekly, hemodialysis
- hypocalcemia
- 8 mg/dL
Monitoring Parameters for CKD-MBD - Goal Ranges
Ca: ___
Phos: ___
25(OH)D: ___
PTH (dialysis and non-dislysis): ___ and ___
- 8.5-10.5 mg/dL
- 2.5-4.5 mg/dL
- ~30 ng/dL
- 100-500 pg/mL, 11-54 pg/mL
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
calcitriol
doxercalciferol requires liver to activate (prodrug)
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
paricalcitol (Zemplar)
Not A or B due to kidney activation, not C due to low Ca
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
RBC, hypoxia-inducible
Anemia
Iron is necessary as well for RBC production. Its absorption and transport are promoted by ___ factor
hypoxia-inducible
Anemia
Hypoxia-inducible factor- degrades under conditions of normal oxygen tension. But in anemia or hypoxia, it promotes gene transcription of ___
EPO
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 ___
- EPO
- uremia
- vitamin (folate, B12, B6)
- dialysis (hemolysis)
anemia
What is MCV
mean corpuscular volume - how big your blood cells are
80-96 mm^3
Normal lab value range for MCV
80-96 mm^3
What is RDW and what is the normal lab value
Red cell Distribution Width
11.5-14.5%
what does microcytic iron deficiency look like on a graph?
What does Macrocyctic B12, folate deficiency look like on a graph?
What does normal MCV and increased RDW look like on a graph?
If you are at the lower end of the MCV graph, you might have ___ deficiency or ___ toxicity
iron, aluminum
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
- chronic disease
- GI
- Erythropoietin
if you are at the high end of the MCV graph, you might have ___ or ___ deficiencies
folate, B12
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 ___
Hb
- annually, twice, 3 months
- 3 months, monthly
Anemia
anemic Hb level for males and females
F: Hb < 12 g/dL
M: Hb < 13 g/dL
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
- erythropoiesis
- 30%, 500 ng/mL
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
- 3 months
- TSAT, ferritin
- 30%, 500 ng/mL
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 ___
hemodialysis
- peritoneal dialysis
- ferrous
- 200 mg, elemental
- stomach
- acidic (stomach), orange juice
- enteric
- PPIs, H2RAs
- 2 hrs
IV Iron - CKD 5D
Iron dextran (InFed, ___ )
- 25 mg ___ dose
- 100 mg IV every hemodialysis session x 10
- cheap
Dexferrum
- test
anaphylaxis to dextran component
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
Ferrlicit
- 125
Venofer
- 200, ND
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
Injectafer
- 750 mg
Feraheme
- 510 mg
- MRI
Other Iron
Triferic (ferric pyrophosphate citrate)
- iron compound added to ___ during dialysis
dialysate
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 ___
- 10 g/dL
- 9-10 g/dL
- 11.5 g/dL
T or F: although quality of life increases as Hb increases, the incidence of cerebrovascular adverse events also increases
T; do not use ESA to push Hb above 11.5 g/dL
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 ___
erythroid
- SC
Aranesp
- 10-11
Mircera
- half life
- 2 weeks
- 0.6 mcg/kg
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 ___
- antibodies
- 23%
- iron
- aluminum
- marrow
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
Jesduvroq
- dialysis
- 4 months
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)
- 12 g/dL
- hepatic
- 2C8
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
iron dextran
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
increase Aranesp dose
plenty of iron for the ESA to work
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 ___
- 60-65
- 0.8
- 1.2
- B and C
- nitrogen, BUN
