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CDM 1 Exam 2 > Renal: Lecture 4 > Flashcards

Renal: Lecture 4 Flashcards

1
Q

Potential CKD Complications

A 
Anemia
CVD
Infection
Acidosis (Dec pH)
Mineral & bone Disorder
Fluid and Electrolyte Disturbance
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2
Q

Common complications of Stage 4/5 CKD

A

CKD Mineral bone disorder
Renal osteodystrophy
Anemia of CKD

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3
Q

CKD-MBD biochemical abnormalities

A

Alterations in serum phosphorus, ca, PTH, and 25(OH)D (inactive form)

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4
Q

Reduced renal mass causes…

A

reduced serum natural and active Vitamin D
Reduced serum calcium
Increased serum phosphate
Increased serum PTH

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5
Q

Vascular calcification leads to….

A

CVD

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6
Q

Bone disease leads to….

A

Fracture risk

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7
Q

several hormones regulate calcium-phosphate homeostasis…..

A

PTH
25-OHD (inactive Vit D)
Active Vit D

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8
Q

Clinical presentation CKD-MBD lab values

A

Dec Ca, Vit D levels, Bone mineral Density

Inc: Phosphate, Ca/Phos product, PTH

Might see fractures

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9
Q

CKD-MBD Screening KDIGO recommendation

A

all patients with GFR <45 are eval yearly (Stage 3a)

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10
Q

Calculating Calcium Phosphate product

A

Corrected Calcium: Ca + ((0.8*(4-albumin))

CaPhos product: Corrected Ca Phosphate

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11
Q

What should Ca*Phosphate product be below?

A

Below 55, >70 you get calcifications

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12
Q

“high Lvls of PTH”

A

150/200 etc going up

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13
Q

CKD-MBD General approach to treatment

A

1st line = dietary phosphate restriction (800-1000mg/day)

2nd line = phosphate binders

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14
Q

Options for CKD-MBD Pharmacologic Treatments

A

Phosphate binding agents

Vit D Therapy

Calcimimemtics

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15
Q

Phosphate binders MOA:

A

Bind to phosphate in GI to reduce absorption of phosphorus (Take w/ Food, usually 3 X day)

Goal: Reduce the Ca*Phos product

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16
Q

KDIGO 2017 guidelines

A

Non-calcium containing phosphate binders preferred

For all phosphate binders, lowest dose that is effective should be used

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17
Q

What to watch out for if calcium-containing binders are used….

A

total dose of elemental calcium should not exceed 2000mg per day.

amount of elemental calcium contained in binder should not exceed 1500mg/day

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18
Q

Phosphate Binders

A

Calcium Carbonate (TUMS): Cheap, but 40% elemental Ca

Calcium Acetate (PhosLo): 25% elemental Ca

Sevelamer Carbonate (Renvela)
Lanthanum Carbonate (Fosrenol)
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19
Q

Which one is less dependent on stomach acid? Calcium Carbonate or Acetate

A

Calcium Acetate

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20
Q

Calcium Carbonate vs Acetate

A

Carbonate: OTC, Cheaper, relies on stomach acid

Acetate: RX, relies less on acid, less ca

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21
Q

Sevelamer Carbonate (Renvela)

A

non calcium containing

Expensive, more expensive than calcium products

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22
Q

Lanthanum Carbonate (Fosrenol)

A

Not really used

Available as chewable tablets

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23
Q

Aluminum Hydroxide

A

Reserved for short term use in pt not responding to binders or other treatments

2-3 days up to month

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24
Q

Phosphate Binders Side effects

A

Gi upset
Nausea
Bloating
Constipation

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25
Counseling points phosphate binders
Taking with food is critical Separate meds with DDI potential by 1hr before or 3 hr after ie Quinolones
26
Drugs used to suppress PTH
Vitamin D Therapy Vitamin D Analogs Calcimimetics
27
Prior to initiation of Vitamin D therapy, important to control....
Ca and Phos as therapy will result in increase of both....increasing the product
28
Treatment of Hyperparathyroidism | (CKD Stage 1-4) If inactive lvl Vit D <30ng/ml, and PTH is at goal then....
Tx w/ oral Vit D precursors is recommended
29
Treatment of Hyperparathyroidism | (CKD Stage 1-4) If inactive lvl Vit D >30ng/ml, but PTH not at goal then....
Tx w/ activated Vit D recommended
30
Treatment of Hyperparathyroidism | For CKD Stage 5, treatment with activated Vit D is....
recommended
31
Calcimimetics are used for patients who are on...
Dialysis and PTH is uncontrolled with phosphate binders and Vit D *Can lead to Hypocalcemia*
32
Inactive forms of Vitamin D
Ergocalciferol (D2) | Cholecalciferol (D3)
33
Activated form of Vitamin D
Calcitriol Paricalcitol and Doxercalciferol (analogs)
34
Benefit of Vitamin D analogs
More specific at PTH gland so less GI side effect but more $$
35
Hypercalcemia and hyperphosphatemia are most pronounced with which activated Vitamin D
calcitriol Least pronounced with paracalcitol
36
Oral Vitamin D
Ergocalciferol (D2) Cholecalciferol (D3) Calcitriol (Both PO and IV)
37
Benefit of having IV version of Vitamin D
billed to part B | Mixed in with other IV meds receiving
38
Peritoneal Dialysis
Can be done at home, through peritoneum | Don't have to go Dialysis unit like with Hemodialysis (Blood)
39
Oral med preferred when...
Peritoneal or no Dialysis
40
IV med preferred when....
Hemodialysis
41
vitamin D pre-cursors only effective in patients with....
Low Vitamin D levels in Stage 1-4 CKD
42
Use Activated Vitamin D or analogs right away in...
Patients with Stage 5 CKD
43
Cinacalcet (Sensipar)
Calcimimetics **Only used in Stage 5 CKD, Dialysis pt Usually use 90mg/day, max 180mg/day
44
Calcimimetics Drug interactions
Have a lot of interactions with Cyp TAKE WITH FOOD, inc absorption 81% **Hypocalcemia Side effect
45
What to monitor in CKD-MBD treatment
``` Calcium Phosphate Ca*Phos Product Vitamin D lvl Bone Density ```
46
How does Anemia occur in CKD
Reduced production of Erythropoietin Hormone | GI absorption of iron impaired
47
Anemia Symptoms Stages 3/4/5 CKD
Fatigue, weakness, SOB Dec Hct, Hgb
48
Who should be screened for anemia w/ CKD
males w/ Hgb <13 | females w/ Hgb <12
49
What should initial anemia workout include
``` * Most important* Hct,Hgb Iron Indices (Tsat and ferritin) ```
50
TSAT is
Transferrin saturation, content of hemoglobin in the reticulocytes Calc: (Serum iron/TIBC) X 100
51
Absolute iron deficiency is diagnosed when....
Tsat <20% | Ferritin <100ng/ml (Predialysis and peritoneal dialysis), <200 hemodialysis patient
52
Goals for Lab markers in Anemia of CKD
Hemoglobin = 10-11.5g/dL Tsat >20-30% Ferritin >100-200(KDOQI), >500 (KDIGO)
53
General Approach to treatment of Anemia of CKD
increase Oxygen carrying capacity, decreasing dyspnea,orthopnea,fatigue Prevent long term consequences of LVH and CV mortality
54
Pharmacologic Treatment of Anemia of CKD
Step 1: Iron | Step 2: ESA (Eryhtropoietin stimulating agents)
55
non pharmacological treatment of Anemia of CKD
Maintain adequate dietary iron intake, most pt require supplement Make sure pts supplements with water-soluble multivitamin as they can be removed by dialysis
56
Indications for Iron in Anemia of CKD
TSAT <30% and Ferritin <500
57
Oral vs IV Iron
IV iron used usually at "absolute deficiency" Oral used for "functional deficiency", above TSAT 20%, Ferritin >200
58
Oral Iron recommendations
200mg elemental/day goal: give on empty stomach but causes GI issues. Most take w/ food Give with some sort of stool softener/laxative
59
Preferred Iron product
Ferrous Sulfate
60
IV iron
Skips the GI side effects | Better for those on dialysis
61
Ferric Gluconate (Ferrlecit)
Dialysis:125 mg over 8 sessions Non-Dialysis: 250mg once a week for 3-4 doses
62
Iron Sucrose (Venofer)
Dialysis: 100mg for 10 sessions | Non-Dialysis: 200mg times 5 over a 2 week period
63
Ferumoxytol (Feraheme)
All pts: 510 mg as single dose followed by second 3-8 days later $$$
64
Drugs/Food interactions that decrease oral iron absorption
Calcium containing products decrease iron decrease quinolone absorption Acid suppressive therapy decrease iron absorption, can be improved with admin of ascorbic acid
65
IV iron Adverse effects and DDI
No DDI Well tolerated, aside from Iron Dextran
66
ESA important info
not recommended to be initiated in patients with Hg > 10g/dL Make sure no bleeding All preventable causes should be corrected
67
when not to use ESA
patients with certain tumor types (Solid organ tumors), they shorten overall survival and or increased risk of tumor progression or recurrence in some clinical studies Used very selectively
68
ESA are generally initiated in patients with....
no contraindications Hgb <10, TSAT >25% and ferritin >200 Hgb target is 10-11.5
69
ESA admin in non-Hemodialysis patients
SubCu is preferred
70
ESA admin in Hemodialysis patients
SubCu is desirable, but most given IV due to ins billing
71
Erythropoietin alpha (Epogen, Procrit)
Dosed in units SC doses = 1/3 IV, longer T1/2
72
Darbepoetin alpha (Aranesp)
Dosed in mcg/kg
73
Erythropoietin alpha (Epogen, Procrit) dosing
Non-HD: 50-100 units/kg IV or SC once weekly or every 2 weeks HD: 50-100 units/kg IV or SC 1-3 times per week **Don't change doses more frequently than every 3-4 weeks, increments of 25%**
74
Darbepoetin alpha (Aranesp) dosing
Non-HD: 0.45 mcg/kg IV or SC once every 4 weeks HD: 0.45 mcg/kg IV or SC once per week or 0.75mcg/kg every 2 weeks ** Don't change dose more frequently than once per month, increments of 25%***
75
Why should you wait to increase doses of ESAs
Takes time to make red blood cells Takes few weeks to see results in Hgb
76
What should you monitor when giving ESAs
Hgb TSAT Serum Ferritin

CDM 1 Exam 2 (16 decks)

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