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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
Q

Counseling points phosphate binders

A

Taking with food is critical

Separate meds with DDI potential by 1hr before or 3 hr after ie Quinolones

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26
Q

Drugs used to suppress PTH

A

Vitamin D Therapy
Vitamin D Analogs
Calcimimetics

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27
Q

Prior to initiation of Vitamin D therapy, important to control….

A

Ca and Phos as therapy will result in increase of both….increasing the product

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28
Q

Treatment of Hyperparathyroidism

(CKD Stage 1-4) If inactive lvl Vit D <30ng/ml, and PTH is at goal then….

A

Tx w/ oral Vit D precursors is recommended

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29
Q

Treatment of Hyperparathyroidism

(CKD Stage 1-4) If inactive lvl Vit D >30ng/ml, but PTH not at goal then….

A

Tx w/ activated Vit D recommended

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30
Q

Treatment of Hyperparathyroidism

For CKD Stage 5, treatment with activated Vit D is….

A

recommended

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31
Q

Calcimimetics are used for patients who are on…

A

Dialysis and PTH is uncontrolled with phosphate binders and Vit D

Can lead to Hypocalcemia

32
Q

Inactive forms of Vitamin D

A

Ergocalciferol (D2)

Cholecalciferol (D3)

33
Q

Activated form of Vitamin D

A

Calcitriol

Paricalcitol and Doxercalciferol (analogs)

34
Q

Benefit of Vitamin D analogs

A

More specific at PTH gland so less GI side effect but more $$

35
Q

Hypercalcemia and hyperphosphatemia are most pronounced with which activated Vitamin D

A

calcitriol

Least pronounced with paracalcitol

36
Q

Oral Vitamin D

A

Ergocalciferol (D2)
Cholecalciferol (D3)
Calcitriol (Both PO and IV)

37
Q

Benefit of having IV version of Vitamin D

A

billed to part B

Mixed in with other IV meds receiving

38
Q

Peritoneal Dialysis

A

Can be done at home, through peritoneum

Don’t have to go Dialysis unit like with Hemodialysis (Blood)

39
Q

Oral med preferred when…

A

Peritoneal or no Dialysis

40
Q

IV med preferred when….

A

Hemodialysis

41
Q

vitamin D pre-cursors only effective in patients with….

A

Low Vitamin D levels in Stage 1-4 CKD

42
Q

Use Activated Vitamin D or analogs right away in…

A

Patients with Stage 5 CKD

43
Q

Cinacalcet (Sensipar)

A

Calcimimetics

**Only used in Stage 5 CKD, Dialysis pt

Usually use 90mg/day, max 180mg/day

44
Q

Calcimimetics Drug interactions

A

Have a lot of interactions with Cyp

TAKE WITH FOOD, inc absorption 81%

**Hypocalcemia Side effect

45
Q

What to monitor in CKD-MBD treatment

A 
Calcium
Phosphate
Ca*Phos Product
Vitamin D lvl
Bone Density
46
Q

How does Anemia occur in CKD

A

Reduced production of Erythropoietin Hormone

GI absorption of iron impaired

47
Q

Anemia Symptoms Stages 3/4/5 CKD

A

Fatigue, weakness, SOB

Dec Hct, Hgb

48
Q

Who should be screened for anemia w/ CKD

A

males w/ Hgb <13

females w/ Hgb <12

49
Q

What should initial anemia workout include

A 
* Most important*
Hct,Hgb
Iron Indices (Tsat and ferritin)
50
Q

TSAT is

A

Transferrin saturation, content of hemoglobin in the reticulocytes

Calc: (Serum iron/TIBC) X 100

51
Q

Absolute iron deficiency is diagnosed when….

A

Tsat <20%

Ferritin <100ng/ml (Predialysis and peritoneal dialysis), <200 hemodialysis patient

52
Q

Goals for Lab markers in Anemia of CKD

A

Hemoglobin = 10-11.5g/dL
Tsat >20-30%
Ferritin >100-200(KDOQI), >500 (KDIGO)

53
Q

General Approach to treatment of Anemia of CKD

A

increase Oxygen carrying capacity, decreasing dyspnea,orthopnea,fatigue

Prevent long term consequences of LVH and CV mortality

54
Q

Pharmacologic Treatment of Anemia of CKD

A

Step 1: Iron

Step 2: ESA (Eryhtropoietin stimulating agents)

55
Q

non pharmacological treatment of Anemia of CKD

A

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
Q

Indications for Iron in Anemia of CKD

A

TSAT <30% and Ferritin <500

57
Q

Oral vs IV Iron

A

IV iron used usually at “absolute deficiency”

Oral used for “functional deficiency”, above TSAT 20%, Ferritin >200

58
Q

Oral Iron recommendations

A

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
Q

Preferred Iron product

A

Ferrous Sulfate

60
Q

IV iron

A

Skips the GI side effects

Better for those on dialysis

61
Q

Ferric Gluconate (Ferrlecit)

A

Dialysis:125 mg over 8 sessions

Non-Dialysis: 250mg once a week for 3-4 doses

62
Q

Iron Sucrose (Venofer)

A

Dialysis: 100mg for 10 sessions

Non-Dialysis: 200mg times 5 over a 2 week period

63
Q

Ferumoxytol (Feraheme)

A

All pts: 510 mg as single dose followed by second 3-8 days later

$$$

64
Q

Drugs/Food interactions that decrease oral iron absorption

A

Calcium containing products decrease

iron decrease quinolone absorption

Acid suppressive therapy decrease iron absorption, can be improved with admin of ascorbic acid

65
Q

IV iron Adverse effects and DDI

A

No DDI

Well tolerated, aside from Iron Dextran

66
Q

ESA important info

A

not recommended to be initiated in patients with Hg > 10g/dL

Make sure no bleeding
All preventable causes should be corrected

67
Q

when not to use ESA

A

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
Q

ESA are generally initiated in patients with….

A

no contraindications

Hgb <10, TSAT >25% and ferritin >200

Hgb target is 10-11.5

69
Q

ESA admin in non-Hemodialysis patients

A

SubCu is preferred

70
Q

ESA admin in Hemodialysis patients

A

SubCu is desirable, but most given IV due to ins billing

71
Q

Erythropoietin alpha (Epogen, Procrit)

A

Dosed in units

SC doses = 1/3 IV, longer T1/2

72
Q

Darbepoetin alpha (Aranesp)

A

Dosed in mcg/kg

73
Q

Erythropoietin alpha (Epogen, Procrit) dosing

A

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
Q

Darbepoetin alpha (Aranesp) dosing

A

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
Q

Why should you wait to increase doses of ESAs

A

Takes time to make red blood cells

Takes few weeks to see results in Hgb

76
Q

What should you monitor when giving ESAs

A

Hgb
TSAT
Serum Ferritin

CDM 1 Exam 2 (16 decks)

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