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Renal disease and dosing considerations Flashcards

1
Q

What type of drugs are hard to filter through the kidneys

A

Large protein compounds and drugs that are bound to albumin

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2
Q

What type of drugs are hard to filter through the kidneys

A

Large protein compounds and drugs that are bound to albumin

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3
Q

Where do thiazide diuretics work

A

distal convoluted tubule

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4
Q

Where do ARA/K sparing diuretics work

A

distal convoluted tuble

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5
Q

Where do loop diuretics work

A

ascending loop of henle

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6
Q

How do loop diuretics work

A

Inhibit the Na/K pump in the ascending loop of Henle – this causes a significant increase in tubular concentration of sodium and less water reabsorption, also alters the electrical gradient causing a decrease in calcium reabsorption

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7
Q

Loop diuretics can have harmful effects on

A

the bone because of a decrease in calcium reabsorption

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8
Q

How do thiazide diuretics work

A

Inhibit the Na/Cl pump in the distal tubule, Weaker than loop diuretics because only 5% of the Na is resorbed in this portion of the nephron

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9
Q

Which diuretic has protective effects on the bones

A

Thiazide diuretics – they increase calcium absorption by affecting the calcium pump in the distal convoluted tubule

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10
Q

What is the primary function of aldosterone in the kidney

A

Increase Na and water retention and lowers K

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11
Q

Spironolactone and eplerenone work by

A

Blocking aldosterone in the collecting duct and the distal convoluted tubule and increase serum potassium

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12
Q

What does BUN stand for and what does it measure

A

BUN – blood urea nitrogen, Amount of nitrogen that comes from urea, a waste product

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13
Q

What other factors can affect the levels of BUN

A

Renal function and hydration

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14
Q

As renal function decreases, creat concentration

A

increases

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15
Q

When is eGFR accuracy limited

A

People with very high or very low muscle mass, obese, liver disease, pregnant or other conditions that cause abnormal muscle turnover

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16
Q

When is Cockcroft-gault not preferable for estimating renal function in order to adjust drug dose

A

Young children
End-stage renal disease
Rapidly fluctuating renal function

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17
Q

Beta-lactams are dosed based on

A

Time above the minimum inhibitory concentration, time-dependent killing properties

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18
Q

Aminoglycosides are dosed based on

A

Extended interval dosing, concentration depending bacterial killing, rely on achieving specific peak concentrations

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19
Q

Quinolones are dosed based on

A

Extended interval dosing, concentration dependent bacterial killing, rely on achieving a specific peak concentration

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20
Q

What are two types of patients who need renal protection using ACE/ARBs

A

Diabetic patients

Patients with proteinuria

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21
Q

Goal blood pressure in kidney disease with no proteinuria

A
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22
Q

Goal blood pressure in kidney disease with proteinuria

A
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23
Q

What are 3 benefits of ace/arbs

A

Preserve renal function
Reduce proteinuria
Provide cardiovascular protection

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24
Q

How do ace/arbs work

A

Inhibit renin-angeotensin-aldosterone system (RAAS) causing efferent arteriolar dialation

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25
ACE/ARBs may cause what during initiation of treatment
30% rise in serum creatinine Do not stop therapy unless the rise is greater than 30% hyperkalemia
26
Monitoring parameters for a patient on ace/arbs
Serum creatinine Potassium Monitor 1-2 wks after initiating ace/arbs if patient has ckd
27
List the drugs that start with A/B/C that should not be used in renal impairment
Avanafil Bisphosphonates Chlorpropamide Cidofovir
28
List the drugs that start with D that should not be used in renal impairment
Dabigatran Dofetilide Duloxetine
29
List the drugs that start with F that should not be used in renal impairment
Fondaparinux | Foscarnet
30
List the drugs that start with G/L/M that should not be used in renal impairment
Glyburide Lithium Meperidine Metformin
31
List the drugs that start with N/P/R that should not be used in renal impairment
a. Nitrofurantoin b. NSAIDs c. Potassium-sparing diuretics d. Ribavirin e. Rivaroxaban
32
List the drugs that start with S/T/V that should not be used in renal impairment
a. Sotalol b. Tadalafil c. Tenofovir d. Tramadol ER e. Voriconazole IV
33
Where is erythropoietin produced
kidneys
34
what does erythropoietin do?
Stimulates production of reticulocytes (in mature red blood cells) in the bone marrow
35
How does a patient get anemia of chronic kidney disease
As kidney function declines, the production of erythropoietin declines causing anemia
36
Explain the treatment of anemia in CKD
Combination of erythropoiesis-stimulating agents and iron supplementation - IV iron is preferred over oral if patient is on hemodialysis and sometimes other pts with CKD d/t poor GI absorption in CKD
37
Patients on erythropoietin-stimulating agents and correction of hemoglobin
Do not correct to normal for patients with CKD (generally lower with CKD) d/t increased risk of CVD, stroke and death
38
What is the initial treatment of hyperphosphatemia
Restricting dietary phosphorus | Avoid dairy, cola, chocolate, and nuts
39
What happens if a patient misses a dose of a phosphate binder
Once food is already absorbed, the dose should be skipped and the patient should resume normal dosing at the next meal or snack
40
Aluminum based phosphate binders
Potent but can accumulate in ckd Toxic to nervous system and bone May lead to dialysis dementia Should only be used, if at all
41
Calcium based phosphate binders
Effective first line agents in ckd | Dose limiting effect is hypercalcemia, problematic for patients taking vit D which increase calcium absorption
42
Iron based phosphate binders
Utilize iron as the cation to bind phosphorus in the gut
43
Aluminum-free calcium-free agents
Effective at controlling phosphorus Do not contain aluminum and calcium, don’t cause problems with excess albumin load and less problem with excess calcium load Not expensive
44
Where do thiazide diuretics work
distal convoluted tubule
45
Where do ARA/K sparing diuretics work
distal convoluted tuble
46
Where do loop diuretics work
ascending loop of henle
47
How do loop diuretics work
Inhibit the Na/K pump in the ascending loop of Henle – this causes a significant increase in tubular concentration of sodium and less water reabsorption, also alters the electrical gradient causing a decrease in calcium reabsorption
48
Loop diuretics can have harmful effects on
the bone because of a decrease in calcium reabsorption
49
How do thiazide diuretics work
Inhibit the Na/Cl pump in the distal tubule, Weaker than loop diuretics because only 5% of the Na is resorbed in this portion of the nephron
50
Which diuretic has protective effects on the bones
Thiazide diuretics – they increase calcium absorption by affecting the calcium pump in the distal convoluted tubule
51
What is the primary function of aldosterone in the kidney
Increase Na and water retention and lowers K
52
Spironolactone and eplerenone work by
Blocking aldosterone in the collecting duct and the distal convoluted tubule and increase serum potassium
53
What does BUN stand for and what does it measure
BUN – blood urea nitrogen, Amount of nitrogen that comes from urea, a waste product
54
What other factors can affect the levels of BUN
Renal function and hydration
55
As renal function decreases, creat concentration
increases
56
When is eGFR accuracy limited
People with very high or very low muscle mass, obese, liver disease, pregnant or other conditions that cause abnormal muscle turnover
57
When is Cockcroft-gault not preferable for estimating renal function in order to adjust drug dose
Young children End-stage renal disease Rapidly fluctuating renal function
58
Beta-lactams are dosed based on
Time above the minimum inhibitory concentration, time-dependent killing properties
59
Aminoglycosides are dosed based on
Extended interval dosing, concentration depending bacterial killing, rely on achieving specific peak concentrations
60
Quinolones are dosed based on
Extended interval dosing, concentration dependent bacterial killing, rely on achieving a specific peak concentration
61
What are two types of patients who need renal protection using ACE/ARBs
Diabetic patients | Patients with proteinuria
62
Goal blood pressure in kidney disease with no proteinuria
less than 140/90
63
Goal blood pressure in kidney disease with proteinuria
less than 130/90
64
What are 3 benefits of ace/arbs
Preserve renal function Reduce proteinuria Provide cardiovascular protection
65
How do ace/arbs work
Inhibit renin-angeotensin-aldosterone system (RAAS) causing efferent arteriolar dialation
66
ACE/ARBs may cause what during initiation of treatment
30% rise in serum creatinine Do not stop therapy unless the rise is greater than 30% hyperkalemia
67
Monitoring parameters for a patient on ace/arbs
Serum creatinine Potassium Monitor 1-2 wks after initiating ace/arbs if patient has ckd
68
List the drugs that start with A/B/C that should not be used in renal impairment
Avanafil Bisphosphonates Chlorpropamide Cidofovir
69
List the drugs that start with D that should not be used in renal impairment
Dabigatran Dofetilide Duloxetine
70
List the drugs that start with F that should not be used in renal impairment
Fondaparinux | Foscarnet
71
List the drugs that start with G/L/M that should not be used in renal impairment
Glyburide Lithium Meperidine Metformin
72
List the drugs that start with N/P/R that should not be used in renal impairment
a. Nitrofurantoin b. NSAIDs c. Potassium-sparing diuretics d. Ribavirin e. Rivaroxaban
73
List the drugs that start with S/T/V that should not be used in renal impairment
a. Sotalol b. Tadalafil c. Tenofovir d. Tramadol ER e. Voriconazole IV
74
Where is erythropoietin produced
kidneys
75
what does erythropoietin do?
Stimulates production of reticulocytes (in mature red blood cells) in the bone marrow
76
How does a patient get anemia of chronic kidney disease
As kidney function declines, the production of erythropoietin declines causing anemia
77
Explain the treatment of anemia in CKD
Combination of erythropoiesis-stimulating agents and iron supplementation - IV iron is preferred over oral if patient is on hemodialysis and sometimes other pts with CKD d/t poor GI absorption in CKD
78
Patients on erythropoietin-stimulating agents and correction of hemoglobin
Do not correct to normal for patients with CKD (generally lower with CKD) d/t increased risk of CVD, stroke and death
79
What is the initial treatment of hyperphosphatemia
Restricting dietary phosphorus | Avoid dairy, cola, chocolate, and nuts
80
What happens if a patient misses a dose of a phosphate binder
Once food is already absorbed, the dose should be skipped and the patient should resume normal dosing at the next meal or snack
81
Aluminum based phosphate binders
Potent but can accumulate in ckd Toxic to nervous system and bone May lead to dialysis dementia Should only be used, if at all
82
Calcium based phosphate binders
Effective first line agents in ckd | Dose limiting effect is hypercalcemia, problematic for patients taking vit D which increase calcium absorption
83
Iron based phosphate binders
Utilize iron as the cation to bind phosphorus in the gut
84
Aluminum-free calcium-free agents
Effective at controlling phosphorus Do not contain aluminum and calcium, don’t cause problems with excess albumin load and less problem with excess calcium load Not expensive

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