Therapeutics - Cassagnol CKD Flashcards

1
Q

in CKD classification, eGFR less than ____ is considered stage 5

what does stage 5 mean

A

less than 15mL/min

KIDNEY FAILURE

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2
Q

explain the general prevention strategies against CKD

A

manage the disorders that can cause or accelerate CKD – ie: hypertension, dyslipidemia, diabetes

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3
Q

which blood pressure agents are preferred in diabetic patients and why

A

ACE inhibitors or ARBs – preferred in diabetes with HTN or albuminuria

bc can slow the progression of CKD

ACE and ARB may even be considered if the pt is NORMOTENSIVE

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4
Q

2 drugs that can induce chronic kidney disease

A

LONG TERM use of NSAIDS, tylenol, codeine, caffeine (only very large amt)

lithium!

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5
Q

pt is taking lithium

what is concern and how often should they be monitored

A

lithium causes LOT of kidney issues and can cause CKD

need to check the SCr every few months for 6 months and then yearly —- need to do risk-benefit analysis if worth continuing

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6
Q

true or false

the complications of CKD become more prominent as the kidney function worsens

A

true

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7
Q

name some complications of CKD

A

fluid and electrolyte abnormalities

anemia

CV disease

mineral and bone issues

malnutrition

drug dose adjustments

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8
Q

lab findings in CKD – state whether elevated or below normal

BUN
phosphate
calcium
potassium

A

high BUN
high phosphate
low calcium
high potassium

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9
Q

CKD can cause the complication of metabolic _____ (alkalosis or acidosis)

A

acidosis

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10
Q

true or false

CKD can cause anemia

A

true

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11
Q

consequence of low calcium from CKD

A

hyperparathyroidism

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12
Q

____ deficiency is a complication of CKD

A

erythropoietin

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13
Q

CLINICAL signs of CKD (not lab)

A

hypertension
uremia (urea accumulation – symptoms are nausea and anorexia)

bleeding, muscle pain, anxiety, depression, pericarditis, itching, fluid retenion, muscle pain, etc

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14
Q

treatment for FLUID OVERLOAD (complication of CKD)

A

diuretics (specifically loops) and sodium restriction (based on extent of overload)

loops usually used, but can add a thiazide (metazolone) if resistant to loops alone (rebound reabsorption in DCT - thiazides will prevent)

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15
Q

thiazide monotherapy is usually not used for fluid overload from CKD, but ESPECIALLY not used if the eGFR is….

A

less than 30 – it’s ineffective at this point

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16
Q

hyperkalemia is a complication of CKD

this can usually be avoided once…

A

routine dialysis is established

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17
Q

WHY does CKD often lead to anemia

A

because there is decreased production of erythropoietin by the kidney – and also a decreased response to erythropoietin and heme production

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18
Q

in order to give exogenous erythropoietin (/erythropoietin stimulating agents) to anemic patients with CKD, what MUST be done first?

A

correct the iron deficiency FIRST - otherwise EPO will not work

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19
Q

we can consider initiating erythropoietin stimulating agents when the hemoglobin is….

A

less than 10g/dL - also consider the symptoms

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20
Q

explain when to reduce/interrupt the dose of ESA’s in dialysis vs non dialysis patients

A

non dialysis - when the hemoglobin is over 10g/dL

dialysis - when over 11g/dL

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21
Q

goal of giving ESA to anemic patients from CKD

A

reduce the need for RBC transfusion!

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22
Q

!!!VERY important consideration when giving erythropoietin stimulating agents

A

***DO NOT TARGET NORMAL HOMOGLOBIN CONCENTRATION!!!!!

13 and over g/dL of hemoglobin changes the viscosity of the blood - prone to clots and CV events like heart attack and stroke!!!!

23
Q

____ is the main cause of ESA unresponsiveness

therefore….

A

iron deficiency

need to check the transferrin saturation (iron ready for production) and ferritin (iron stores)

24
Q

true or false

just correcting the iron deficiency may resolve the anemia, without even having to use ESA

A

TRUE - and this is preferred

25
when correcting the iron deficiency, what formulations are tried 1st and what if they fail state an issue with the initial route
give PO first -- but these have low bioavailability and poor adherence use IF formulations if oral fail
26
COUNSELING POINT for PO iron
needs acidic environment to absorb, so take on EMPTY STOMACH with ascorbic acid (orange juice)
27
bone and mineral disorders are a complication of CKD what are the goals
to manage the serum levels of phosphate and calcium, AND to manage the secondary hyperparathyroidism that occurs bc of the low calcium
28
a complication of CKD is elevated phosphate explain the stepwise approach to correcting this
1st - diet restriction on phosphate - less than 1000mg/day if fails - use phosphate binding agent (calcium containing first) BUT if the patient is hypercalcemic OR has signs of calciphylaxis OR if calcium x phosphorus 55 or more -- SWITCH TO NON CALCIUM CONTAINING BINDER
29
true or false phosphate is NOT adequately removed by dialysis, so we put a dietary restriction to 1000mg a day
true
30
foods to avoid when trying to limit phophate intake
preservatives and added salts, and dark carbonated beverages
31
important counseling point for phosphate binding agents
GIVE WITH FOOD! to bind the dietary phosphorus
32
issue with giving a calcium containing binder for hyperphosphatemia
can fix the hypocalcemia BUT can cause hypercalcemia
33
name 2 non-calcium containing binders
sevelamar lanthanum
34
what 2 salts is sevelamar available as and which should be avoided in cases of metabolic acidosis
HCl and carbonate avoid HCl if metabolic acidosis
35
__ and __ containing binders and products should be avoided to treat hyperphosphatemia
aluminum and magnesium containing
36
what is the name of the calcium-containing binder for hyperphosphatemia
calcium acetate (phos-low)
37
true or false Vitamin D elevation is a complication of CKD
FALSE - deficiency bc the final conversion to calcitriol (vitamin D) is done by the kidney
38
2 precursors to vitamin D that can be used to treat deficiency
ergocalciferol and cholecalciferol
39
*when should ACTIVE vitamin D (calcitriol) and NOT its precursors be used
when PTH is high!!!!
40
concern with giving vitamin D
can elevate calcium and phosphorus!!!! need to check every month
41
name a calcimimetic
cinacalcet (sensipar)
42
only thing that cinacalcet is approved for what does it do? high risk of what?
ESRD and on dialysis lower PTH either as an alternative or in addition to vitamin D analogs high risk of hypocalcemia!!!! - START LOW DOSE - 30mg/day
43
the goal for cinacalcet is to decrease and titrate the PTH how often to check? how often to check calcium and phosphorus?
every 2-4 weeks check calcium and phoshorus within ONE WEEK for safety (may cause hypocalcemia)
44
true or false CKD patients -- ALL MEDICATION dependent on the kidneys for elimination need to be assessed for dose reduction
true
45
which type of dialysis is more often done at home
peritoneal dialysis
46
concern with dialysis
removes FOLATE and not vitamin A need to supplement vitamins (inc folate) -- nephrocaps
47
when giving ESAs, need to check hemoglobin how often?? what to do if.... increase over 1 g/dL (or target exceeded) increased less than 1g/dL after 4 weeks
2 weeks after initiation, or 2 weeks after a dose change over 1g/dL - decrease dose by 25% less -- increase the dose (50% epoeitin and 25% darbepoetin)
48
differentiate between paricalcitol and doxercalciferol
paricalcitiol - decreases PTH and does NOT increase calcium or phosphorus (GOOD) doxercalciferol - decreases PTH but INCREASES CALCIUM AND PHOSPHORUS
49
doxercalciferol is only used in CKD if... how is it dosed
patient is on dialysis TIW
50
calcitriol is started at what dose and why
LOWEST DOSE - to avoid hypercalcemia
51
1mcg calcitriol = ____mcg paricalcitiol
4
52
true or false cancer is an adverse even of ESAs
true
53
most common adverse event from ESA
hypertension
54