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NAPLEX Review > Renal Disease > Flashcards

Renal Disease Flashcards

1
Q

Drugs < _____ daltons can pass through the glomerular capillaries into the filtrate

A

40,000

***if the kidneys are damaged larger particles can pass through (like albumin/RBC)

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2
Q

Where do SGLT2 inhibitors work in the kidney?

A

Proximal tubule

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3
Q

Where does antidiuretic hormone (ADH) or vasopressin work in the kidneys?

A

Descending loop of Henle

Promotes resorption of fluid into blood (anti-diuresis)

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4
Q

Where do loop diuretics work in the kidneys?

A

Ascending loop of Henle

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5
Q

Where do thiazide diuretics work in the kidneys?

A

Distal convoluted tubule

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6
Q

Which diuretics have an effect on bone density?

A

Loop - decrease bone density (decrease calcium)

Thiazide - increase bone density (increase calcium)

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7
Q

Where do aldosterone antagonists work?

A

Distal convoluted tubule and collecting duct

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8
Q

What are some medications that have a high incidence of kidney disease?

A 
Aminoglycosides
Amphotericin B
Cisplatin
Cyclosporine
Loop diuretics
NSAIDs
Polymyxins
Radiographic contrast dye
Tacrolimus
Vancomycin
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9
Q

CrCl calculation

A

[(140-age)/(72*SCr)] x weight (kg) x 0.85 if female

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10
Q

What 2 things indicate someone has CKD

A

GFR < 60 and/or albuminuria >30

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11
Q

What are the first line drugs to prevent progression of disease in patients with CKD, diabetes, and/or HTN if albuminuria is present?

A

ACE/ARB

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12
Q

Blood pressure goal for someone with CKD

A

if proteinuria: <130/80

if no proteinuria: <140/80

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13
Q

How much can an ACE or ARB transiently increase the SCr when initiated?

A

30% - DO NOT D/C

***if >30% discontinue

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14
Q

Monitoring for ACE and ARB

A

Potassium 1-2 weeks after initiation

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15
Q 
ACE and ARB for albuminuria
Who to give it to
Why
How it works
What it does
A

All patients with albuminuria
To prevent kidney disease progression
MOA: inhibits renin-angiotensin-aldosterone system (RAAS), causing efferent arteriolar dilation
Reduces pressure in the glomerulus, decreases albuminuria nad provides cardiovascular protection

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16
Q

What are some key drugs that require renal adjustments?

A 
Antibiotics
LMWH
Rivaroxaban, apixiban, dabigatran (AFib only)
Famotadine
Metoclopramide
Bisphosphonates
Lithium
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17
Q

What are some key drugs that are contraindicated in CKD

A

CrCl < 60: Nitrofurantoin
CrCl < 50: Tenofovir disoproxil, voriconazole IV
CrCl < 30: Tenofovir alafenamide, NSAIDs, Dabigatran, Rivaroxaban
GFR < 30: SGLT2i, metformin

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18
Q

What lab tests are associated with CKD and mineral bone disorder?

A

High Parathyroid hormone (PTH)
High Calcium
High phosphorus
Low vitamin D levels

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19
Q

When are phosphate binders dosed?

A

With each meal! If meal is skipped, skip binder!

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20
Q

What are the 3 types of phosphate binders and which are first line?

A

Aluminum-based
Calcium-based - first line
Aluminum and Calcium free

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21
Q

Why are aluminum based phosphate binders rarely used?

A

Potent but can cause aluminum accumulation which results in nervous system and bone toxicity
Limit treatment duration to 4 weeks

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22
Q

Side effects/monitoring of

Aluminum hydroxide phosphate binders

A

SE: aluminum intoxication, osteomalacia, constipation, nausea
Monitoring: Ca, PO4, PTH, s/sx aluminum toxicity

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23
Q

Side effects/monitoring of

Calcium-based phosphate binders

A

SE: Hypercalcemia, constipation, nausea
Monitoring: calcium, PO4, PTH
Calcium acetate binds more phosphorus than calcium carbonate

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24
Q

Dose of calcium acetate

A

1334 mg PO TID with meals titrated

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25
Q

Dose of calcium carbonate

A

500mg PO TID with meals

26
Q

What should the total daily dose of elemental calcium be?

A

<2000 mg from diet and supplements

27
Q

Calcium acetate brand names

A

Phoslyra, PhosLo

28
Q

Calcium carbonate brand names

A

Tums

29
Q

What drugs are aluminum-free, calcium-free phosphate binders? What are their pros/cons?

A

Sucroferric oxyhydroxice (Velphoro), Ferric citrate (Auryxia), Lanthanum carbonate (Fosrenol), sevelamer

No aluminum accumulation, less hypercalcemia, but VERY expensive

30
Q

What non-calcium, non-aluminum phosphate binder is not systemically absorbed?

A

Sevelamer carbonate (Renvela)

31
Q 
Warnings, side effects, monitoring for
Sucroferric oxyhydroxide (Velphoro) and Ferric citrate (Auryxia)
A

Warning: iron absorption occurrs with ferric citrate, dose reduction of IV iron may be necessary
Side effects: diarrhea, constipation, black feces
Monitoring: Iron, ferritin, TSAT (ferric citrate), PO4, PTH
*Absorption is minimal with sucroferric oxyhydroxide

32
Q

CI, warnings, side effects, monitoring for

Lanthanum carbonate

A

CI: GI obstruction, fecal impactions, ileus
Warning: GI perforation
SE: N/V/D, constipation, abdominal pain
Monitoring: Ca, PO4, PTH

33
Q

Warnings, side effects, monitoring for

Sevelamer

A

CI: bowel obstruction
Warning: can reduce diatary absorption of vitamins DEK and folic acid; tablets can cause dysphagia and get stuck in esophagus - use powder if swallowing is difficult
SE: N/V/D, dyspepsia, constipation, abdominal pain, flatulence
Monitoring: Ca, PO4, HCO3, Cl, PTH

34
Q

Which phosphate binder can lower total cholesterol and LDL and by how much?

A 
Sevelamer carbonate (Renvela/Renagel)
15-30%
35
Q

Phosphate binders should be administered separately from what 2 medications

A

levothyroxine

abx that chealate (quinolones, tetracyclines)

36
Q

Calcium based phosphate binders interact with what types of medications?

A

Quinolones, tetracyclines, oral bisphosphonates, and thyroid products

37
Q

Sucroferric oxyhydroxide and ferric citrate should be separated from doxycycline, ciprofloxacin, and levothyroxine by how long?

A

Doxy - take one hour before phosphate binder
Cipro - take two hours before phosphate binder
Do not use with levothyroxine

38
Q

Lanthanum carbonate should be separated from quinolones and levothyroine by how long?

A

Quinolone - take 2 hours before or 6 hours after sevelamer

39
Q

2 drug classes for treatment of secondary hyperparathyroidism

A

Vitamin D analogs

Calcimimetic

40
Q

MOA, CI, warnings, SE, monitoring for

Vitamin D analog in secondary hyperparathyroidism

A

MOA: increase intestinal absorption of Ca, provides negative feedback to the parathyroid gland
CI: Hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SE: hypercalcemia, hyperphosphatemia, N/V/D
Monitoring: Ca, PO4, PTH, 25-hydroxyvitamin D

41
Q

____ is a prodrug of calcitriol?

A

Calcifediol (Rocaltrol)

42
Q

MOA, CI, warnings, SE, monitoring for

Cinacalcet

A

MOA: increase sensitivity of calcium-sensing receptor on the parathyroid gland, causing lower PTH, Ca and PO4
CI: hypocalcemia
Warning: caution in patients with hx of seizures
SE: Hypocalcemia, N/V/D, parethesia, HA, fatigue, depression, anorexia, constipation, bone fracture, weakness, arthralgia, myalgia, limb pain, URTIs
Monitoring: Ca, PO4, PTH

43
Q

MOA, CI, warnings, SE, monitoring for

Etelcalcetide

A

MOA: increase sensitivity of calcium-sensing receptor on the parathyroid gland, causing lower PTH, Ca and PO4
Warning: hypocalcemia, worsening HF, GI bleeding, decreased bone turnover
SE: muscle spasms, paresthesia, N/V/D
Monitoring: Ca, PO4, PTH

44
Q

What medications are Vitamin D analogs?

A

Calcitriol (Rocaltrol)
Calcifediol (Rayaldee)
Doxercalciferol (Hectorol)
Paricalcitrol (Zemplar)

45
Q

What medications are calcimimetics?

A

Cinacalcet (Sensipar)

Etelcalcetide (Parsabiv)

46
Q

What are ESAs used for and what do they do?

A

Anemia of CKD

Promote production of red blood cells

47
Q

What are 2 ESAs used in CKD?

A 
epoetin alfa (Procrit, Epogen)
darbepoetin alfa (Aranesp) - longer lasting
48
Q

When to use ESA, risks, and important clinical pearls

A

Only use with Hgb < 10
do NOT give if Hgb >11
Increased risk for elevated blood pressure and thrombosis
Only effective if adequate iron is available to make hemoglobin (may need to supplement with IV iron)

49
Q

Patients with CKD AND diabetes are at an increased risk for hyperkalemia. Why?

A

CKD: kidneys can not excrete potassium as readily
Diabetes: insulin can help push potassium intracellularly; in diabetes there may be a deficiency of insulin

50
Q

What drugs can increase potassium?

A 
ACE inhibitors
Aldosterone receptor antagonists
Aliskiren
ARBs
Canagliflozin
Drospirenone-containing COCs
Bactrim
Transplant drugs (cyclosporine, everolimus, tacrolimus)
Glycopyrrolate
Heparin (chronic use)
NSAIDs
Pentamidine
51
Q

3 steps for treating severe hyperkalemia:

A 
Stabilize the heart
Move it (shift K intracellularly)
Remove it (eliminate K from body)
52
Q

What medication is used to stabilize the heart in severe hyperkalemia

A

Calcium gluconate
Onset: 1-2 mins
Does not decrease total potassium, just stabilizes myocardial cells to prevent arrhythmias

53
Q

What medications are used to shift potassium intracellularly in hyperkalemia?

A

Regular insulin: co administered with glucose or dextrose to prevent hypoglycemia
Dextrose: stimulates insulin secretion, but does not shift K intracellulary on its own
Sodium bicarb: Used when metabolic acidosis is present
Albuterol: monitor for tachycardia and chest pain

54
Q

What medications are used to eliminate potassium from the body?

A

Furosemide: via urine, monitor volume status
Sodium polystyrine sulfonate: do not use for acute emergencies, binds K in GI tract, may take hours or days to work
Patiromer: binds K in GI tract, not for acute or emergency uses b/c delayed onset
Sodium zirconium cyclosilicate: binds K in GI tract, not for acute or emergency uses b/d delayed onset
Hemodialysis: removes K from blood, takes several hours to set up/complete dialysis; used in conjunction with other methods

55
Q

Warnings, SE, Monitoring for

Sodium polystyrene sulfonate

A

Warnings: electrolyte disturbances, fecal impaction, GI necrosis; can bind other oral medications
SE: N/V/D, constipation
Monitoring: K, Mg, Na, Ca
Do not mix with fruit juices containing K

56
Q

Warnings, SE, Monitoring for

Patiromer (Veltassa)

A

Warnings: can worsen GI motility, hypomagnesemia; can bind to other oral meds; separate by at least 3 hours before or after other meds
SE: constipation, N/D
Monitoring: K, Mg
Store powder in refrigerator

57
Q

Warnings, SE, Monitoring for

Sodium zirconium cyclosilicate (Lokelma)

A

Warnings: Can worsen GI motility, edema, contains sodium, can bind other drugs; separate by at least 2 hours before and after
SE: peripheral edema

58
Q

What acid base disorder can CKD cause?

A

Metabolic acidosis

59
Q

What drug characteristics affect drug removal during dialysis?

A

Molecular weight/size - smaller molecules are more readily removed by dialysis
Volume of distribution - drugs with a large Vd are less likely to be removed by dialysis
Protein-binding - Highly protein-bound drugs are less likely to be removed by dialysis

60
Q

What dialysis factors affect drug removal during dialysis?

A

Membrane - high-flux (large pore size) and high-efficiency (large surface area) HD filters remove more substances than conventional/low-flux filters
Blood flow rate - higher dialysis blood flow rates increase drug removal over a given time interval

NAPLEX Review (79 decks)

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