Renal disease and dosing considerations Flashcards
What type of drugs are hard to filter through the kidneys
Large protein compounds and drugs that are bound to albumin
What type of drugs are hard to filter through the kidneys
Large protein compounds and drugs that are bound to albumin
Where do thiazide diuretics work
distal convoluted tubule
Where do ARA/K sparing diuretics work
distal convoluted tuble
Where do loop diuretics work
ascending loop of henle
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
Loop diuretics can have harmful effects on
the bone because of a decrease in calcium reabsorption
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
Which diuretic has protective effects on the bones
Thiazide diuretics – they increase calcium absorption by affecting the calcium pump in the distal convoluted tubule
What is the primary function of aldosterone in the kidney
Increase Na and water retention and lowers K
Spironolactone and eplerenone work by
Blocking aldosterone in the collecting duct and the distal convoluted tubule and increase serum potassium
What does BUN stand for and what does it measure
BUN – blood urea nitrogen, Amount of nitrogen that comes from urea, a waste product
What other factors can affect the levels of BUN
Renal function and hydration
As renal function decreases, creat concentration
increases
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
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
Beta-lactams are dosed based on
Time above the minimum inhibitory concentration, time-dependent killing properties
Aminoglycosides are dosed based on
Extended interval dosing, concentration depending bacterial killing, rely on achieving specific peak concentrations
Quinolones are dosed based on
Extended interval dosing, concentration dependent bacterial killing, rely on achieving a specific peak concentration
What are two types of patients who need renal protection using ACE/ARBs
Diabetic patients
Patients with proteinuria
Goal blood pressure in kidney disease with no proteinuria
Goal blood pressure in kidney disease with proteinuria
What are 3 benefits of ace/arbs
Preserve renal function
Reduce proteinuria
Provide cardiovascular protection
How do ace/arbs work
Inhibit renin-angeotensin-aldosterone system (RAAS) causing efferent arteriolar dialation
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
Monitoring parameters for a patient on ace/arbs
Serum creatinine
Potassium
Monitor 1-2 wks after initiating ace/arbs if patient has ckd
List the drugs that start with A/B/C that should not be used in renal impairment
Avanafil
Bisphosphonates
Chlorpropamide
Cidofovir
List the drugs that start with D that should not be used in renal impairment
Dabigatran
Dofetilide
Duloxetine
List the drugs that start with F that should not be used in renal impairment
Fondaparinux
Foscarnet
List the drugs that start with G/L/M that should not be used in renal impairment
Glyburide
Lithium
Meperidine
Metformin
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
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
Where is erythropoietin produced
kidneys
what does erythropoietin do?
Stimulates production of reticulocytes (in mature red blood cells) in the bone marrow
How does a patient get anemia of chronic kidney disease
As kidney function declines, the production of erythropoietin declines causing anemia
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
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
What is the initial treatment of hyperphosphatemia
Restricting dietary phosphorus
Avoid dairy, cola, chocolate, and nuts
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
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
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
Iron based phosphate binders
Utilize iron as the cation to bind phosphorus in the gut
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
Where do thiazide diuretics work
distal convoluted tubule
Where do ARA/K sparing diuretics work
distal convoluted tuble
Where do loop diuretics work
ascending loop of henle
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
Loop diuretics can have harmful effects on
the bone because of a decrease in calcium reabsorption
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
Which diuretic has protective effects on the bones
Thiazide diuretics – they increase calcium absorption by affecting the calcium pump in the distal convoluted tubule
What is the primary function of aldosterone in the kidney
Increase Na and water retention and lowers K
Spironolactone and eplerenone work by
Blocking aldosterone in the collecting duct and the distal convoluted tubule and increase serum potassium
What does BUN stand for and what does it measure
BUN – blood urea nitrogen, Amount of nitrogen that comes from urea, a waste product
What other factors can affect the levels of BUN
Renal function and hydration
As renal function decreases, creat concentration
increases
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
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
Beta-lactams are dosed based on
Time above the minimum inhibitory concentration, time-dependent killing properties
Aminoglycosides are dosed based on
Extended interval dosing, concentration depending bacterial killing, rely on achieving specific peak concentrations
Quinolones are dosed based on
Extended interval dosing, concentration dependent bacterial killing, rely on achieving a specific peak concentration
What are two types of patients who need renal protection using ACE/ARBs
Diabetic patients
Patients with proteinuria
Goal blood pressure in kidney disease with no proteinuria
less than 140/90
Goal blood pressure in kidney disease with proteinuria
less than 130/90
What are 3 benefits of ace/arbs
Preserve renal function
Reduce proteinuria
Provide cardiovascular protection
How do ace/arbs work
Inhibit renin-angeotensin-aldosterone system (RAAS) causing efferent arteriolar dialation
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
Monitoring parameters for a patient on ace/arbs
Serum creatinine
Potassium
Monitor 1-2 wks after initiating ace/arbs if patient has ckd
List the drugs that start with A/B/C that should not be used in renal impairment
Avanafil
Bisphosphonates
Chlorpropamide
Cidofovir
List the drugs that start with D that should not be used in renal impairment
Dabigatran
Dofetilide
Duloxetine
List the drugs that start with F that should not be used in renal impairment
Fondaparinux
Foscarnet
List the drugs that start with G/L/M that should not be used in renal impairment
Glyburide
Lithium
Meperidine
Metformin
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
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
Where is erythropoietin produced
kidneys
what does erythropoietin do?
Stimulates production of reticulocytes (in mature red blood cells) in the bone marrow
How does a patient get anemia of chronic kidney disease
As kidney function declines, the production of erythropoietin declines causing anemia
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
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
What is the initial treatment of hyperphosphatemia
Restricting dietary phosphorus
Avoid dairy, cola, chocolate, and nuts
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
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
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
Iron based phosphate binders
Utilize iron as the cation to bind phosphorus in the gut
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
