Renal Therapeutics Flashcards
how long does an AKI last?
7 days or less
when does AKD occur?
7 to 90 days after AKI
AKI Dx
1) SCr 1.5-1.9 x baseline over 7 days
or
2) SCr increase greater than or equal to 0.3 mg/dL over 48 hours
monitoring for AKI loop use?
dec intravascular volume
dec BP
inc HR
alkalosis
nephrotoxins
aminoglycosides (gentamicin, …)
amphotericin
iodinated contrast
vancomycin
drugs to avoid in AKI prevention
sodium bicarbonate
vitamin C
dopamine
fenoldapam
pre-renal AKI Dx
FeNa < 1%
or
if on loop, FeUrea < 35%
what kidney assessment measure do you avoid in AKI?
SCr –> lags 1-2 days behind GFR
drugs to temporarily hold in hemodynamic AKI?
- ACEi
- ARB
- SGLT2i
- calcineurin inhibitors
- NSAIDs
drugs to temporality hold in pre-renal AKI?
- loop diuretic
- thiazide diuretic (HCTZ, chlorthalidone)
dialysis modalities
hemodialysis
peritoneal dialysis
continuous kidney replacement therapy
HD access points
1) arteriovenous fistula
2) arteriovenous graft
3) central venous catheter
which HD access is highest risk of infection, thrombosis, inadequate dialysis?
central venous catheter
HD fistula characteristics
preferred long-term access, takes 6-12 weeks to mature after surgical creation, lowest infection/thrombosis risk
HD graft characteristics
plastic tube outside of body
HD catheter characteristics
last-line option, used short-term (while bridging to fistula), highest infection/thrombosis risk
what are the risk factors associated with HD access?
- thrombosis
- infection
- inadequate dialysis (slower blood flow)
peritoneal dialysis complications
infection of peritoneal membrane
- can occur from site of entry and tip of catheter infection
- ensure aseptic technique
when to do HD TDM?
prior to HD
- bc after HD there is 4-6 hours of redistribution and fluid shifts, therefore fluctuating drug concentrations
when to do PD TDM?
random
when to do CRRT TDM?
random
HD complications
hypotension
cramping
fatigue
infection
thrombosis
bleeding
PD complications
peritonitis
fluid overload
hyperglycemia
midodrine indication
HD hypotension complication
midodrine MoA
alpha-1 agonist –> stimulates peripheral vasoconstriction (pro-drug) -> inc BP
midodrine dosing
2.5-10mg po 30 min before HD
midodrine AE
bradycardia, hypertension, peripheral ischemia, urinary retention
midodrine CI
severe PVD
midodrine DDI
MAOIs, sympathomimetics
vitamin E indication
HD cramping symptom improvement
vitamin E dose
400 IU po qhs
what to avoid to treat HD cramping
quinine
HD thrombosis treatment and dose
alteplase (cathflo) 2mg/2mL instilled for 30-120 min
HD hypotension and cramping treatment
100-250mL 0.9% NaCl
vancomycin efficacy failure vs toxicity for dialysis
toxicity: ototoxicity, nephrotoxicity, red man’s syndrome (puritis, …)
efficacy failure: infection mortality and morbidity
what drug characteristics allow for no renal dosing?
large therapeutic index
and
fraction excreted unchanged in urine 30% or less
and
inactive or no metabolites
which kidney assessment do you use for CKD staging?
eGFR (CKD-EPI)
which kidney assessment do you use for drug dosing?
eCrCl (cockcroft-gault)
opioids safe in kidney disease
fentanyl
methadone
opioids caution in kidney disease
hydromorphone
oxycodone
hydrocodone
opioids avoid in kidney disease
morphine
codeine (pro-drug of morphine)
meperidine
loading dose most impacted by
Vd
digoxin LD consideration
lower Vd –> cut LD by 50%
hydrophilic antibiotics LD considerations
higher Vd –> inc dose
hydrophilic antibiotics
aminoglycosides (gentamicin)
beta lactams
carbapenems
linezolid
colistin
glycopeptides (vancomycin)
maintenance dose most impacted by
CL
antimicrobials that do not require kidney dosing
metronidazole
azithromycin
nafcillin
tigecycline
oxacillin
linezolid
doxycycline
moxifloxacin
erythromycin
quinupristin/dalfopristin
clindamycin
ceftriaxone
normal SCr
around 1.2 mg/dL
normal BUN
24 mg/dL ish
DOAC with lowest percent kidney CL
apixaban
LMWH with lowest percent kidney CL
tinzaparin
metformin CI
eGFR < 30
SU bad for kidneys
glyburide
SU preferred for kidney
glipizide (no beers too)
DPP4i without renal adjustment
linagliptin
thiazide renal impact
not effective for HTN when CrCl < 30
K sparing and aldosterone antag CI
CrCl <30 bc hyperkalemia
loop dietetic starting dose
40 mg furosemide po ???
how does loop dose change with renal impairment
CrCl 25-50: 2x dose
CrCl < 25: 4x dose
analgesic to avoid kidney dysfunction
- NSAIDs (inc progression of CKD, can use ESRD bc no progression to prevent against – already happened)
- gabapentin/pregabalin (falls, altered mentation)
preferred analgesic in kidney dysfunction
APAP
1000mg po tid
duloxetine CI
CrCl < 30
anemia Dx
male: Hgb < 13 g/dL
female: Hgb < 12 g/dL
anemia treatment labs
Hgb 10-11 g/dL –> o2 carrying capacity
serum ferritin > 500 ng/mL –> storage form iron
transferrin saturation (Tsat) > 30% –> functional form iron
most common cause of erythropoeitin resistance?
iron deficiency
when to hold IV iron
Tsat > 50%
ferritin > 1200 ng/dL
oral iron characteristics
10-15% F (low)
slow replenishment of iron
iv iron characteristics
high F
rapid replenishment of iron
risk of iron overload
oral iron AE
**GI upset –> nausea, cramp, constipation
dark stool
DDI
iv iron AE
infusion reactions (itching, hypotension, edema, chest pain)
anaphylactic
**infection
IV iron CI
active systemic infections
oral iron tid dosing AE
more iron –> inc hepcidin –> dec iron absorption –> need more iron
to dec risk of this: qd or every other day dose
oral iron CI (ish)
PPI, H2RA –> need low gastric pH to absorb
oral iron DDIs
drugs that are impacted by iron and therefore need 2 hr separation
- fluoroquinolones
- levothyroxine
- tetracyclines
- mycophenolate
- methyldopa
- levodopa
ferric gluconate brand, dose
iv
ferrlecit
125 mg tiw 8 doses
iron sucrose brand, dose
iv
venofer
100mg 1-3x weekly, total 1g
what is the marker of good ESA response
2.5% inc in reticulocytes in 1-2 weeks
longest acting ESA
methoxy polyethylene glycol epoetin beta (Mircera)
cheapest ESA
epoetin alfa epbx (Retacrit)
epoetin alfa
Epogen
darbapoetin alfa
Aranesp
dialysis ESA goals
initiate: Hg < 9-10
target: Hg < 10-11
non-dialysis ESA goals
initiate: Hg < 10
target: Hg < 10
how long does it take for ESA to improve Hg?
4-6 weeks
goal ESA Hg change
1-2 g/dL/month
when to lower ESA dose
by 25% if
- Hg approach 12
- Hg inc by > 1 g/dL in 2 weeks
for AE
causes of ESA resistance
1: iron deficiency
ACEi
hyperparathyroidism
aluminum toxicity
folate or b12 deficiency
infection
malignancy
trauma
inflammation
ESA AE
hypertension
hypercoagulability
HA
progression of malignancy
ESA CI
active malignancy with anticipated cure
high risk CVA (stroke)
Hgb > 11 g/dL
blood transfusion indication
Hgb < 7
- 1 unit PRBC = 200mg elemental iron, inc Hgb 1 g/dL
consequences of CKD MBD
cv disease
bone disease
calciphylaxis
MBD labs
calcium 8.5-10.2 mg/dL
phosphorus 3.5-5.5 mg/dL
iPTH 2-9X ULN (150-600 pg/mL)
how to take phosphate binders
with food
renvela
sevelamer carbonate
ca based phosphate binders AE
stones, bones, abdominal groans
nephrolithiasis
calciphylaxis
bone pain
abdominal discomfort
phoslo
calcium acetate (first line)
which ca based phos binder has mire binding capacity
calcium acetate (renvela)
which ca based phos binder has mire binding capacity
calcium acetate (renvela
which non-ca phos binder do you have to chew
lanthanum carbonate (Fosrerol)
cinacelcet dose
30mg/day start –> titrate q2-4 weeks up to MDD 180mg
cinacalcet consideration
need to treat Ca if Ca < 8.4
top ckd causes in us
- DM
- HTN
- glomerulonephritis
- polycystic kidney disease
