Lipids/CKD Flashcards
CKD is defined as ____ or more months of either kidney damage or eGFR < _____.
3, 60
Dominant risk factors for CKD
DM and HTN
Four interventions to reduce CKD progression
blood pressure control goal <130/80
use of ACE/ARB (not together) for albuminuria
DM control HgBA1C target <7%
correction of metabolic acidosis
eGFR Stages of CKD
Stage 1- 90-100 normal Stage 2- 60-89% mild Stage 3- 30-59% moderate Stage 4- 15-29% severe Stage 5- 14% and less- failure
Which stage of CKD? eGFR 90-100%, asymptomatic, with health issues such as DM, HTN, and obesity
Stage 1
Modifiable risk factors for CKD
DM
HTN
frequent NSAID use
hx of AKI
Non-modifiable risk factors for CKD
family hx of CKD
age 60 or older
ethnicity- AA, Hispanic, Asian/PI, or American Indian
What lab tests are used to diagnose CKD?
eGFR
ACR- albumin to creatinine ratio, urine (kidney damage marker)
Normal UACR level
<30
Severe albuminuria UACR level
> 300
Urine dipstick proteinuria if level is > ____.
30
Especially avoid these medications in CKD
NSAIDs Bisphosphonates IV contrast Metformin RAAS blockers
Starting at stage 3 CKD these additional labs are needed
Serum albumin
phosphorus
calcium
intact parathyroid hormone (PTH)
At what stage should nephrology be consulted in patients with CKD
Stage 3 or eGFR <30
or persistent albuminuria UACR >300
Clinicians should not only check patients blood creatinine levels but also check their ______.
Urine- low pH, high specific gravity, protein, RBC/WBCs are early indicators of potential issues.
In order for erythropoiesis-stimulating agents (ESA) to be effective, this medication is needed
Iron supplementation
Sodium should be limited to ___g/day and phosphorus ___-____mg/day in patients with CKD
2
800-1000
Animal protein consumption should be reduced to
___-___g/kg/day in CKD patients
0.6-0.8
What stage of CKD do complications usually begin>
Stage 3 (anemia, bone/mineral issues, CV dz, low serum albumin)
Common meds that require dose reduction
Allopurinol Gabapentin Reglan Narcotics- methadone/fentanyl Beta-blockers Digoxin Statins- lova, prava, simva, fluva, rosuva Antimicrobials- sulfa, Macrobid, aminoglycosides Lovenox methotrexate colchicine
Treatment of hyperkalemia in CKD
Stop NSAIDs and Cox-2 inhibitors
Stop K+ sparing diuretics (spironolactone)
Avoid salt substitutes
CKD increases the risk for ____ disease.
CV
Increased waist circumference, increased trigs, decreased HDL, increased BP, and increased fasting glucose are indicators of:
metabolic syndrome
How do ACE/ARBs help with CKD?
lowers BP and reduces hyperfiltration injury inpatients with limited nephrons
What is the primary intervention for metabolic syndrome?
lifestyle therapy
Statin intensity for clinical ASCVD
high intensity if <75y
mod-high if >75y
Statin intensity for age 40-75 with DM and LDL 70-189
moderate intensity, consider increase if multiple ASCVD risk factors
Severe primary hypercholesterolemia LDL >190 initiate ____ intensity statin without calculating ASCVD risk
high
Statin intensity for age 20-75 with LDL >190
high
ASCVD risk enhancers
family hx of premature ASCVD persistently elevated LDL >160 or trigs >175 CKD metabolic syndrome preeclampsia, premature menopause Inflammatory disorders: RA, psoriasis, HIV ethnicity (South Asian ancestry) ABI <0.9
Signs/Symptoms of Stage 2 CKD
eGFR 60-89%
protein leaking in urine <200mcg
Signs/Symptoms of Stage 3 CKD
eGFR 30-59% Edema Fatigue Back pain Foamy, darker urine Microalbumin >200mcg Food restrictions: Na+ and phosphorus
Signs/Symptoms of Stage 4 CKD
eGFR 15-29% Stage 3 symptoms plus: n/v difficulty concentrating tingling in fingers/toes loss of appetite sleep problems dialysis need renal dietician required less dietary potassium intake
Signs/Symptoms of Stage 5 CKD
eGFR 0-14% Stage 4 symptoms plus: fatigue/weakness easy bruising/bleeding anemia thirst/cramps skin color changes making little to no urine dialysis or transplant
A daily dose of high-intensity statin can lower LDL by ____%
50
A daily dose of moderate-intensity statin can lower LDL by ____%
30-49%
A daily dose of low-intensity statin can lower LDL by ____%
<30%
High-intensity statins have a longer _____-_____ and can be given any time of day. These medications are good for patients who have adherence problems.
half-life
High-intensity statin list
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
Moderate-intensity statin list
Atorvastatin 10-20mg Rosuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lovastatin 40mg Fluvastatin XL 80mg Fluvastatin 40mg BID Pitavastatin 2-4mg
Low-intensity statin list
Simvastatin 10mg
Pravastatin 20mg
Lovastatin 20mg
Fluvastatin 20-40mg
If CAC score is > ____ or >_____ percentile, statin therapy is indicated unless patient refuses.
100, 75th
After beginning the treatment plan, lipids should be repeated in ___ to ____ weeks and repeat every ___ to ___ months if needed to check for statin intolerance.
4-12 weeks
3-12 months
If ASCVD risk <5% (low risk) the clinician should:
discuss risk and emphasize healthy lifestyle habits to reduce risk factors
If ASCVD risk 5% to <7.5% (borderline risk) the clinician should:
If the patient has risk enhancing factors, consider mod-intensity statin. If the decision about statin remains uncertain it is reasonable to use a CAC score to withhold, postpone or initiate therapy.
If ASCVD >7.5% to <20% (intermediate risk) the clinician should:
Consider mod-high intensity statin or a nonstatin for those who cannot tolerate statins. Consider requesting a CAC score.
If ASCVD >20% (high risk) the clinician should:
High risk with multiple high-risk clinical factors, initiate statin therapy to reduce LDL by 50%
If LDL remains >70 despite max tolerated statin therapy, the clinician should consider adding:
Zetia (add to moderate-intensity statin)
Major ASCVD events
ACS in past 12months
hx of MI or ischemic stroke
symptomatic PAD ( hx of claudication with ABI <0.85 or previous revascularization or amputation)
Bile sequestrants may increase ________.
triglycerides
Patients with impaired renal function should be prescribed which statins?
Atorvastatin or fluvastatin. Caution use of Rosuvastatin in these patients.
Patients with heart failure related to ischemic disease should be started on what intensity statin?
moderate
Adults with severe hypertriglyceridemia (>1000) should begin statin therapy. If the level remains high, the clinician should also prescribe _______.
fibrate therapy (fenofibrate) to prevent acute pancreatitis. Dietary modifications are also needed: a very low-fat diet, no refined carbs or ETOH, add omega 3.
To have a true statin intolerance, the symptoms must:
occur after initiating therapy, improve with statin DC, and reappear when reintroducing statin.
True or False: Statins can be given during pregnancy
False. Statins are listed as category X
LDL target for patients with very high risk CV disease is
50
ALL patients should limit this in their dietary intake:
sat/trans fat, sweets, sugar-sweetened beverages, red meats
Universal pediatric lipid screening is recommended at what ages?
ALL 9-11-year-olds
12-17-year-olds with new family hx, a parent with HLD, or other risk factors
ALL 17-21-year-olds
In children and adolescents 10 years or older with an LDL persistently >190 or 160 with family hx, who do not respond adequately with __-__ months of lifestyle therapy it is reasonable to initiate statin.
3-6
These statin medications have been approved for use in children beginning at age 8.
Rosuvastatin and Pravastatin
Children with LDL 250 or greater and or trigs >500 should be referred to a _____ _________.
Lipid specialist
Xanthomas are indicative of ________ _________.
Familial hyperlipidemia
These non-statin medications may be added with statins to help further reduce LDL.
Ezetimibe
Bile sequestrants (Questran, Colestipol)
PCSK9 inhibitors
Niacin and Fibrates
Statin associated side effects
BILATERAL myalgias (most common) hepatotoxicity GI upset cataracts Rhabdomyolysis Increased risk of DM
Hydrophilic statins are _____ soluble and may be tolerated better due to less distribution into the body’s tissues.
water
Lipophilic statins are _____ soluble and tend to cause more muscle-related adverse effects since they are distributed into the body’s fat.
fat
Patients with complaints of myalgias would benefit from _______ statins.
Hydrophilic
List hydrophilic statins
Rosuvastatin
Pravastatin
Fluvastatin
Pitavastatin (slightly hydrophilic)
List lipophilic statins
Atorvastatin
Lovastatin
Simvastatin
Patients on statin therapy should avoid this fruit.
Grapefruit
Drug-drug interactions with statins (Simvastatin, Lovastatin, Atorvastatin) metabolized through CYP3A4
Amiodarone Amlodipine Azole antifungals Diltiazem Verapamil
