Renal Disease Flashcards
Most common causes of CKD
diabetes and HTN
what measures are used to determine the severity of kidney disease
proteinuria and GFR
MOA of loop diuretics
inhibit the Na-K pump in the ascending loop of Henle -> less water reabsorbed
Long term use of loop diuretics effect on calcium
depletion of calcium (harmful to bone)
MOA of thiazide diuretics
inhibit the Na-Cl pump in the distal tubule
long term use of thiazide diuretics on calcium
increases calcium reabsorption - protective effect on bone
Aldosterone MOA
increase Na and water retention and decrease K in the distal tubule
Risk factors for DIKD
multiple nephrotoxic medications, baseline reduction in renal blood flow, large doses or frequent use of nephrotoxic medications, and increased age
common medications associated with DIKD
aminioglycosides, amphotericin B, cisplatin, colistimethate, cyclosporine, loop diuretics, NSAIDs, radiographic contrast dye, tacrolimus, and vancomycin
When is CrCl based estimations of kidney function limited
low or high muscle mass, obese, liver disease, pregnancy
GFR considered normal or high in CKD
90+ and kidney damage
GFR considered mild decrease in CKD
60-89 with kidney damage
GFR considered mild-moderate disease in CKD
45-59
GFR considered moderate-severe disease in CKD
30-44
GFR considered severe disease in CKD
15-29
GFR considered kidney failure in CKD
GFR category G1
90+ and kidney damage
GFR category G2
60-89 and kidney damage
GFR category G3a
45-49
GFR category G3b
30-44
GFR category G4
15-29
GFR category G5
CKD stage 1 GFR
90+ and kidney damage
CKD stage 2 GFR
60-89 and kidney damage
CKD stage 3 GFR
30-59
CKD stage 4 GFR
15-29
CKD stage 5 GFR
Normal to mild increase in measured urine albumin
measured urine albumin termed a moderate increase
30-300
a severe increase in measured urine albumin
> 300
ALbumiuria category 1
Albuminuria category 2
30-300
Albuminuria category 3
> 300
Goal BP in CKD (KDIGO)
When should ACE/ARB be stopped due to SCr increase?
> 30%
Dose reductions effect on peaks and troughs of medications
reduce peaks but maintain trough concentrations
Extending dosing intervals effect on peaks and troughs of medications
maintain peaks but reduce trough concentrations
Antimicrobials/antivirals/antifungals requiring dosage adjustments for impaired kidney function
acyclovir, valacyclovir, amantadine, amphotericin, aminoglycosides, azole antifungals, anti-tuberculosis medications ethambutol, pyrazinamide, aztreonam, beta lactams, ganciclovir, valganciclovir, maraviroc, NRTIs, polymyxins, quinolones (except moxifloxacin), SMZ/TMP, vancomycin
Cardiovascular medications that require dosage adjustments for impaired kidney function
antiarrhythmics (digoxin, disopyramide, procainamide, sotalol), dabigatran, LMWHs, Rivaroxaban, statins
Pain/gout medications that require dosage adjustments for impaired kidney function
allopurinol, colchicine, gabapentin, pregabalin, morphine, codeine, tramadol IR
GI medications that require dosage adjustments for impaired kidney function
Famotidine, ranitidine, metoclopramide
Drugs contraindicated in CrCl
chlorpropamide, cidofovir, ribavirin, voriconazole IV
Drugs contraindicated in CrCl
Avanafil, bisphosphonates, dabigatran, duloxetine, fondaparinux, NSAIDs, potassium sparing diuretics, ribavirin, rivaroxaban, tadalafil, tramadol ER, SGLT2 inhibitors
CKD patients should be screened for what abnormalities associated with CKD-MBD
PTH, phosphorus, calcium, vitamin D
treatment of secondary hyperparathyroidism in CKD
phosphate restricted diet, phosphate binders
Duration of use for aluminum based phosphate binders
4 weeks - aluminum is toxic to the nervous system and bone
which phosphate binders are used first line for hyperphosphatemia of CKD
calcium based phosphate binders
Aluminum hydroxide brand name
AlternaGEL, Amphojel,
Aluminum hydroxide dosing in hyperphosphatemia of CKD
300-600 mg TID with meals
Aluminum hydroxide side effects
constipation, poor taste, nausea, aluminum intoxication, dialysis dementia, osteomalacia
Aluminum hydroxide monitoring
Ca, PO4, serum aluminum concentrations, PTH
Calcium acetate brand name
PhosLo, Phoslyra
Calcium acetate dosing in hyperphosphatemia of CKD
667-1334 mg TID with meals
Calcium carbonate brand name
Tums
Calcium carbonate dosing in hyperphosphatemia of CKD
500 mg TID with meals
calcium based phosphate binders side effects
constipation, nausea, hypercalcemia
calcium base phosphate binders monitoring
Ca, PO4, PTH
sucroferric oxyhydroxide brand name
velphoro
sucroferric oxyhydroxide dosing for hyperphosphatemia in CKD
500 mg TID with meals
ferric citrate brand name
auryxia
ferric citrate dosing in hyperphosphatemia of CKD
2000 mg TID with meals up to 12 grams per day
side effects of sucroferric oxyhydroxide and ferric citrate
diarrhea, discolored (black) feces
monitoring for sucroferric oxyhydroxide and ferric citrate
PO4, iron, ferritin, TSAT (ferric citrate only)
Lanthnum carbonate brand name
Fosrenol
Lanthanum carbonate dosing for hyperphosphatemia of CKD
500-1000 mg TID with meals - must chew thoroughly
Contraindications for Lanthanum carbonate
Bowel obstruction, fecal impaction, ileus
Side effects of lanthanum carbonate
N/V/d, constipation, abdominal pain
Monitoring for lanthanum carbonate
Ca, PO4, PTH
Sevelamer carbonate brand name
Renvela
Sevelamer hydrochloride brand name
Renagel
Sevelamer dosing for hyperphosphatemia in CKD
800-1600 mg TID with meals
Sevelamer contraindictions
bowel obstruction
Sevelamer side effects
N/V/d (>20%), constipation, abdominal pain
Sevelamer monitoring
Ca, PO4, HCO3, Cl, PTH
treatment of elevations in PTH in CKD
controlling hyperphosphatemia, vitamin D
vitamin D3 other name
cholecalciferol
vitamin D2 other name
ergocalciferol
active form of vitamin D
calcitriol
calcitriol brand name
Rocaltrol, calcijex
Advantage of newer vitamin D analogs
less hypercalcemia than calcitriol
calcitriol dosing in CKD
0.25 mcg PO 3x/week to daily. take with food to decrease stomache upset
calcitriol dosing in dialysis
0.5-1 mcg PO daily or 0.5-4 mcg IV 3x/week. take with food to decrease stomach upset
doxercalciferol brand name
hectorol
doxercalciferol dosing in CKD
1 mcg PO 3x/week to daily
doxercalciferol dosing in dialysis
2.5-10 mcg PO 3x/week, 1-4 mcg IV 3x/week
paricalcitol brand name
Zemplar
paricalcitol dosing in CKD
1 mcg PO 3x/week to daily
paricalcitol dosing in dialysis
2.8-7 mcg IV 3x/week, 2-4 mcg PO 3x/week
Vitamin d analogs contraindications
hypercalcemia, vitamin D toxicity
vitamin D analogs side effects
N/V/d, hypercalcemia, hyperphosphatemia
vitamin D analogs monitoring
Ca, PO4, PTH
cinacalcet brand name
sensipar
cinacalcet MOA
increase sensitivity of calcium receptor on the parathyroid. decrease PTH, decrease Ca, decrease Phosphorus
cinacalcet dosing for hyperparathyrodism
30-180 mg PO daily with food - Swallow whole
contraindications to cinacalcet
hypocalcemia
cinacalcet warning
caution in patients with a history of seizures
cinacalcet side effects
hypocalcemia, N/V/d, paresthesia, fatigue, depression, anorexia, constipation, bone fractures, weakess, arthralagia, myalgia, limb pain, URTIs
cinacalcet monitoring
Ca, PO4, PTH
most common cause of hyperkalemia
decreased renal excretion due to kidney failure
drugs that raise potassium levels
ACE/ARB, aldosterone receptor antagonists, aliskiren, NSAIDs, cyclosporine, tacrolimus, everolimus, mycophenolate, glycopyrrolate, drospirenone, SMZ/TMP, chronic heparin use, canagliflozin, pentamidine
s/s of hyperkalemia
muscle weakness, bradycardia, fatal arrhythmias
3 steps for treating severe hyperkalemia
- stabilize the heart 2. move it 3. remove it
how to stabilize the heart during severe hyperkalemia
calcium gluconate IV
how to move it during severe hyperkalemia
- insulin with dextrose or glucose 2. sodium bicarbonate (if metabolic acidosis) 3. beta-agonists (albuterol)
hot to remove it during severe hyperkalemia
- loop diuretics 2. SPS or Veltassa (takes hours to days) 3. Fludrocortisone (Florinef) (if hypoaldosteronism) 4. Dialysis
Sodium polsteyrene sulfate brand names
SPS, kayexalate, kalexate, kionex
SPS dosing
PO: 15 grams 1-4x/day (DO NOT MIX with fruit juices containing K) rectal: 30-50 grams Q6H
SPS warnings
electrolyte disturbances including hypokalemia, fecal impaction, do not mix oral products with sorbitol (increased risk of GI necrosis)
SPS side effects
Hypernatremia, hypocalcemia, hypokalemia, hypomagnesemia, N/V/d, constipation
SPS monitoring
K, Mg, Na, Ca
Patiromer brand name
Veltassa
Patiromer dosing
8.4 grams PO daily with food. max 25.2 grams/day
Patiromer administration
Add veltassa packet to 30 ml of water and stir well. Add 60 ml of water and stir (will be cloudy). drink immediately. add water and drink if powder remains in cup
Patiromer warnings
give 6 hours before or after other drugs (binds), Can worsen GI motility and cause hypomagnesemia
patiromer side effects
constipation, hypomagnesemia, hypokalemia, N/d
patiromer monitoring
K, Mg
When is treatment for metabolic acidosis initiated
serum bicarbonate
Sodium bicarbonate dosing for metabolic acidosis in CKD
1-2 tabs PO 1-3x/day
sodium bicarbonate contraindications
alkalosis, hypernatremia, hypocalcemia, pulmonary edema, unknown abdominal pain
sodium bicarbonate warnings
caution in HTN, cardiovascular disease, fluid retention (Na load)
sodium bicarbonate side effects
N/V/d, hypernatremia
sodium bicarbonate monitoring
Na, HCO3
Sodium citrate/citric acid brand names
Bicitra, Cytra-2, Oracit, Shohl’s solution
Sodium citrate/citric acid dosing
10-30 ml PO with water after meals and at bedtime (chilled improves taste, timing to avoid laxative effect)
Sodium citrate/citric acid contraindications
Alkalosis, Na restricted diet, hypernatremia
Sodium citrate/citric acid side effects
N/V/d metabolic alkalosis, tetany
sodium citrate/citric acid monitoring
Na, HCO3, urinary pH
Sodium citrate/citric acid counseling note on drug interactions
avoid use with aluminum containing products
Effect of MW/size on drug removal during dialysis
smaller molecules are more readily removed
Effect of Vd on drug removal during dialysis
large Vd are less likely to be removed
Effect of Protein binding on drug removal during dialysis
highly protein bound are less likely to be removed
Effect of the membrane on drug removal during dialysis
high flux and high efficiency are more likely to remove drug
Effect of the blood flow rate on drug removal during dialysis
higher blood flow rates increase drug removal over a given time interval