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ckd > mineral bone disease > Flashcards

mineral bone disease Flashcards

1
Q

What are the mechanisms that potentiate hyperparathyroidism in CKD?

A
  1. Phosphate retention
  2. Hypocalcemia
  3. Decreased production of 1,25-dihydroxyvitaminD3 -> also leads to hypocalcemia
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2
Q

Monitoring parameters for CKD-MBD

A

Calcium and Phosphorous, iPTH, and 25-OH Vitamin D

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3
Q

Corrected calcium equation

A

measured calcium + 0.8(4 - albumin)

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4
Q

CKD Stage 3 Monitoring Parameters

A

Calcium and Phos: Q6-12 months
iPTH: Q12 months
25-OH Vitamin D: at baseline

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5
Q

CKD Stage 4 Monitoring Parameters

A

Calcium and Phos: Q3-6 months
iPTH: Q3-12 months

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6
Q

CKD Stage 5 Monitoring Parameters

A

Calcium and Phos: Q1-3 months
iPTH: Q3-6 months

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7
Q

what are some consequences of CKD-MBD?

A
  1. CV Disease
  2. Bone Disease
  3. Calciphylaxis (CUA)

CUA = calcific uremic arteriolopathy ~ extravascular calcification

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8
Q

types of renal osteodystrophy (2)

A
  1. adynamic bone osteomalacia
  2. ostetis fibrosa
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9
Q

adynamic bone osteomalacia vs. ostetis fibrosa

A

adynamic bone osteomalacia = over-treated hyperparathyroidism -> low bone turnover

ostetis fibrosa = under-treated hyperparathyroidism -> high bone turnover

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10
Q

goals of treatment of CKD-MBD (4)

A
  1. prevent consequences of cardiovascular and extravascular calcification
  2. prevent the development of secondary hyperparathyroidism and renal osteodystrophy
  3. maintain critical biochemical parameters (Ca, Phos, and iPTH) within target ranges
  4. Prevent mortality (NONE decrease mortality)
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11
Q

General Approach to Pharmacologic Treatment of CKD-MBD

A

First line: Phosphate binders
Second line: Activated Vitamin D (or calcimimetic)
Third line: Calcimimetic (or activated vitamin D - whichever one you didn’t choose for 2)

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12
Q

how do phosphate binders help treat CKD-MBD?

A

they help prevent the initial pathologic mechanism of phosphate retention by binding phosphate in the diet and preventing absorption!

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13
Q

Phosphate Pyramid

A

Dark sodas (lots of phosphate)
Egg white, fruits and veggies, protein-free products (less phosphate)

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14
Q

If corrected calcium is LOW, what phosphate binder do you use…?

A

Calcium based binder:
Less Ca2+ More $ = Calcium acetate (PhosLo)

More Ca2+ Less $ = Calcium carbonate

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15
Q

Calcium based binder effects

A

increases serum Ca2+ and decreases serum phosphate concentration

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16
Q

Calcium acetate

A

Calcium based phosphate binder
PhosLo
25% elemental Ca2+
Less Ca2+ and More $
Rx only
2x phosphate binding capacity vs. carbonate

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17
Q

Calcium carbonate

A

Calcium based phosphate binder
40% elemental Ca2+
-> MORE risk of hypercalcemia
More Ca2+ and Less $
OTC
*requires acidic pH for phosphate binding

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18
Q

If corrected calcium is NORMAL-HIGH, what phosphate binder do you use…?

A

Non-Calcium based binder
First line: Sevelamer
Lanthanum carbonate (chewable)
Ferric citrate (iron deficiency anemia)
Sucroferric oxyhydroxide (lowers pill burden)

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19
Q

Sevelamer dosing

A

based on serum phospahte (higher = more drug)
5.5-7.5 mg/dL: 800 mg PO TID
7.5-9 mg/dL: 1200-1600 mg PO TID
> 9 mg/dL: 1600 mg PO TID

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20
Q

Sevelamer

A

Non-calcium based phosphate binder
Renvela
1st line!

also helps to decrease LDL and increase HDL

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21
Q

Sevelamer DDIs

A

take other meds 1 hour before or 3 hours after taking sevelamer

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22
Q

adverse effects of Sevelamer

A

Gi upset, DIARRHEA

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23
Q

Lanthanum carbonate

A

Non-calcium based phosphate binder
Fosrenol
Chewable!

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24
Q

counseling point for Lanthanum carbonate

A

tablet MUST be chewed

25
Q

adverse effects of Lanthanum carbonate

A

GI upset, lanthanum accumulation

26
Q

Lanthanum carbonate DDIs

A

take other meds 1 hour before and 3 hours after taking Lanthanum carbonate (not as many DDIs as Sevelamer)

27
Q

Ferric citrate

A

Non-calcium based phosphate binder
Auryxia
IDA -> iron supplement AND phosphate binder

28
Q

dosing of Ferric citrate

A

420 mg ferric iron 92 tabs) PO TID

29
Q

adverse effects of Ferric citrate

A

GI, diarrhea, iron overload, stool discoloration

30
Q

Sucroferric oxyhydroxide

A

Non-calcium based phosphate binder
Velphoro
lowers pill burden
VERY potent phosphate binder and ALSO CHEWABLE

31
Q

dosing of sucroferric oxyhydroxide

A

500 mg iron PO TID MUST be chewed

32
Q

adverse effects of sucroferric oxyhydroxide

A

GI upset, diarrhea

33
Q

what is an advantage of sucroferric oxyhydroxide?

A

lower pill burden
(non-inferior to sevelamer carbonate)

34
Q

if corrected serum calcium AFTER phosphate binding is at a stable dose is NORMAL-LOW…

A

activated vitamin D and analogs
endogenous:
calcitriol (rocaltrol)
less increase in Ca/PO4:
paricalcitol
doxercalciferol (hectorol)
(less hypercalcemia and hyperphosphatemia)

35
Q

if corrected serum calcium AFTER phosphate binding is at a stable dose is NORMAL-HIGH…

A

Calcimimetic (dec. serum Ca)
PO: cinacalcet (sensipar)
IV: etelcalcitide (parsabiv)

36
Q

KDIGO 2017 Guidelines for serum calcium, serum phosphate, and iPTH

A

goal serum calcium: avoid hypercalcemia; asymptomatic hypocalcemia is ok

goal serum phosphate: towards the normal range (3.5-5.5 mg/dL)

goal iPTH: 2-9x ULN (~ 150-600 pg/mL)

37
Q

Phosphorous Balance and Hemodialysis

A

to achieve neutral phosphate balance, binders must remove 257 mg/day

38
Q

most important counseling point for phospahte binders?

A

TAKE WITH FOOD!

39
Q

what are some adverse effects of calcium based phosphate binders?

A
  • abdominal discomfort, nephrolithiasis
  • “Stones, Bones, and Abdominal Groans”
  • Calciphylaxis - systemic calcification
40
Q

Calcium Based Phosphate Binders DDIs

A

Fluroquinolones
Levothyroxine (Synthroid)
Iron

separate administration ~ 2 hours

41
Q

Non-Calcium Based Phosphate Binders

A

First line: Sevelamer carbonate
*HCl not used due to worsening metabolic acidosis

Second line: Lanthanum carbonate (Fosrenol)

Third line: Aluminum hydroxide (Amphojel)

42
Q

what is a disadvantage of Sevelamer and Lanthanum carbonate?

A

they are both expensive!

43
Q

Aluminum based binders

A

LAST LINE
aluminum hydroxide (amphojel)
very effective phosphate binding

44
Q

adverse effects of aluminum hydroxide

A

GI upset, CNS toxicity (dialysis encephalopathy), microcytic anemia

risk of aluminuk toxicity
-> inc. serum aluminum leads to aluminum deposition and toxicity (osteomalacia, microcytic anemia, neurologic sequelae) also ESA resistance

45
Q

Goals of therapy for Phosphate Binders

A

Corrected calcium: 8.5-10.2 mg/dL (avoid hypercalcemia; asymptomatic hypocalcemia is ok)

Normal serum phosphorous towards the normal range: 2.7-4.6 mg/dL (or 3.5-5.5 for some)

46
Q

Clinical Pearls for Phosphate Binders

A
  • adherence is critical
  • counsel to TAKE WITH FOOD
  • combo of calcium AND non-calcium binders can be used
47
Q

when should vitamin D/calcitriol be used in a CKD-MBD patient?

A
  1. elevated iPTH despite calcium and phosphate at goal
  2. persistent hypocalcemia with hyperparathyroidism
48
Q

when should vitamin D/calcitriol NOT be used in a CKD-MBD patient?

A

hypercalcemia and/or hyperphosphatemia
(use calcimimetics and optimize phosphate binders first!!!)

49
Q

what is the target therapy with vitamin D/calcitriol agents in ESRD?

A

iPTH maintained 2-9x ULN (~150-600 pg/mL)
prevent hypercalcemia

50
Q

what is recommended in CKD and ESRD if vitamin D deficiency?

A

serum 25-hydroxycholecalciferol < 30 ng/mL

ergocalciferol (vitamin D2)
cholecalciferol (vitamin D3)
inactive forms of Vitamin D

51
Q

ergocalciferol and cholecalciferol

A

vitamin D2 and D3
- poor conversion to active form (calciferol) in ESRD
- available OTC
- inexpensive

52
Q

calcifediol (rayaldee)

A

prohormone of active form of vitamin D

approved for CKD stages 3 and 4 (NOT ESKD; no dialysis or CKD 5)

53
Q

initiation requirements for calcifediol

A

serum calcium must be < 9.8 mg/mL and phosphorous </= 5.5 mg/dL

54
Q

side effects of calcifediol

A

hypercalcemia and hyperphosphatemia

55
Q

cinacalcet MOA

A

calcimimetic -> sensitizes parathyroid gland

56
Q

adverse effects of cinacalcet

A

GI - N/V very common
hypocalcemia - paresthesias, myalgia, cramping, tetany

monitor Ca for 1 week then monthly

QT prolongation (due to hypocalcemia)

57
Q

etelcalcetide (parsabiv)

A

IV calcimimetic dosed at HD
less GI side effects
hypocalcemia
QT prolongation

58
Q

General Treatment Algorithm

A

Treat to targets of:
- towards normal phosphate range
- avoiding hypercalcemia; asymptomatic hypocalcemia is ok
USE CORRECTED CALCIUM!!
- iPTH ~ 150-600 pg/mL

Start with Phosphate Binders
- initial choice based on serum calcium (CORRECTED)

Add active Vitamin D or calcimimetic based on trends of Ca, Phos, and iPTH
- active vitamin D if Ca LOW, Phos at target, iPTH HIGH
- calcimimetic if Ca HIGH, Phos at target, iPTH HIGH

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