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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
Dose of calcium carbonate
500mg PO TID with meals
26
What should the total daily dose of elemental calcium be?
<2000 mg from diet and supplements
27
Calcium acetate brand names
Phoslyra, PhosLo
28
Calcium carbonate brand names
Tums
29
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
30
What non-calcium, non-aluminum phosphate binder is not systemically absorbed?
Sevelamer carbonate (Renvela)
31
``` 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
32
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
33
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
34
Which phosphate binder can lower total cholesterol and LDL and by how much?
``` Sevelamer carbonate (Renvela/Renagel) 15-30% ```
35
Phosphate binders should be administered separately from what 2 medications
levothyroxine | abx that chealate (quinolones, tetracyclines)
36
Calcium based phosphate binders interact with what types of medications?
Quinolones, tetracyclines, oral bisphosphonates, and thyroid products
37
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
38
Lanthanum carbonate should be separated from quinolones and levothyroine by how long?
Quinolone - take 2 hours before or 6 hours after sevelamer
39
2 drug classes for treatment of secondary hyperparathyroidism
Vitamin D analogs | Calcimimetic
40
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
41
____ is a prodrug of calcitriol?
Calcifediol (Rocaltrol)
42
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
43
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
44
What medications are Vitamin D analogs?
Calcitriol (Rocaltrol) Calcifediol (Rayaldee) Doxercalciferol (Hectorol) Paricalcitrol (Zemplar)
45
What medications are calcimimetics?
Cinacalcet (Sensipar) | Etelcalcetide (Parsabiv)
46
What are ESAs used for and what do they do?
Anemia of CKD | Promote production of red blood cells
47
What are 2 ESAs used in CKD?
``` epoetin alfa (Procrit, Epogen) darbepoetin alfa (Aranesp) - longer lasting ```
48
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)
49
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
50
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 ```
51
3 steps for treating severe hyperkalemia:
``` Stabilize the heart Move it (shift K intracellularly) Remove it (eliminate K from body) ```
52
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
53
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
54
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
55
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
56
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
57
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
58
What acid base disorder can CKD cause?
Metabolic acidosis
59
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
60
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

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