Renal Disease

Question 1

Pathophysiology / Complications of CKD

Answer 1

1) Increased PO4
* kidney cannot excrete PO4
- high PO4 stimulates release of PTH

2) Decreased Vit D & Ca
* Decreased activation to 1,25-dihydroxy Vit D, thus decreased GI absorption of Ca
- low Ca stimulates release of PTH

3) Decreased Erythropoietin (EPO)
* Anemia of Chronic Disease

Question 2

Pathophysiology of Secondary Hyper-PTH

Answer 2

High PTH = stimulated by High PO4 / Low Ca

- signals kidneys to reabsorb more Ca into blood but in CKD cannot do this, so it pulls it from the BONES

Question 3

Treatments of Hyperphosphatemia

Answer 3

Phosphate Binders: take with food

1st Line: Calcium-based

1) Calcium acetate (Phoslyra)
2) Calcium carbonate (Tums)

2nd Line: Non-Aluminum/Calcium

1) Sevelemer (Renvela / Renagel)
2) Lanthanum carbonate (Fosrenol)
3) Velphoro (sucroferric oxyhydroxide)
4) Auryxia (Ferric citrate)

Last Line: Aluminum-based

Question 4

ADRs of Phosphate Binders

Answer 4

1st Line: Calcium-based

1) Hypercalcemia
2) constipation

2nd Line: Non-Aluminum/Calcium

1) Iron-based
2) Lanthanum carbonate = chew thoroughly (GI obstruction)

Last Line: Aluminum-based

1) Potent, short-term
2) toxic to Bone & CNS

Question 5

Phosphate Binder DDIs

Answer 5

1) Levothyroxine
2) FQ & Tetracyclines
3) Bisphosphonates

Question 6

Vit D considerations in CKD

Answer 6

Require activation by kidney, ineffective in CKD!

1) Vit D3 = cholecalciferol (sun)
2) Vit D2 = ergocalciferol (plants)

Question 7

Vit D Deficiency in CKD

Answer 7

Vit D Analog: increase Ca reabsorption in gut
1) Calcitriol (Rocaltrol)
ADR = HYPER-calcemia

Calcimimetic: signals Ca-receptor on Parathyroid Gland to stop producing PTH, thus decreasing resorption of Ca into blood
2) Cinacalcet (Sensipar)
ADR = HYPO-calcemia

Question 8

Treatment of Anemia of CKD

Answer 8

1) Epoetin alfa (Procrit / Epogen)

2) Darbepoetin alfa (Aranesp)

Question 9

ESA (Erythropoiesis-Stimulating Agent) considerations

Answer 9

ADRs:

1) HTN
2) Thrombosis

Supplement with Iron
Initiate if Hgb < 10
Discontinue if Hgb > 11

Question 10

Hyperkalemia Steps

Answer 10

[Stabilize Heart]
1) CaCl: CaGluc = 3:1

[Move K+ intracellularly]

1) Regular Insulin (+ Dextrose to prevent hypoglycemia / stimulates insulin release)
2) Sodium bicarbonate
3) Albuterol

[Removing from body]

1) Furosemide (loop diuretics)
2) SPS (Kayexylate)
3) Patiromer (Veltassa)
4) Sodium zirconium cyclosilicate (Lokelma)
5) Hemodialysis