Renal Disease Flashcards
Drugs < _____ daltons can pass through the glomerular capillaries into the filtrate
40,000
***if the kidneys are damaged larger particles can pass through (like albumin/RBC)
Where do SGLT2 inhibitors work in the kidney?
Proximal tubule
Where does antidiuretic hormone (ADH) or vasopressin work in the kidneys?
Descending loop of Henle
Promotes resorption of fluid into blood (anti-diuresis)
Where do loop diuretics work in the kidneys?
Ascending loop of Henle
Where do thiazide diuretics work in the kidneys?
Distal convoluted tubule
Which diuretics have an effect on bone density?
Loop - decrease bone density (decrease calcium)
Thiazide - increase bone density (increase calcium)
Where do aldosterone antagonists work?
Distal convoluted tubule and collecting duct
What are some medications that have a high incidence of kidney disease?
Aminoglycosides Amphotericin B Cisplatin Cyclosporine Loop diuretics NSAIDs Polymyxins Radiographic contrast dye Tacrolimus Vancomycin
CrCl calculation
[(140-age)/(72*SCr)] x weight (kg) x 0.85 if female
What 2 things indicate someone has CKD
GFR < 60 and/or albuminuria >30
What are the first line drugs to prevent progression of disease in patients with CKD, diabetes, and/or HTN if albuminuria is present?
ACE/ARB
Blood pressure goal for someone with CKD
if proteinuria: <130/80
if no proteinuria: <140/80
How much can an ACE or ARB transiently increase the SCr when initiated?
30% - DO NOT D/C
***if >30% discontinue
Monitoring for ACE and ARB
Potassium 1-2 weeks after initiation
ACE and ARB for albuminuria Who to give it to Why How it works What it does
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
What are some key drugs that require renal adjustments?
Antibiotics LMWH Rivaroxaban, apixiban, dabigatran (AFib only) Famotadine Metoclopramide Bisphosphonates Lithium
What are some key drugs that are contraindicated in CKD
CrCl < 60: Nitrofurantoin
CrCl < 50: Tenofovir disoproxil, voriconazole IV
CrCl < 30: Tenofovir alafenamide, NSAIDs, Dabigatran, Rivaroxaban
GFR < 30: SGLT2i, metformin
What lab tests are associated with CKD and mineral bone disorder?
High Parathyroid hormone (PTH)
High Calcium
High phosphorus
Low vitamin D levels
When are phosphate binders dosed?
With each meal! If meal is skipped, skip binder!
What are the 3 types of phosphate binders and which are first line?
Aluminum-based
Calcium-based - first line
Aluminum and Calcium free
Why are aluminum based phosphate binders rarely used?
Potent but can cause aluminum accumulation which results in nervous system and bone toxicity
Limit treatment duration to 4 weeks
Side effects/monitoring of
Aluminum hydroxide phosphate binders
SE: aluminum intoxication, osteomalacia, constipation, nausea
Monitoring: Ca, PO4, PTH, s/sx aluminum toxicity
Side effects/monitoring of
Calcium-based phosphate binders
SE: Hypercalcemia, constipation, nausea
Monitoring: calcium, PO4, PTH
Calcium acetate binds more phosphorus than calcium carbonate
Dose of calcium acetate
1334 mg PO TID with meals titrated
Dose of calcium carbonate
500mg PO TID with meals
What should the total daily dose of elemental calcium be?
<2000 mg from diet and supplements
Calcium acetate brand names
Phoslyra, PhosLo
Calcium carbonate brand names
Tums
What drugs are aluminum-free, calcium-free phosphate binders? What are their pros/cons?
Sucroferric oxyhydroxice (Velphoro), Ferric citrate (Auryxia), Lanthanum carbonate (Fosrenol), sevelamer
No aluminum accumulation, less hypercalcemia, but VERY expensive
What non-calcium, non-aluminum phosphate binder is not systemically absorbed?
Sevelamer carbonate (Renvela)
Warnings, side effects, monitoring for Sucroferric oxyhydroxide (Velphoro) and Ferric citrate (Auryxia)
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
CI, warnings, side effects, monitoring for
Lanthanum carbonate
CI: GI obstruction, fecal impactions, ileus
Warning: GI perforation
SE: N/V/D, constipation, abdominal pain
Monitoring: Ca, PO4, PTH
Warnings, side effects, monitoring for
Sevelamer
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
Which phosphate binder can lower total cholesterol and LDL and by how much?
Sevelamer carbonate (Renvela/Renagel) 15-30%
Phosphate binders should be administered separately from what 2 medications
levothyroxine
abx that chealate (quinolones, tetracyclines)
Calcium based phosphate binders interact with what types of medications?
Quinolones, tetracyclines, oral bisphosphonates, and thyroid products
Sucroferric oxyhydroxide and ferric citrate should be separated from doxycycline, ciprofloxacin, and levothyroxine by how long?
Doxy - take one hour before phosphate binder
Cipro - take two hours before phosphate binder
Do not use with levothyroxine
Lanthanum carbonate should be separated from quinolones and levothyroine by how long?
Quinolone - take 2 hours before or 6 hours after sevelamer
2 drug classes for treatment of secondary hyperparathyroidism
Vitamin D analogs
Calcimimetic
MOA, CI, warnings, SE, monitoring for
Vitamin D analog in secondary hyperparathyroidism
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
____ is a prodrug of calcitriol?
Calcifediol (Rocaltrol)
MOA, CI, warnings, SE, monitoring for
Cinacalcet
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
MOA, CI, warnings, SE, monitoring for
Etelcalcetide
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
What medications are Vitamin D analogs?
Calcitriol (Rocaltrol)
Calcifediol (Rayaldee)
Doxercalciferol (Hectorol)
Paricalcitrol (Zemplar)
What medications are calcimimetics?
Cinacalcet (Sensipar)
Etelcalcetide (Parsabiv)
What are ESAs used for and what do they do?
Anemia of CKD
Promote production of red blood cells
What are 2 ESAs used in CKD?
epoetin alfa (Procrit, Epogen) darbepoetin alfa (Aranesp) - longer lasting
When to use ESA, risks, and important clinical pearls
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)
Patients with CKD AND diabetes are at an increased risk for hyperkalemia. Why?
CKD: kidneys can not excrete potassium as readily
Diabetes: insulin can help push potassium intracellularly; in diabetes there may be a deficiency of insulin
What drugs can increase potassium?
ACE inhibitors Aldosterone receptor antagonists Aliskiren ARBs Canagliflozin Drospirenone-containing COCs Bactrim Transplant drugs (cyclosporine, everolimus, tacrolimus) Glycopyrrolate Heparin (chronic use) NSAIDs Pentamidine
3 steps for treating severe hyperkalemia:
Stabilize the heart Move it (shift K intracellularly) Remove it (eliminate K from body)
What medication is used to stabilize the heart in severe hyperkalemia
Calcium gluconate
Onset: 1-2 mins
Does not decrease total potassium, just stabilizes myocardial cells to prevent arrhythmias
What medications are used to shift potassium intracellularly in hyperkalemia?
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
What medications are used to eliminate potassium from the body?
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
Warnings, SE, Monitoring for
Sodium polystyrene sulfonate
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
Warnings, SE, Monitoring for
Patiromer (Veltassa)
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
Warnings, SE, Monitoring for
Sodium zirconium cyclosilicate (Lokelma)
Warnings: Can worsen GI motility, edema, contains sodium, can bind other drugs; separate by at least 2 hours before and after
SE: peripheral edema
What acid base disorder can CKD cause?
Metabolic acidosis
What drug characteristics affect drug removal during dialysis?
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
What dialysis factors affect drug removal during dialysis?
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
