Renal Dx & Dosing Consideration Flashcards by Renny Oye

List drugs usually removed in dialysis?

Amikacin

Cefazolin, Cefepime, Cephalexin

Lithium

Meropenem

Tobramycin

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List factors that affect drug removal during dialysis

Molecular size

Protein binding

Vol of distribution (Vd)

Plasma clearance

Dialysis membrane

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What’s used to gauge the severity of kidney damage in pts with kidney or nephropathy?

Albumin in urine (micro or macroalbuminuria)

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What’s used as a marker of renal fxn in various estimating equations?

Conc of creatinine in the serum

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What does Blood Urea Nitrogen (BUN) measure?

Amt of nitrogen that comes from set product urea

BUN increases with renal impairment (not used independently)

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Role of loop diuretics?

Loop diuretics inhibit the Na-K pump in the ascending limb of the loop of Henle

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Common drugs that req dosage reductions or increased dosing intervals with decreased renal fxn?

Acyclovir, Valacyclovir

Allopurinol, Amantadine, Amphotericin, Aminoglycosides, Azoles,
Antiarrhythmics, Anti-TB, Azteronam

Beta-lactam antibiotics

Colchicine, Cyclosporine

Dabigatran

Famotidine, ranitidine

Gabapentin, pregabalin

Ganciclovir, Valganciclovir

NRTIs (didanosine, Lamivudine, Stavudine, Tenofovir, zidovudine)

LMWH (Enoxaparin)

Macrolides (Clarithromycin, erythromycin)

Maraviroc, Metoclopramide, Morphine and codeine

Penicillin

Quinolone antibiotics (Cipro, Levo)

Statins

SMX/TMP

Tramadol

Vancomycin

Venlafaxine, Desvenlafaxine

Zoledronic acid

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Role of Thiazide diuretics?

Inhibitors Na-Cl pump in distal tubule

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Why does long-term use of thiazides have a protective effect on bone?

Thiazides increase Ca absorption by affecting Ca pump in distal convoluted tubul

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Primary fxn of aldosterone?

Increase Na and water retention and to lower K

T4 aldosterone antagonists (Spironolactone or Eplerenone) increases serum K

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What’s the normal range of serum creatinine?

0.6 to 1.2 mg/dL

Creatinine above this range indicate kidneys aren’t functioning properly

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Common drugs that shouldn’t be used in severe renal impairment?

Avanafil

Bisphosphonates

Chlorpromazine, Cidofovir

Dabigatran, Dofetilide, Duloxetine

Fondaparinux, Foscarnet

Glyburide

Lithium

Meperidine, Metformin

Nitrofurantoin, NSAIDs

Potassium-sparing diuretics

Ribavirin, Rivaroxaban

Sotalol (Betapace AF)

Tadalafil, Tenofovir, Tramadol ER

Voriconazole IV

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Know Cockcroft-Gault equation

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How are drug regimens modified in renal impairment?

Either by reducing the dose and/or extending the dosing interval

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List risk factors for progression of CKD?

Uncontrolled HTN

Proteinuria

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Role of ACE-I or ARBs in nephropathy?

Strong evidence to support use of ACE-I or ARBs to prevent progression of nephropathy in DM and non-DM pts with Proteinuria

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ACE-I or ARBs and serum creatinine?

ACE-I or ARBs can cause a 30% rise in serum creatinine during initiation of therapy

This rise is generally acceptable and NOT a reason to stop therapy

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Recommended monitoring (1-2 wks after initiation) of ACE-I or ARBs?

Serum creatinine

Potassium

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Primary tx of secondary Hyperphosphatemia?

Restrict dietary phosphorus

Such as Diary pdts, dark colored sodas, chocolate and nuts

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Pharmacologic tx of secondary Hyperphosphatemia?

Aluminum-based agents (AlternaGel, others) - short-term use only as
Al can accumulate in CKD

Ca-based agents (calcium acetate & carbonate) - many CKD pts are on Vit. D, which raises Ca levels and can’t tolerate additional Ca

Aluminum-free, Ca-free agents. (Most expensive)

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MOA of phosphate binders?

They bind meal-time phosphate in the gut that’s coming from the diet

(If a dose is missed & food is absorbed, there’s no pork t taking it later or doubling up on next dose)

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Role of Aluminum-based pdt (Aluminum hydroxide - AlternaGel, Amphojel, others) in Hyperphosphatemia?

Most potent phosphate binder, but use limited to 4 wks due to risk of accumulation

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What’s first-line therapy for Hyperphosphatemia of CKD?

Calcium-based pdts e.g.

Calcium acetate (PhosLo, Phoslyra, others)

Calcium carbonate (Tums, Store brands)

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Agents under Aluminum-free, Ca-free agent?

Lanthanum carbonate (Fosrenol)

Howz Lanthanum carbonate (Fosrenol): Al-free, Ca-free taken?

Chewable...must chew thoroughly

Role of Sevelamer in Hyperphosphatemia?

Non-Ca, Non-Al based phosphate binder that's NOT systemically absorbed Also has benefit of lowering TC & LDL by 15-30%

Agents under Sevelamer? Which may be preferred?

Sevelamer carbonate (Renvela) - preferred Sevelamer hydrochloride (Renagel)

Tx of Vit. D deficiency and secondary Hyperparathyroidism?

After controlling Hyperphosphatemia, elevations in PTH are treated primarily thru the use of Vit. D

Types of Vit. D?

Vit. D3 or Cholecalciferol (synthesized in skin after exposure to ultraviolet light) Vit. D2 or Ergocalciferol (produced from plant sterols and is the primary dietary source of Vit. D)

What's used in pts with CKD to increase Ca absorption from gut, raise serum Ca conc and inhibit PTH secretion?

Calcitriol (Rocaltrol) - active form of Vit. D3

List agents for tx of secondary Hyperparathyroidism

Vit. D analogs - increase intestinal absorption of Ca + provide negative feedback to parathyroid gland Calcitriol (Rocaltrol, Calcijex) Doxercalciferol (Hectorol) Paricalcitol (Zemplar)

Dose of Calcitriol (Rocaltrol, Calcijex) - Vit. D analog - used in CKD?

Calcitriol 0.25 mcg PO 3 times weekly to daily

Dose of Calcitriol (Rocaltrol, Calcijex) - Vit. D analog - used in Dialysis?

0.5 - 1 mcg PO daily Or 0.5 - 4 mcg IV 3 x weekly

Dose of Doxercalciferol (Hectorol) - Vit. D analog - used in CKD?

1 mcg PO 3 x weekly to daily

Dose of Doxercalciferol (Hectorol) - Vit. D analog - used in Dialysis?

2.5 - 10 mcg PO 3 x weekly Or 1 - 4 mcg IV 3 x weekly

Dose of Paricalcitrol (Zemplar) - Vit. D analog - used in CKD?

1 mcg PO 3 x weekly to daily

Dose of Paricalcitrol (Zemplar) - Vit. D analog - used in Dialysis?

2.8 - 7 mcg IV 3 x weekly Or 2 - 4 mcg PO 3 x weekly

CI to Vit. D analogs?

Hypercalcemia Vit. D toxicity

MOA of Calcimimetic

Increased sensitivity of Ca-sensing receptor on the parathyroid gland, => reduces PTH, Ca, Phos and prevent progressive bone dx

Agent under Calcimimetic?

Cinacalcet (Sensipar)

CI to Cinacalcet (Sensipar) use?

Hypocalcemia

Tx of Vit. D deficiency when serum 25(OH) Vit. D level < 5 ng/mL?

Ergocalciferol 50,000 units PO every week x 12 wks Then 50,000 units PO monthly Total duration = 6 months

Tx of Vit. D deficiency when serum 25(OH) Vit. D level 5 - 15 ng/mL?

Ergocalciferol 50,000 units PO every week x 4 wks Then 50,000 units PO monthly Total duration = 6 months

Tx of Vit. D deficiency when serum 25(OH) Vit. D level 16 - 30 ng/mL?

Ergocalciferol 50,000 units PO monthly Total duration = 6 months

Value of normal potassium level?

3.5 - 5 mEq/L

Whats hyperkalemia (high potassium)?

K level > 5 mEq/L

What's the most abundant intracellular cation?

What increases potassium excretion?

Aldosterone Diuretics (strongly by loops, weakly by thiazides)

How does the body deal with acute rise in K?

Body releases INSULIN, which would cause K to shift into cells

Whats the most common cause of hyperkalemia?

Decreased renal excretion due to renal failure

List drugs that raise K

K-sparing diuretics ACEIs ARBs NSAIDs OCPs that contain Drospirenone (YAZ, etc) Cyclosporine Tacrolimus Heparin Canagliflozin Pentamadine SMX/TMP K supplements K present in IV fluids including TPN

Whys a DM pt at risk of hyperkalemia?

They have insulin deficiency, which reduce ability to shift K into cells (role of insulin on k) Diets are often high in Na and low in K + are on ACEIs or ARBs

Role of IV Ca in hyperkalemia?

Stabilizes the cardiac tissue (doesn't lower K, but prevents cardiotoxicity that may occur from hyperkalemia)

How do u enhance K uptake into cells in hyperkalemia?

Give Glucose (to stimulate insulin secretion) + Insulin ( given with glucose to prevent hypoglycemia) Or Beta-agonist e.g. Nebulized Albuterol Consider use of cation exchange resin, sodium polystyrene sulfonate (Kayexelate$

How's SPS (Kayexelate) given in hyperkalemia?

PO or rectally

What route of SPS (Kayexelate) is preferred for high (emergency) tx of hyperkalemia?

Rectal

SEs of SPS (Kayexelate)?

Reduced appetite N/V Constipation (less commonly diarrhea)

When's tx of metabolic acidosis initiated?

Serum bicarbonate conc < 22 mEq/L

List agents used to replace bicarbonate in metabolic acidosis of CKD?

Sodium bicarbonate tabs, granules, powder Sodium citrate/Citric acid (Bicitra, Cytra-2, Oracit, Shohl's soln)