Managing Comorbidities in Pts w/ CKD Flashcards
CKD is classified based on what 3 things?
- Cause
- GFR
- Extent of proteinuria
What are complications of CKD? (5)
- Altered Na & H2O balance
- Metabolic acidosis
- Anemia
- MBD
- Cardiac disease
What is the leading cause of CKD & ultimately ESRD?
DM
What is the 2nd leading cause of ESRD?
HTN
What is the 3rd leading cause of ESRD?
Glomerulonephritis
What is the patho of CKD?
Irreversible parenchymal damage & ESRD
- Loss of nephron mass
- Glomerular HTN
- Proteinuria
What are 2 contributing concerns of CKD?
- Smoking (decreases GFR & increases albumin excretion)
- Obesity
What is 1st line therapy for diabetes if the urine albumin excretion is >30/24hrs?
ACEI or ARB
How long is the ACEI or ARB dose increased for the tx of diabetes?
Increased until:
- Albuminuria is reduced by 30-50% OR
- Sig. drop in eGFR OR
- Hyperkalemia
What are the renal changes of ACEIs & ARBs?
- Renal hemodynamics
- Reduction of BP
Define anemia. What is a contributing factor?
Deficiency in production of endogenous erythropoietin by the kidney
Iron deficiency
How do you manage anemia?
- Administer erythropoietic-stimulating agents (ESAs)
- Iron supplements (oral or IV)
What are administration limits when treating anemia?
- Higher risk of cardiac events
- When Hgb > 11
What guidelines are used for grading & strength recommendations?
KDIGO
KDIGO: Level 1 vs level 2
Level 1 = “we recommend”
Level 2 = “we suggest”
KDIGO: Grades
A: High
B: Moderate
C: Low
D: Very low
When do you initiate ESA in a ND-CKD pt?
- Hgb < 10
- Consider Hgb rate of fall
When should you NOT initiate ESA in a ND-CKD pt?
Hgb ≥10
When do you initiate ESA in a CKD pt who is dialysis dependent?
Hgb btwn 9-10
In ND-CKD, do NOT use ESAs to…
- intentionally increase Hgb
- maintain Hgb > 11.5
When do you initiate iron in a ND-CKD pt?
TSat ≤ 30% & ferritin ≤ 500
What are examples of ESAs?
- Epoetin alfa
- Darbepoetin alfa
- Methoxy PEG-epoetin beta
How often should you use epoetin alfa?
3 times/wk
How often should you use darbepoetin alfa?
once every 4 wks
How often should you use methoxy PEG-epoetin beta
Every 2 wks
When do you double the dose of methoxy PEG-epoetin beta?
Once Hgb stabilizes, double the dose & administer monthly
What is the MOA of ESAs?
- Induce erythropoiesis by stimulating the division of erythroid progenitor cells
- Induce release of reticulocytes from bone marrow into blood
What are clinical indications for ESAs?
- Anemia due to myelosuppresion
- Anemia due to CKD
What is the box warning for ESAs?
Increased CV & CKD events w/ Hgb > 11
What are other ADEs of ESAs?
- CA
- Shortened survival or progression or recurrence in breast, cervical, head/neck, & non-small cell lung cancer pts ≥ 12
- Increased risk of DVT
What are abnormalities in CKD-MBD?
- PTH
- Ca, phosphorus & product
- Vit D
- Bone turnover
- Soft tissue calcifications
What is the net effect on serum levels w/ PTH?
Ca increase, phosphate decrease
What is the net effect on serum levels w/ vit D?
Both Ca & phosphate increase
What is the net effect on serum levels w/ FGF23?
Decreased phosphate
How do you manage CKD-MBD?
- Phosphorus restriction
- Phosphate-binding agents
- Vit D
- Calcimimetic therapy
What phosphate-binding agents can you use for tx of hyperphosphatemia in CKD?
- Ca based binders
- Iron based binders
- Resin binders
- Other elemental binders
What are 2 examples of Ca based binders?
Ca acetate
Ca carbonate
What are 2 examples of iron based binders?
Ferric citrate
Sucroferric oxyhydroxide
What are the effects of ferric citrate?
- Increase in iron, ferritin, & TSat
- Discolored stools
What is an ADE of sucroferric oxyhydroxide?
Discolored stools
What are 2 examples of resin binders?
Sevelamer carbonate
Sevelamer hydrochloride
What are the effects of sevelamer carbonate?
- Lowers LDL
- May interact w/ cipro & mycophenolate
What are 2 examples of other elemental binders?
- Lanthanum carbonate
- Aluminium hydroxide (not 1st line, short-term use)
What are ADEs of lanthanum carbonate?
- Accumulation due to GI absorption
- N/V/abd pain
- Bowel obstruction, constipation, dyspepsia
- Fecal impaction, ileus
What are ADEs of aluminum hydroxide?
- Aluminum toxicity
- Constipation, fecal impaction
- Hypomagnesmia, hypophosphatemia
Do not use aluminum hydroxide w/ ….
citrate-containing products
What is the MOA of Ca based phosphate binding agents for hyperphosphatemia in CKD pts?
- Binds w/ dietary phosphate to form Ca phosphate
- Excreted in feces
What are ADEs of Ca based phosphate-binding agents?
- Hypercalciumia
- Hypophosphatemia
- Milk-alkali syndrome
What is the MOA of sevelamer hydrochloride (a resin-binder)
- Binds phosphate within intestinal lumen –> decreased absorption & phosphate concentrations
- Lowers LDL
What are ADEs of sevelamer hydrochloride?
- Metabolic acidosis (esp. in children)
- N/V/D & dyspepsia
What is the MOA of lanthanum carbonate?
Binds dietary phosphate –> insoluble complexes w/ net decreases in phosphate & Ca levels
What is the MOA of aluminum hydroxide?
Binds phosphate in GI tract, preventing absorption of phosphate
What vit D agents can cause hypercalcemia?
- Ergocalciferol D2
- Cholecalciferol D3
What is the MOA of ergocalciferol D2 & cholecalciferol D3?
- Stimulate Ca & phosphate absorption from small intestine
- Promote secretion of Ca from bone to blood
- Promote renal tubule phosphate resorption
