Renal disease Flashcards
2 most common causes of renal disease
diabetes and hypertension
acute kidney injury
sudden loss of kidney function due to non renal condition
(ex. drugs) often reversible/ temporary, but can be permanent.
common cause of AKI
dehydration
BUN:SCR
20:1 or greater
chronic kidney disease (ckd)
progressive loss of kidney function over months or years
ESRD (end stage renal disease)
BAD! total and permanent renal failure
dialysis (or transplant) is needed to perform functions of the kidneys
if the glomerulus is damaged some ___ passes into the urine and this is used along with glomeular filtration rate (GFR) to determine severity of kidney disease also called ____
albumin
nephropathy
thiazides work on the
distal convoluted tubule
afferent =
in
efferent=
out
SGLT2s work at the
proximal tubule
k sparing diuretics work at the
collecting duct
loops work at the
ascending loop of henle
antidiuretic hormone (ADH) is also called
vasopressin
loops inhibit the ___ pump
na-k pump
sodium potassium pump
loops lose ___
calcium
so calcium is decreased
can lead to decreased bone density if used long term
what pump do thiazides inhibit
na-cl
sodium chloride pump
thiazides increase ___
calcium and have a protective effect on bones overtime
spironolactone and epleronone increase
potassium
must know! select drugs that can cause kidney disease
aminoglycosides amphotericin b cisplatin cyclosporine/tacrolimus loops NSAIDS polymyxins radiographic contrast dye vancomycin
for crcl use
actual body weight if less than IBW
IBW if normal weight by BMI
adjusted body weight if overweight by BMI
BUN is
blood urea nitrogen and measures the amount of nitrogen in the blood that comes from urea
two common lab markers for kidney function
increased BUN- but can also be a sign of dehydration
increased SCr
creatinine is a waste product of ___ metabolism
muscle
normal range for SCr
0.6-1.3
GFR is calculated using which two equations
MDRD- modification of diet in renal disease
CKD-EPI- chronic kidney disease epidemiology collaboration
____ is the primary protein that is measured in the urine to assess kidney diease
albumin
___ is sometimes referred to as proteinuria
albuminuria
aces and arbs increase what electrolyte
potassium
KDIGO
kidney disease improving global outcomes
what two things are measured to determine the degree of renal impairment
what are the levels that indicate a patient has ckd and requires specific treatments
GFR and albumin (ACR or AER)
GFR <60
Albuminuria (ACR or AER) 30 or greater
it’s important to control what two things in CKD for progression of disease
blood pressure
blood glucose
when starting tx with an ace or arb the baseline scr can increase by up to ___. this is expected and treatment should not be stopped. if scr increases by greater than ___ tx should be dc and patient will be referred to a nephrologist.
30%
30%
use an __ or __ if albuminuria is present acr or aer 30 or greater
ace or arb
basic principle of med dosing with impaired renal fx
dose adj. may be necessary when crcl is <60
when crcl is 30 or less additional adj. may be required or may be CI
renal fx
120 (normal)
60 (1/2 normal) dose adjust
30 (1/4 normal) CI/dose adjust
drugs that require decrease dose or increase interval in CKD
aminoglycosides beta lactam antibiotics (except nafcillin,oxacillin etc. and ceftriaxone) fluconazole quinolones (except moxifloxacin) vancomycin
LMWHs (enoxaparin, dalteparin)
apixaban
rivaroxaban
dabigatran
H2RAs (famotidine, ranitidine)
metoclopramide
Bisphosphonates
Lithium
drugs that are CI inCKD CRCL less than 60
macrobid
drugs that are CI inCKD CRCL less than 50
TDF products
stribild, complera, atripla, symfi, symfi lo
voriconazole IV only
drugs that are CI inCKD CRCL less than 30
TAF products
genvoya, biktarvy, descovy, odesefy, symtuza
NSAIDS
Dabigatran
Rivaroxaban
drugs that are CI inCKD GFR less than 30
SGLT2 I (canagliflozin, dapagliflozin, empagliflozin) metformin, for treated patients, do not start treatment if gfr is 45 or less
meperidine not specified
complications that need treatment in CKD
high serum phosphate
anemia
hyperparathyroidism
vit d deficency
CKD-MBD is
CKD mineral bone disorder
treatment for high serum phosphate in CKD
1) dietary phosphate restriction
2) phosphate binders
how are phosphate binders taken
prior to each meal
they bind phosphate from meals in the intestine
if meal is skipped phosphate binder should be ___
skipped
3 types of phosphate binders
1 aluminum based
2 calcium based (first line)
3 aluminum free-calcium free
aluminum hydroxide suspension
rarely used due to risk of aluminum accumulation
can cause nervous system and bone toxicity
“dialysis dementia”
aluminum hydroxide suspension is a ___ that is limited to how long of a treatment duration
phosphate binder
4 weeks
calcium based phosphate binders are ___ ___
what are the two examples
first line
calcium acetate and calcium carbonate
calcium acetate brands
phoslyra, phosLo
calcium carbonate brands
tums
SEs with calcium based phosphate binders
hypercalcemia, consipation
what binds more dietary phosphorus calcium acetate or carbonate
acetate
what vitamin increases the risk of hypercalemia when taking calcium
vitamin d
sucroferric oxyhydroxide (velphora) ferric citrate (auryxia) what are these
aluminum free
calcium free
phosphate binders
no aluminum accumulation
less hypercalemia
but more expensive
*warnings: iron absorption occurs with ferric citrate
lanthanum carbonate brand name
fosrenol
fosrenol (lanthanum carbonate)
what is it
phosphate binder
aluminium free calcium free
GI obstruction! must chew tablet throughly to avoid
N/V/D/C (lots of GI)
a non aluminium non calcium baded phosphate binder that is not systemically absorbed
sevelamer carbonate (renvela) sevelamer hcl (renagel)
sevelamer (renvela) SEs
N/V/D
can lower TC and LDL by 15-30%
can reduce absorption of ADEK consider multivitamin
phosphate binders BIND so because of this they have many __, seperate administration from ___ and ___ that chelate.
DI
levothyroxine
antibiotics(quinolones, tetracyclines
calcium based phosphate binders interact with what drugs
quinolones
tetracyclines
bisphosphonates
thyroid products
in general drugs to seperate from phosphate binders are
levothyroxine
quinolones
bisphosphonates
tetracyclines
elevations in parathyroid hormone are treated primarily with
vitamin D
or calcimimetic to decrease pth
vitamin d3
cholcalciferol skin and sun
vitamin d2
ergocalciferol dietary source
what is the active form of vitamin d3
calcitriol
cinacalcet or senispar is only used in ___ patients
dialysis
what are the vitamin d analogs
calcitriol
calcifediol
doxercalciferol
paricalcitol
what do vitamin d analogs do
they increase intestinal absorption of calcium
which provides negative feedback to the parathyroid gland
and reduces elevations in pth
vit d analogs SEs
hypercalcemia, monitor calcium
sensipar causes hypo or hypercalcemia
hypo
anemia is defined as a hgb or hemoglobin level of less than
13
anemia of CKD is caused by lack of ___
epo
as kidney function declines, epo declines
esas can prevent the need for ___ in CKD
blood transfusions
esas include
epoetin alfa (procrit, epogen) darbopoetin alfa (aranesp)
longer lasting esa
aranesp (darbopoetin alfa)
risks with ESAs
high BP
thrombosis (clots)
only use ESAs when Hgb is less than
10
DC if hgb exceeds 11
ESAs require adequate ___
iron
what is a normal potassium
3.5-5
drugs that raise potassium
aces arbs aliskiren aldosterone receptor antagonists canagliflozin drosperinone containing OCs bactrim transplant drugs (cyclosporine/tacrolimus) NSAIDs
insulin causes potassium to shift
into the cells, it can treat hyperkalemia
the most common cause of hyperkalemia is decreased renal excretion due to ___ failure
kidney
patients with diabetes are at increased risk of hyperkalemia as insulin deficiency reduces the ability to shift ___ into the cells and many of these patients take aces or arbs
potassium
symptoms of hyperkalemia
muscle weakness, bradycardia, fatal arrhythmias
steps for treating hypercalemia acute/emergency
1) stabilize the heart: to prevent arrhythmias: calcium gluconate
2) move the potassium: shift it intracellulary: regular insulin, dextrose, sodium bicarb, albuterol
3) remove it: eliminate k from the body: furosemide, sodium polystyrene sulfonate
sodium polystyrene sulfonate (kayexalate)
potassium binder (non absorbed cation exchange resin) can bind other oral meds (separate)
metabolic acidosis can happen in CKD when to treat
when serum bicarb is less than 22
treat low bicarb with
sodium bicarb or sodium citrate/citric acid soln and monitor sodium level and use caution in patients with hypertention and CVD
