Renal Disease Flashcards
A patient who was receiving enalapril and spironolactone developed renal insufficiency secondary to acute febrile illness with vomiting and diarrhea. Fluid resuscitation is begun and an ECG is obtained in the emergency department, which demonstrates changes consistent with hyperkalemia. What should be administered immediately to this patient to prevent potentially fatal cardiac arrhythmias?
Answer
A Albuterol B Sodium bicarbonate C Dextrose D Calcium gluconate E Kayexalate
D. Calcium gluconate
In situations where the serum potassium is high enough to affect cardiac conduction, calcium (either as chloride or gluconate) should be administered intravenously immediately.
Which of the following drugs can be given to a patient with a GFR of 25?
Answer
A Invokana B Stribild C Metformin D Zosyn E Meperidine
D. Zosyn
Refer to the 2017 RxPrep Course Book, page 334. Meperidine should be avoided in renal impairment. The GFR cutoff is not defined, however, a GFR of 25 is significantly reduced, making meperidine a suboptimal choice.
Many drugs are renally cleared and must have their doses adjusted if significant renal impairment is present. Drugs that require adjustment in renal impairment include: (Select ALL that apply.)
Answer
A Enoxaparin B Gentamicin C Dabigatran D Voriconazole E Fluconazole
Enoxaparin, Gentamicin, Dabigatran, Fluconazole
Demadex and other loop diuretics inhibit sodium reabsorption in the which part of the kidney?
thick ascending limb of the Loop of Henle.
Which of the following statements concerning vitamin D supplementation in chronic kidney disease (CKD) is correct?
Answer
A
Calcitriol (Rocaltrol) is the active form of vitamin D2.
B
The newer vitamin D analogs such as doxercalciferol and paricalcitol are associated with higher degrees of hypercalcemia, which makes them of little use.
C
Vitamin D3 is ergocalciferol.
D
Vitamin D works to decrease calcium levels, which in turn decreases parathyroid hormone release.
E
Vitamin D supplementation is often required in renal disease, but results in increased dietary calcium absorption, which can be harmful.
E
Vitamin D supplementation is often required in renal disease, but results in increased dietary calcium absorption, which can be harmful.
Calcitriol (Rocaltrol) is the active form of vitamin D3, which is cholecalciferol. Vitamin D2 is ergocalciferol. The newer vitamin D analogs such as doxercalciferol and paricalcitol are associated with LOWER degrees of hypercalcemia, which can be beneficial. See figure on page 335 of the 2017 RxPrep Course Book.
Which of the following statements concerning acid-base disturbances associated with chronic kidney disease (CKD) are correct? (Select ALL that apply.)
Answer
A
The kidneys’ ability to generate bicarb decreases as CKD progresses.
B
The decrease in bicarb can lead to metabolic acidosis.
C
Agents to replace bicarb include sodium bicarbonate (Neut) and Bicitra.
D
Sodium level should be monitored closely when using Neut or Bictra to avoid fluid overload that can exacerbate hypertension and heart failure.
E
Neut can cause diuresis.
A
The kidneys’ ability to generate bicarb decreases as CKD progresses.
B
The decrease in bicarb can lead to metabolic acidosis.
C
Agents to replace bicarb include sodium bicarbonate (Neut) and Bicitra.
D
Sodium level should be monitored closely when using Neut or Bictra to avoid fluid overload that can exacerbate hypertension and heart failure.
Many drugs must be “dose-adjusted” with renal impairment. Which of the following agents require adjustment with impaired renal function? (Select ALL that apply.)
Answer
A Cefazolin B Ceftriaxone C Vancomycin D Linezolid E Moxifloxacin
A Cefazolin C Vancomycin Refer to the 2018 RxPrep Course Book, page 341. Moxifloxacin and ceftriaxone are class exceptions-the other quinolones and most other beta-lactams require renal dosage adjustment.
TH is a 57 year old male who presents to the ED on January 12 by ambulance with decreased level of consciousness. He was found next to his bed by his daughter, who came to check on him after a call from the dialysis center that he had missed 2 sessions. She had spoken to him 2 days prior, when he told her he had been to the doctor and gotten a prescription for Tamiflu.
Past Medical History: End stage renal disease (anuric), hemodialysis on MWF for 3.5 hours each session; hypertension and restless leg syndrome
Medications:
Ropinirole 0.5 mg PO daily
Diovan 160 mg PO daily
Calcium acetate 667 mg 2 capsules PO TID with meals
Calcitriol 0.5 mg PO daily
Procrit 10,000 units 3x/week on hemodialysis
Tamiflu 30 mg PO daily x 5 days (started 2 days prior to admission)
Allergies: Captopril (cough), peanuts (hives, stopped breathing)
Vitals: Height: 5'8" Weight: 198 lbs BP: 98/57 mmHg HR: 111 BPM RR: 26 BPM Temp: 100.4ºF Pain: 1/10
Tests:
ECG shows peaked T-waves, widened QRS interval.
Chest X-ray: cardiac enlargement, thin bilateral pleural effusions
Labs (1/12):
GLU (65 - 99 mg/dL) 112
Na (135 - 145 mEq/L) 141
K (3.5 - 5 mEq/L) 6.7
Cl (95 - 103 mEq/L) 100
HCO3 (24 - 30 mEq/L) 20
BUN (7 - 20 mg/dL) 30
SCr (0.6 - 1.3 mg/dL) 12.1
Mg (1.3 - 2.1 mEq/L) 1.9
PO4 6.2 (2.3 - 4.7 mg/dL) 6.2
Ca (8.5 - 10.5 mg/dL) 12.5
AST (10 - 40 units/L) 48
ALT (10 - 40 units/L) 42
Question
Due to his life-threatening condition, the nephrologist has ordered several medications. A new nurse has called the pharmacy, unsure about which to medication to give first. Which of the following represents the order in which the medications should be given?
Answer
A
Sodium polystyrene sulfonate (SPS), sodium bicarbonate, regular insulin plus D50W, calcium gluconate
B
Calcium gluconate, regular insulin plus D50W, sodium bicarbonate, SPS
C
Calcium gluconate, regular insulin plus D0W, sodium bicarbonate, SPS, furosemide
D
Regular insulin plus D50W, SPS, calcium gluconate, sodium bicarbonate
E
Sodium bicarbonate, calcium gluconate, regular insulin plus D50W, SPS, furosemide
B
Calcium gluconate, regular insulin plus D50W, sodium bicarbonate, SPS
The patient’s potassium level is critical and he has ECG changes that could lead to cardiac arrest if not treated immediately. Calcium should be given immediately to stabilize the myocardium. The other medications work to push potassium intracellularly or eliminate it from the body. Furosemide will be ineffective in a patient who does not make urine. Refer to 2017 RxPrep Course Book, pages 340-342.
TH is a 57 year old male who presents to the ED on January 12 by ambulance with decreased level of consciousness. He was found next to his bed by his daughter, who came to check on him after a call from the dialysis center that he had missed 2 sessions. She had spoken to him 2 days prior, when he told her he had been to the doctor and gotten a prescription for Tamiflu.
Past Medical History: End stage renal disease (anuric), hemodialysis on MWF for 3.5 hours each session; hypertension and restless leg syndrome
Medications:
Ropinirole 0.5 mg PO daily
Diovan 160 mg PO daily
Calcium acetate 667 mg 2 capsules PO TID with meals
Calcitriol 0.5 mg PO daily
Procrit 10,000 units 3x/week on hemodialysis
Tamiflu 30 mg PO daily x 5 days (started 2 days prior to admission)
Allergies: Captopril (cough), peanuts (hives, stopped breathing)
Vitals: Height: 5'8" Weight: 198 lbs BP: 98/57 mmHg HR: 111 BPM RR: 26 BPM Temp: 100.4ºF Pain: 1/10
Tests:
ECG shows peaked T-waves, widened QRS interval.
Chest X-ray: cardiac enlargement, thin bilateral pleural effusions
Labs (1/12):
GLU (65 - 99 mg/dL) 112
Na (135 - 145 mEq/L) 141
K (3.5 - 5 mEq/L) 6.7
Cl (95 - 103 mEq/L) 100
HCO3 (24 - 30 mEq/L) 20
BUN (7 - 20 mg/dL) 30
SCr (0.6 - 1.3 mg/dL) 12.1
Mg (1.3 - 2.1 mEq/L) 1.9
PO4 6.2 (2.3 - 4.7 mg/dL) 6.2
Ca (8.5 - 10.5 mg/dL) 12.5
AST (10 - 40 units/L) 48
ALT (10 - 40 units/L) 42
Question
Because of the new infiltrate on CXR, the nephrologist wishes to start empiric antibiotics for suspected pneumonia. Orders were written for vancomycin, Zosyn, and tobramycin. Choose the best answer regarding adjustments needed for antibiotics in renal impairment?
Answer
A
The tobramycin interval should be increased to maintain an high trough concentrations.
B
Zosyn, vancomycin and tobramycin all require adjustment in a patient on hemodialysis.
C
The Zosyn dose should be increased to overcome poor distribution.
D
Vancomycin does not require renal dose or interval adjustment.
E
With tobramycin, the interval should be decreased to maintain time above AUC.
B
Zosyn, vancomycin and tobramycin all require adjustment in a patient on hemodialysis.
Tobramycin is a concentration-dependent agent so the best approach is to increase the interval to maintain peak concentrations while avoiding accumulation and toxicity. Piperacillin/tazobactam, Zosyn is a time-dependent beta-lactam antibiotic that requires dosage/interval adjustment. Vancomycin requires renal dose adjustment, which can be either the dose, the interval or both, depending on individual pharmacokinetic parameters.
Which of the following statements concerning hyperphosphatemia in chronic kidney disease (CKD) is correct? (Select ALL that apply.)
Answer
A
Limiting dietary phosphate intake is first line treatment and is usually sufficient for most patients long-term.
B
Lanthanum is a calcium-free, aluminum-free phosphate binder.
C
Calcium-based agents are cheap, work well and side effects are minor.
D
Auryxia contains ferric citrate, a form of iron that is systemically absorbed.
E
Sevelamer products (Renvela, Renagel) are aluminum-free, calcium-free phosphate binders that have the added benefit of lowering LDL cholesterol.
B
Lanthanum is a calcium-free, aluminum-free phosphate binder.
D
Auryxia contains ferric citrate, a form of iron that is systemically absorbed.
E
Sevelamer products (Renvela, Renagel) are aluminum-free, calcium-free phosphate binders that have the added benefit of lowering LDL cholesterol.
Dietary phosphate restriction is rarely sufficient in the long-term; medications are often required to reduce phosphate levels. Calcium-based agents are cheap and work well but cause hypercalcemia in many patients, particularly those who are taking vitamin D supplements, which increases gut absorption of calcium.
Which of the following statements is correct regarding vitamin D?
Answer
A
Calcitriol is used to decrease dietary phosphate absorption.
B
Cholecalciferol is synthesized in the skin with ultraviolet light exposure.
C
Vitamin D3 is the primary dietary source of vitamin D.
D
Calcitriol is the active form of vitamin D2.
E
Vitamin D analogs (paricalcitol and doxercalciferol) cause more hypercalcemia than calcitriol.
.
B
Cholecalciferol is synthesized in the skin with ultraviolet light exposure.
Calcitriol increases calcium absorption which helps inhibit PTH secretion. Cholecalciferol (vitamin D3) is synthesized in the skin. Remember cholecalciferol and calcitriol start with “C” which rhymes with “3” (for D3) and you can also “see” sunlight on the skin. Ergocalciferol is vitamin D2 which is produced in plants. The vitamin D analogs are associated with less hypercalcemia than calcitriol
TR has end stage renal disease. He goes to dialysis 3 times per week for 3.5 hours per session.
Current Medications: Calcitriol 0.5 mg PO daily Renvela 1,600 mg PO TID with meals Sensipar 60 mg PO daily Ferric gluconate 125 mg IV with each dialysis session x 8 Levothroid 125 mcg PO daily Bisoprolol 5 mg PO daily TUMS TID PRN dyspepsia Nephrovite 1 tablet PO daily Question
Choose the best answer below regarding administration of TR’s medications?
Answer
A
Levothroid administration should be separated from Renvela
B
Levothroid administration should be separated from TUMS
C
Levothroid administration should be separated from both Renvela and TUMS
D
Levothroid administration should be separated from ferric gluconate
E
Calcitriol administration should be separated from ferric gluconate
C
Levothroid administration should be separated from both Renvela and TUMS
Levothyroxine should be separated from calcium (TUMS) and from phosphate binders, as absorption could be affected. The ferric gluconate is administered IV, so there is not a co-administration issue with the oral medications.
Which of the following agents requires dose adjustment with impaired renal function?
Answer
A Nafcillin B Clindamycin C Oxacillin D Metoclopramide E Tigecycline
D
Metoclopramide
GK is a 68 year old African American male with chronic kidney disease due to a long history of uncontrolled hypertension. He presents to his primary care provider for a routine check up and labs. Height 175 cm Weight 73 kg Allergies NKA 8/7 Value (Normal) Glucose 88 (65-99 mg/dL) Sodium 140 (135-145 mEq/L) Potassium 4.8 (3.5-5 mEq/L) Chloride 100 (95-103 meq/L) HCO3 26 (24-30 mEq) BUN 24 (7-20 mg/dL) Creatinine 2.8 (0.6-1.3 mg/dL) Magnesium 2.0 (1.3-2.1 mEq/L) Phosphate 4.2 (2.3-4.7 mg/dL) Calcium 9.5 (8.5-10.5 g/dL) AST 40 (10-40 units/L) ALT 38 (10-40 units/L) Urine Albumin to Creatinine Ratio (ACR) 180
Which of the following statements are accurate? (Select ALL that apply.)
Answer
A
GK has albuminuria.
B
GK should receive ACE inhibitor or ARB treatment if there are no contraindications.
C
GK’s potassium and creatinine should be monitored within the first few weeks if an ACE inhibitor or ARB is initiated.
D
GK should be encouraged to use salt substitutes to avoid excess sodium that could cause fluid overload and worsen his hypertension.
E
The patient’s blood pressure should be controlled to less than 110/70 mmHg with this degree of albuminuria.
A
GK has albuminuria.
B
GK should receive ACE inhibitor or ARB treatment if there are no contraindications.
C
GK’s potassium and creatinine should be monitored within the first few weeks if an ACE inhibitor or ARB is initiated.
A normal ACR is < 30 mg/g. All patients with albuminuria should receive treatment with an ACE inhibitor or an ARB to decrease the progression of kidney damage, even if no hypertension or diabetes is present. Monitor K and SCr after initiating an ACE inhibitor or ARB in patients with renal impairment. Avoid potassium supplements and salt substitutes. Per KDIGO, goal BP is 130/80 mmHg in patients with proteinuria (140/90 mmHg in patients without proteinuria).
HV is a 57 year old male with chronic kidney disease due to long-term overuse of ibuprofen for osteoarthritis of the knee. He was recently started on candesartan and aspirin. On a routine follow-up of his labs the following result was obtained.
4/3 Value (Normal) Glucose 107 (65-99 mg/dL) Sodium 140 (135-145 mEq/L) Potassium 6.1 (3.5-5 mEq/L) Chloride 100 (95-103 meq/L) HCO3 24 (24-30 mEq) BUN 28 (7-20 mg/dL) Creatinine 3.4 (0.6-1.3 mg/dL) Magnesium 1.8 (1.3-2.1 mEq/L) Phosphate 5.1 (2.3-4.7 mg/dL) Calcium 10.5 (8.5-10.5 g/dL) AST 47 (10-40 units/L) ALT 47 (10-40 units/L) An ECG was ordered, which revealed abnormalities including peaked T-waves. He was admitted to the hospital to be treated for hyperkalemia.
Question: Which of the following agents is not used to lower serum potassium?
Answer
A Sodium polystyrene sulfonate B Albuterol C Insulin plus dextrose D Calcium gluconate E All of the above are used to lower potassium
D
Calcium gluconate
All of the above agents are used in the treatment of hyperkalemia but calcium is not used to lower potassium; it is used to stabilize the cardiac tissue (to prevent arrhythmia).
