renal Flashcards
Aluminum hydroxide
AlternaGel, Amphojel
Calcium acetate
PhosLo, Phoslyra
Calcium carbonate
Tums
Lanthanum carbonate
Fosrenol
Sevelamer carbonate
Renvela
Sevelamer hydrochloride
Renagel
Calcitriol
Rocaltrol, Calcijex
Doxercalciferol
Hectorol
Paricalcitrol
Zemplar
Cinacalcet
Sensipar
Fludrocortisone
Florinef
Sodium polystyrene sulfonate
Kayexelate
Sodium citrate/Citric acid
Bicitra, Cytra-2, Oracit, Shohl’s solution
What are the Aluminum-based phosphate binder?
- Aluminum hydroxide (AlternaGel, Amphojel)
Calcium based phosphate binders = First line therapy for hyperphoshatemia of CKD
- Calcium acetate (PhosLo, Phoslyra)
2. Calcium Carbonate (Tums)
What are the Aluminum free/Calcium free phosphate binders?
- Lanthanum carbonate (Fosrenol)
2. Sevelamer carbonate (Renvela)
How to take phosphate binder?
Take with food TID
How to take Fosrenol?
Must Chew thoroughly to reduce the risk of serious adverse GI events
What is the advantage of sevelamer carbonate over sevelamer hydrochloride?
*Carbonate maintaing bicarbonate concentrations is good because these patient tend to be acidotic so Bicarb will neutralize the acidosis
Which phosphate binders can lower total cholesterol and LDL by 15 - 30%?
Sevelamer (Renvela, Renagel)
What is the contraindication for fosrenol?
Patient with bowel obstruction, ileus, and fecal impaction
What are two form of Vitamin D ?
- D3 = cholecalciferol synthesized in skin
2. D2 = ergocalciferol produced from diet
Vitamin D analogs used to treat secondary hyperparathyroidism
- Calcitriol ( Rocaltrol, Calcijex)
- Doxercalciferol (Hectorol)
- Paricalcitol (Zemplar)
Calcimimetic used to treat secondary hyperparathyroidism
Cinacalcet ( Sensipar) = Doesn’t affect calcium level
What type of EKG changes occurs with hyperkalemia?
- flattened P wave
2. Elevated T wave
Treatment of metabolic acidosis of CKD
Bicarb in the form of
- Sodium bicarbonate (tab, granules, powder)
- Sodium Citrate/Citric acid (Oracit, Shohl’s solution)
What are the drugs that should not be used in severe renal impairment?
- Avanafil
- Bisphosphonates
- Chlorpropamide
4.Dabigatran - Duloxetine
- NSAIDs
- Glyburide
- Lithium
- Nitrofurantoin
- Potasisum sparing diurectics
- Tadalafil
12 Tenofovir
What is the duration limitation associated with aluminum based phosphate binders?
Limited duration to 4 weeks
What are the complications associated with CKD?
- Anemia
- Bone abnormalities [ initially due to elevation of phosphorus, to compensate for hyperphosphatemia = increases release of PTH = overtime lead to secondary hyperparathyroidism]
- hyperkalemia
What are some drugs that *increases potassium levels *?
- Potassium sparing diuretics
- ACEIs/ARBs
- NSAIDs
- Cyclosporin/tacrolimus
- Heparin
- canaglifozin
- Bactrim
- supplements
- drospairenone OC (Yaz)
What can be given to stabilize the cardiac tissue due to low potassium ?
IV calcium
What are the options to lower potassium levels?
- remove sources of potassium intake
- enhance potassium uptake by the cells [ via Insulin + glucose=stimulate insulin secretion/prevent hypoglycemia]
- if pt has metabolic acidosis = Sodium bicarb
- nbeulized abluterol
- increase renal excretion w/ furosemide or fludrocortisone (Florinef)
- Cation exchange resin (Kayexolate /SPS)
- Emergeny dialysis
what are the most common causes of CKD
DM and HTN
what are complications that can arise due to CKD
anemia, bone and mineral metabolism, acid-base and electrolyte disturbances
what are the two types of dialysis
Hemodialysis and peritoneal dialysis
what are the factors that affect drug removal during dialysis
molecular size,
protein binding (highly protein bound drugs will generally not be removed),
plasma clearance (will not remove highly hepatic drugs),
volume of distribution (drugs with a large Vd will not be effectively removed), and the
dialysis membrane
what are some things that can be used to gauge the severity of kidney damage
SCr, albumin in the urine, BUN
what must you take into account when using SCr to estimate kidney function
degree of muscle mass and metabolism in the patient
what are some other things that affect the BUN
level of hydration, protein consumption BUN increases with renal impairment
what is used as a marker of renal function in various estimating equations
serum creatinine
what measures the amount of nitrogen that comes from the waste product urea
BUN
what is mainly reabsorbed at the descending limb of the loop of henle
water
what is primarily reabsorbed at the ascending limb of the loop of henle
Na, Cl
what effect do loop diuretics have on calcium
they increase calcium absorption and long-term use of thiazide diuretics have a protective effect on bone
where do loop diuretics act
inhibit Na/K pumps of ASCENDING limb of loop of henle
where do TZD act
inhibit Na-Cl pump in distal tubule
the collecting duct is primarily affected by
aldosterone and ADH
what is the primary effect of aldosterone
increase Na, water retention and to lower K+
what are drugs that are aldosterone antagonist (name the generic)
spironolactone, eplerenone, amiloride These block the effects of aldosterone and can cause an increase in serum potassium.
what is the normal range for SCr
0.6 - 1.2 mg/dL
when is the Cockcroft-Gault equation not preferabele
in young children, ESRD, when renal status is rapidly changing
CrCL of what indicates dialysis
< 15
when making an adjustment to a drug regimen based on CrCl what are your options
changing the dose (decreasing) or changing the dosing interval (extending)
if a patient has poor renal clearance and they are on a aminoglycoside and quinolone what should you do
change the dosing interval since they have concentration dependent killing properties
if a patient has poor renal clearance and they are on a Beta lactam what should you do
change the dose since they have time dependent killing properties
if a patient has CKD and proteinuria what medication should they be on regardless of whether they also have DM
ACE-I or ARB they decrease proteinuria
what are the main benefits of ACE-I/ARBs in CKD pt
preserve renal function, decrease proteinuria, and provide cardiovascular protection
what may you see once you begin a CKD pt on an ACE-I or ARB
a 30% increase in their SCr (d/c if > 30% increase)
what electrolyte is effected by ACE-I/ARBs and how
potassium, they increase serum K
how long should a CKD patient be monitored when starting an ACE-I or ARB and what are you monitoring
monitor SCr and K for 1-2 weeks after initiation of therapy
why do CKD patients become anemic
kidney produces EPO which declines as kidney function declines
what are some foods high in phosphorous
dairy products, dark colored sodas, chocolate, nuts
what type of phosphate binders are 1st line
calcium based such as calcium acetate and carbonate (PhosLo)
what are the aluminum based phosphate binders
Alternagel. Should only be used short term to decrease phosphorous
how do you initially treat hyperphosphatemia
dietary restrictions
why must phosphate binders be taken with food
they only bind the phosphate coming from your diet. don’t take it after you eat, there is no point.
what are the SE of using an aluminum based phosphate binder
constipation, osteomalacia, poor taste, intoxication (neurotoxicity)
why are aluminum based phosphate binders not used much
accumulation b/c its renally cleared and potential for osteomalacia and aluminum intoxication
what are the calcium based phosphate binders Brand (Generic)
PhosLo, Phoslyria (calcium acetate)
Tums (calcium carbonate- although calcium acetate binds more phosphorus than Tums)
what are the SE of using a calcium based phosphate binder
constipation, hypercalcemia, nasea
what are the aluminum and calcium free phosphate binders Brand (Generic)
sevelamir (Renvela, Renagel), lanthinum carbonate (Fosrenol)
elevation in PTH is primarily treated with
Vitamin D
what form of Vit D is given to CKD patients
Calcitrol
what is the effect of active Vit D3
increase calcium absorption from the gut, increase serum calcium concentrations, and inhibits PTH secretion
how do calcimimetics works
increase sensitivity of calcium sensing receptor on PT gland therefore decreasing Ca, PTH, PO4 and preventing progression of bone disease
calcimimetics are used to treat what condition
secondary hyperparathyroidism
what is an example of a calcimimetic Brand (generic)
Sensipar (Cinacalcet)
what is the normal range of potassium
3.5 - 5 meq/L
what is the most abundant intracellular cation
potassium
what is the most abundant extracellular cation
sodium
what are some things that increase K+ excretion
diuretics (strongly loops, weakly TZD), aldosterone agonist, bicarbonate
what effect does insulin have on potassium
causes it to shift inside the cells
what is the most common cause of hyperkalemia
decrease renal excretion due to renal failure
why are diabetics at a higher risk of having hyperkalemia
insulin deficiency
what are some SSx a patient may experience when hyperkalemic
muscle weakness, bradycardia, fatal arrhythmias, paresthesias may occur
why is calcium given to patients with hyperkalemia
to stabilize cardiac tissues therefore help prevent arrhythmias
what can be given to enhance K+ uptake by cells
glucose + insulin
why is glucose given along with insulin when treating hyperkalemia
to prevent hypoglycemia
a patient is suffering from hypoaldosteronism and is now hyperkalemic what can you give them
fludrocortisone (Florinef)
what cation exchange resin can be used to treat hyperkalemia
Kayexelate (SPS) can reduce K+ by 2 mEq/L
what dosage forms does Kayexelate come in and what precaution must be taken with one of them
rectal (preferred in emergencies) and oral, don’t give sorbitol when giving orally due to risk of GI necrosis
what are common side effects of kayexelate
decrease appetite, constipation, nausea, vomiting
serum bicarbonates levels of what indicate starting treatment of metabolic acidosis
< 22 mEq/L
what effect does sevelamer have on cholesterol
decreases ldl and cholesterol
Which beta-lactam antibiotics are not adjusted for renal issues
Nafcillin
Oxacillin
Dicoloxacillin
