Renal Disease Flashcards
What are the two most common causes of renal disease?
diabetes and hypertension
What is an Acute Kidney Injury?
- A sudden loss in kidney function due to another condition (drugs, dehydration). Often reversible but can be permanent if not corrected
Chronic Kidney disease?
- Progressive loss of kidney function over months or years
- Measured by GFR CrCl, albuminuria
End-Stage-renal disease
Total and permenant kidney failure
dialysis required
What is the nephrons primary function?
What else does this regulate?
To control the concentration of sodium and water
Regulates blood volume–> in turn effects blood pressure
Where does a majority of Na, H2O and Cl, Ca get reabsorbed within the kidneys?
In the proximal tubule: closest to the bowmans capsule
How is blood pH regulated?
By the exchange of hydrogen and Bicarb ions
If antidiuretic hormone is present (vasopressin) what happens?
Water passes through the ascending limb and is reabsorbed into the blood reducing water excretion
What do loop diuretics do?
- inhibit the Na-K pump in the ascending limb of the Loop of Henle
- less Na is reabsorbed and increased in urine
- By blocking this pump they also limit Ca reabsorption leading to Ca depletion which can decrease bone density
What is the distal convoluted tubule responsible for?
Regulation of, Na, K, Ca, pH
What do thiazide diuretics do?
What type of effect do they have?
Na-Cl pump inhibition
Less potent compared to loops due to small amount of Na
Facilitate Ca reabsorption so actually have a bone protection effect
What is the collecting duct involved with?
water and electrolyte balance
What does aldosterone do?
works in the collecting and distal convoluted tubules to increase Na and water reabsorption
When Aldosterone antagonists are used like spironolactone or eplerenone there is an increase in Na and H20 excretion and increased serum K
10 select drugs that cause kidney disease
- NSAIDs
- Aminoglycosides
- Vancomycin
- Amphotericin B
- Cisplatin
- Cyclosporine
- Loop diuretics
- Polymyxins
- Radiographic contrast dye
- Tacolimus
As kidney function declines what happens to BUN?
BUN increases
As kidney function declines what happeneds to SCr?
- SCr increases
- Normal range is 0.6-1.3 mg/dL
Cockcroft is not recommended in what patients?
in very young children or in unstable renal function
What drugs use GFR for dosing?
SGLT2 and Metformin
What wt to use in Cockcrauft?
Use Actual body wight if < IBW, use IBW if normal weight by BMI, use adjusted if pt is overweight
What levels indicate a pt has CKD?
GFR < 60 ml/min/1.72 m2
Albuminuria ACR or AER >=30
What is first line for the prevention of progression of CKD, DM and or HTN if proteinuria is present?
ACE or ARB
ACE and ARB notes
- SCr can increase by 30% when therapy is initiated which is ok
- if > 30% med should be stopped
- They iincrease potassium which can cause hyperkalemia patients should be monitors by Scr and K 1-2 wks after initiation
What drugs need dosage adjustments or interval changes?
- Aminoglycosides increase dosing interval
- Beta-lactams (most)
- Fluconazole
- Quinolones (except moxifloxacin)
- Vancomycin
- LMWH
- Rivaroxaban
- H2RA (famotidine, ranitidine)
- Metoclopramide
- Bisphosphonates
- Lithium
- Ampho B
- Anti TB (ethambutol, pyrazinamide)
- Antivirals (acyclovir, valacy, ganciclovir, valgan, oseltamivir)
- Aztreonam
- NRTIs including tenofovir
- Polymyxins
- Bactrim
- Digoxin, disopyramide, dofetilide, procainamide, sotalol
- Apixaban
- Dabigatran
- Statins (most)
- Allopurinol
- Colchine
- gabepentin, pregabalin
- Morphine and codeine
- Tramadol ERRRR
- Cyclosporine
- Tacrolimus
- Topiramate
Drugs that are contraindicated in CKD
CrCl < 60 ml/minute
- Nitrofurantoin
<50
- Tenofovir containing products (Stribild, Complera, Atripla, Symfi, Symfi Lo
- Voriconazole IV due to the vehicle
GFR < 30
- SGLT2 flozins
- Metformin
- Other meperidine
Common CrCl cut off when looking at meds for dose adjustments?
<60 ml/min
What needs to be monitored in patients with CKD?
parathyroid PTH, phosporus, Ca, Vitamin D levels
How is hyperphosphatemia treated in CKD patients?
First dietary restrictions and then phosphate binders are likely required
If you miss a phosphate binder dose you should skip it
What are the 3 types of phosphate binders?
- Aluminum based
- Calcium-based
- aluminum free, calcium free agents
Aluminum based phosphate binders
Potent but rarely used to due to aluminum accumulations which can cause nervous system and bone toxicities
Treatment is limited to 4 wks
SIDE effects: dialysis dementia
Calcium based phosphate binders
First line:
SIde effects: Hypercalemia
Monitor Ca
Hypercalemia can be even more problematic when Vitamin D is used
Tums, PhosLo
Aluminum free calcium free binders, less side effects more expensive
Sucroferric (velphoro), Ferric citrate (Auryxia
Iron absoprtion occurs with ferric citrate and IV iron may need to be reduced
Lanthanum
Al free Ca free
SEs: N/V/D/constipation
Sevelamer
Carbonate better than hydrocholoride in maintaining bicarb
Not systemiccally aborbed phosphate binder also reduces cholesterol and LDL by 15-30%
SEs: N/V/D > 20% very common
Reduce dietary absorption of vitamins DEK and folic acid
Phosphate binder drug interactions
Separate administration of levothyroxine and antibiotics that chelate (quinolones, tetracyclines)
CKD first treat hyperphosphatemia then treat _____ with?
elevations in PTH are treated with Vitamin D
- Vit D def occurs when the kidney is unable to hydroxylate Vit D into the active form 1,5-dihydroxy Vit D
- Vit D3 cholecalciferol which is synthesized in the skin after exposure to ultraviolet light
- Vit D2: ergocalciferol produced from plant sterols PRIMARY DIETARY Source
- Active form of vitamin D3 Calcitriol (used in later stages CKD or ESRD)
- Cincacalcet: Calcimimetic mimics the action of calcium on the parathyroid gland which further reduces PTH (ONLY USED FOR PATIENTS ON Dialysis
Vitamin D analogs: 4
- Calcitriol Rocaltrol
- Calcifediol (rayaldee) ER
- Doxercalciferol (Hectorol)
- Paricalcitol (Zemplar)
SIDE effects hypercalemia
Monitor Ca
Calcimimetics
Cincacalcet (Sensipar)
Hypocalemia
Etelcalcetide (Parsabiv): warning for hypocalemia, muscle spasms, paresthesia (burning sensation on skin)
How is anemia caused in CKD?
lack of erythropoeitin which is produced by the kidneys, which causes the stimulation of the production of RBCs
What can limit the need for blood transfusions in CKD anemia
ESA
Erythropoeisis Stimulating Agents
- Epoetin Alfa (procrit,epogen) and longer lasting darbepoetin (Aranesp)
- Risks: elevated blood pressure, should only be used inf Hgb <10g/dL
- Then should be held if hgb exceeds 11
- Only works if there is enough Iron so look at iron levels
Hyperkalemia in CKD
Considered at levels > 5 mEq/L
Renal potassium is increased by aldosterone, diuretics (loop>thiazide)
Pts with DM are at an increased risk due to insulin deficiency reducing the ability to shift potassium into the cell
Key drugs that increase potassium levels 8
- ACE
- Aldosterone receptor antagonists
- Aliskeren
- ARBs
- Canagliflozin
- Drospirenone-containing COCs
- Bactrim
- Transplant drugs (cyclosporine, everolimus, tacrolimus)
Treatement of Hyperkalemia
DC in potassium agents
Stabilize the mycardial cells and to rapidly shift potassium in cells or eliminate
- Stabilize heart with calcium gluconate
- Move K into cells, regular insulin, dextrose, sodium bicarb, ALbuterol
- Remove it: Furosemide, Sodium polystyrene, Patiromer, zirconium, hemodialysis
Sodium polystyrene
SPS, kayexalate
Bind to other drugs watch DIs
Patiromer (Veltassa)
Hypomagnesia
Binds to many drugs separate by 3 hours
Not for emergency use neither is sodium zirconium
