Renal disease and Dosing consideration Flashcards
what five factors determine the dialyzability of a drug?
molecular size (MW) protein binding volume of distribution (VD) plasma clearance Dialysis membrane
what does the level of albumin in the urine tell you?
it can be used to gage the severity of kidney damage in patients w/ kidney disease or nephropathy
what is creatinine?
a waste product of muscle metabolism
what is BUN?
the ammount of nitrogen that comes from the waste product UREA. Higher BUN: more renal impairment (can also be affeccted by level of hydration)
what mainly happens in the proximal tubule?
water, Na+, cl- reabsorption. Some exchange of H+ and HCO3- ions here
what is the MOA of the LOOP diuretics?
the inhibit the Sodium potassium pump of the ascending loop of Henle . Sodium reabsorpiton is interrupted, meaning less water is absorbed. Also less calcium is absorbed
what is the MOA of thiazide diuretics?
they inhibit the Na-Cl pump in the distal tubule.
what explains a positive benefit for thiazides at the distal tubule?
They also increase calcium absorption here (leading to protective bone effect)
where is the MOA of potassium sparing diuretics?
thye were in the collecting duct by blocking the abosorption of Na and water by aldosterone. They also lead to potassium retention there.
renal function stage 1
clcr > 90
renal function stage 2
clcr 60-89
renal function stage 3
clcr: 30-59
renal function stage 4
clcr 15-29
renal function stage 5
clcr < 15
what are the side effects of gabapentin?
Dizziness and somnolence
what is metoclopramide used for?
nausea and poor GI motility
which patients should receive ACE/ARBS for kidney protection?
those patients w/ proteinuria
what is the goal blood pressure in patients w/ kidney disease?
<130/80
how do ACE/ARBs provide a kidney protective benefit?
they cause efferent artiolar dilation (less pressure in the kidney and blood the Renin Angiotension alsdosterone system): decrease blood pressure: less kidney damage
what lab marker is expected to increase w/ ACE arbs and how much? should you stop the medicine?
expect to have a 30% increase in Serum Createnine. Dont stop uless it goes higher than 30%increase
also expect increase in potassium
after starting ACE/ARB, when should you check a Scr and K
1-2 weeks after starting or changing the dose
what is the function of erythropoeitin?
production of reticulocytes in the bone marrow (blood production)
if a patient has a CKD stage 3 or more, what recommnded CA x pO4 number
<55 or you get precipitation in the blood
what are the three main types of phosphate binders?
aluminum based agents (not currently used)
calcium based agents : calcium acentatie and carbonate)
non-calcium/non-aluminum
what is the firt line agents for hyperphosphatemia?
calcium acetate or calcium carbonate
which are the most expesnive phosphate binders?
the ones that do not contain calcium or aluminum
how do phophate binders work?
they bind meal-time phosphate. So must be taken with food
what are the aluminum phophate binders?
aluminum hydroxide
max time to use aluminum phosphate binders? why?
4 weeks because of risk of accumulation and toxicity
dose of aluminum hydroxide
300mg po TID w/ meals
600mg po tid w/ meals
side effects of Alumin hydroxide
constipation
poor taste
nausea
osteomalacia
brand calcium acetate?
phoslo, phoslyra
brand calcium carb?
tums
calcium carbonate dose for phosphate binding
500mg po tid w/ meals
calcium acetate dose for phospate binding ?
667-1334 mg po tid w/ meals
side effect of calcium phophate binders?
constipation
hypercalcemia
nausea
which calcium phospahte binder binds more phosphate?
calcium acetate
name two non-calcium/non aluminum phosphate binders?
lantahmum carbonate
sevelamer (carbonate vs hydrochloride)
brand lanthanum?
fosrenol
counseling point on administration of lanthanum?
musht chew tablets thoroughly
side effects of lanthanum?
N,V
abd pain
constipation / diarrhea
contrainidations for lanthanum?
bowel obstruction
fecal impaction
ileus
whats an additional benefit of sevelamer?
can loswer TC and LDL by 15-30%
advantage of sevelamer carbonate over sevelamer hydrochloride?
can mainatina bicarbonate concentrations
brand sevelamer Carbonate
renvela
brand sevelamer HCL
renagel
contrindications for sevelamer
bowel obstruction
SE sevelamer
N,V,
constipation/diarrhea
abd pain
what is the active form of vitamin D3 called (brand and generic)
calcitriol (rocaltrol)
what is the function of vitamin d3 (calcitrol)
increase calcium absorption in the gut
raise serum calcium concentration
inhibit PTH secretion
where does vitamin D3 come from?
conversion in skin from the sun
where does vitamin D2 come from
from eating palnts
what is the dose for calicitriol CKD dose?
0.25mcg po TIW to daily
brand calcitriol
rocaltrol
calcijex
brand doxercalciferol
hectorol
doxercaliciferol ckd dose
1mc po tiW to qd
paricalcitol brand
zemplar
paricalcitol dose ckd
1mct po tiw to qd
Vitamin D3 and analogs Side effects
hypercalcemia
hyperphohatemia
NVD
contraindications to VIT d therapy
hypercacemia
vitamin D toxicity
how can you prevent N/V/D w/ vitamin D
take w/ food
what is the MOA of cinacalcet?
mimetic of calcium activeting the PTH receptor
what are the two treatment for hyperparathyroidism (secondary)?
Vitamin D (calcitrioll, doxercalciferol, paricalcitol) Cinacalcet
what are the side effects of cinacalcet?
hypocalcemia
NVD
duration of treatement for vitamin D deficiency in CKD?
6 months
vitamin D3 dose for vitamin d deff in ckd
2000 IU po qd
vitamin D2 dose for vit def in CKD?
level < 5: 50,000 u po q week x 12 weeks, then every month
5-15: 50,000 U po q w x 4 weeks, then every month
16-30 : 50, 000 U po Q month
normal potassium level
3.5-5.o mEQ/L
which type sof medications mostly leed to hypokalemia?
diuretics (excetp potassium sparing)
aldosterone
what is the effect of insulin to potassium?
it causes potassium to shift into the cells
whats the most common cause of hyperkalemia?
renal failure leading to less excrtion or due to medcaitons
which meds increas potassium?
ACEI /ARBs NSAIDS K+ sparing diuretics OC w/ drospirenone cyclosporine/tacrolimus SMX/TMP K supplements Potassium if IV fluids like TPN
what are the consequences of hyperkalemia?
muscle weakness
bradycardia
fatal arrhythmias
when should you administer IV calcium in hyperkaelmia?
if the ECG shows cardiac instability
what are the quick active agents can give to treat hyperkalemia?
insulin and glucose (drive k into cells) Albuterol if metbolic acidoses HCO3 rectal SPS (works in 2 hours)
how much can kayexaelate lower Potassium by?
2mEQ/L in 2 hours
generic kayexelate?
sodium polystyrene sulfonate
longer term tx for hyperkalemia?
SPS
furosemide (diuretics)
fludrocortisone (florinef)
treatment of metabolic acidosis
soidum bicarb
soitium citrate/citric acid
when do you start tx for metabolic acidosis in an ambulatory care setting?
when bicarb is < 22mEq/L
what dose to use for sodium vicar in metabolic acidosis cod?
1-2 tabs po 1-3 times per day
SE of NaHCO3?
NVD
increased sodium
contraindications of nahco3
hypernatremia hypocalcemia pulmonary edema alkalosis Caution w/ HTN, CVD and fluid problems
moa of sodium citrate?
nnetds to be metabolized by the liver to bicarrbonated to work
when to take sodium citarted and whhy?
take after meals to avoid laxiative effect
