Renal Disease Flashcards
physiology, DIKD, CrCl, CKD, dosing, CKD complications, dialysis
proximal tubule function
Na Ca and Cl are filtered into the nephron
pH regulated with H and bicarb exchange
SGLT2 transporter is here
where do SGLT2-i work
proximal tubule
descending LOH function
water reabsorption into the blood
ascending LOH function
water reabsorption via ADH (vasopressin)
~25% Na and Cl reabsorption into blood
Ca resorption
where do loops work and on what receptor
work on the ascending LOH where they block Na K pump to prevent sodium reabsorption
also block Ca reabsorption and can cause dec MBD with time
distal convoluted tubule function
K, Na, Ca, pH regulation
~5% of Na a reabsorbed into the blood here
thiazides work here and increase Ca reabsorption and are therefore bone-protective
collecting duct function
connect kidney to ureter
H2O and electrolyte final balancing via ADH and aldosterone
MRAs work here to dec Na and H2O reabsorption without affecting K
aldosterone function
increases K excretion in collecting duct
risk factors for DIKD
dec renal BF (HF, CKD, HLD, dec BP)
inc age
nephrotoxins
what are the major nephrotoxins
AGs
Amph B
loops
vanco
cisplatin
cyclosporine
NSAIDs
polymixins
radiographic contrast dye
tacrolimus
what is the BUN
amount of nitrogen in the blood that comes from urea, a waste product of protein metabolism
as renal disease progresses, kidneys are unable to filter urea out of the blood as it should
normal <20
what is Scr
waste product of muscle metabolism
norm 0.6-1.3
what GFR is stage 3a
45-59
what GFR is stage 3b
30-44
what GFR is stage 1
> /= 90
what GFR is stage 2
60-89
what GFR is stage 5
</= 15
what GFR is stage 4
15-29
how do we delay CKD progression
treat comorbidities DM and HTN
finerenone
first line for CKD + HTN +/- hyperalbuminuria
ACE or ARB
what is the BP target for CKD and HTN
SBP <120
what is an adverse effect of ACEi/ARBs that is expected with initiation? When do we hold ACEi/ARB?
inc Scr </=30% from baseline
hold when SCr increases over 30% from baseline
first line for patients with CKD + DM
SGLT2-i
what medication prevents CKD progression? What are the criteria for starting it?
finerenone
start when on SGLT2-i and on max tolerated ACEi or ARB + eGFR 25+
which drugs require CrCl adjustments
ABX (SMX/TMP, B lactams except anti staph and CTX, AGs, fluconazole, FQ, vancomycin)
Cardiac (LMWH, xarelto for afib, xarelto for afib, dabigatran for afib, most statins)
H2RAs
others (bisphosphonates, lithium gabapentin, metformin, morphine, pregabalin, codeine)
what drug(s) are CI at CrCl <60
nitrofurantoin
what drug(s) are CI at CrCl <50
TDF
voriconazole IV
what drug(s) are CI at CrCl 30
TAF
NSAIDs
dabigatran (DVT/PE)
rivaroxaban (DVT/PE)
MRAs
duloxetine
bisphosphonates
what drug(s) are CI at eGFR <30
metformin
SGLT2i
meperidine
what are the complications of CKD
MBD
anemia of CKD
hyperkalemia
metabolic acidosis
what is considered microalbuminuria
UA 30-300
what is considered macroalbuminuria
UA >300
what are treatment options of MBD in CKD
restrict dietary phosphate
phosphate binders
calcimimetics
Vit D analogs
why do patients with MBD in CKD have inc serum phosphate, low vitamin D levels and variable Ca levels
kidney damage prevents phosphate clearance which stimulates PTH and increases bone resorption
dec EPO production decreases active Vit D production and therefore dec Ca absorption from gut –> PTH overcompensates by stimulating bone resorption to inc serum Ca
Ca levels vary due to dec GI absorption and increased Ca resorption from bone
sevelamer
brand name
MOA
dosing
ADE
Renvela
non Ca-based phosphate binder that binds phos in gut and is eliminated
800-1600mg TID W MEALS
ADE NVD :////
sevelamer is CI in
bowel obstruction
sevelamer effects on lipid panel
can decrease TG and LDL by 15-30%
what drugs does sevelamer interact with/binds them
levothyroxine
FQ
TTC
sevelamer can dec absorption of what from the gut
phos (obv)
Vitamins D E K
folic acid
what are the calcium based phosphate binders
what is the concern
ca acetate
ca carbonate
concern for hypercalcemia
what are the vitamin D analogs
MOA?
concern?
increase Ca absorption in the gut
calcitriol (Rocaltrol)
calcifediol (Rayaldee)
doxercalciferol
hypercalcemia risk?
cincalcet
brand
MOA
dosing
ADE
Sensipar
calcimimetic
30-180mg PO daily with food
hypocalcemia risk
hyperkalemia
K = _____
s/sx
K >5
s/sx : muscle weakness, bradycardia, arrhythmias
drugs that cause hyperkalemia
ACE-i
ARB
aliskerin
SMX/TMP
MRAs (aldosterone antagonists)
TPN
K supplements
NSAIDs
CYA, tacro
steps to treat hyperkalmenia
d/c sources of hyperkalemia
stabilize cardiac membranes
move it intracellularly
remove it in the gut
how do we shift K into the cell in hyperkalemia
regular insulin + dextrose to prevent hypoglycemia
sod bicarb if acidotic
albuterol
how do we remove potassium in hyperkalemia
loops
HD
SPS (Kayexalate)
SZC (Lokelma)
patiromer
lokelma
generic
dosing
administration
sodium zirconium cyclosilate
10 grams PO TID W MEALS
separate other drugs by 2 hours before and after
in 3tbsp of water each time
Kayexalate
generic
dosing
CI
administration
sodium polystyrene sulfate
15 grams PO QD-QID
CI GI necrosis
Kayexalate can cause GI necrosis especially when combined with ___________
sorbitol
what characteristics of the drug / HD / PD can increase removal by dialysis
dec MW/size
dec Vd
dec ppb
high flux (large pore size)
high efficiency (inc SA)
inc dialysis BF rate
