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Therapeutics > CKD > Flashcards

CKD Flashcards

1
Q

CKD defined as ?

A

Abnormalities of kidney structure or function present for at least 3 months w/implications for health

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2
Q

CKD classified based on cause, ____ and ___

A

GFR category
Albuminuria category

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3
Q

Categorize the values and description for each GFR categorie

  1. G1
  2. G2
  3. G3a
  4. G3b
  5. G4
  6. G5
A
  1. Normal or high >= 90
  2. Mildly decr 60-89
  3. Mildly to mod decr 45-59
  4. Mildy to severely decr 30-44
  5. severely decr 15-29
  6. kidney failure <15
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4
Q

Albuminuria categories

  1. A1
  2. A2
  3. A3
A
  1. Normal to mildly incr <30 mg/g or <3 mg/mmol
  2. mod incr –> 30-300 mg/g or 3-30 mg/mmol
  3. severely incr >300 mg/g or >30 mg/mmol
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5
Q

What’s the most widely used endog marker for detection of kidney disease?

A

Creatinine

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6
Q

Creatinine production
average for men and women?

A
  1. Men : 20-25 mg/kg
  2. women : 15-20 mg/kg (About 1 gram per day)
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7
Q

Factors that affect Scr? (5)

A

Age
Muscle mass
strenuous exercise
high protein diet
creatine supplementation

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8
Q

What happens to SCr of aa individuals?

A

GFR is 16% higher than white pt’s

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9
Q

Measured Creatinine Clearance : Timed Collection

Useful in pt’s with?
How long is the collection?
What’s the equation?

A
  1. NON GFR determinants of creatinine bc u cant assume standard creatinine production rates
  2. 12 or 24 hr collection
  3. CLcr (mL/min) = ([Creatinine] urine * Volume of Urine ) / (1440 * [Creatinine] plasma)
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10
Q

Urinalysis : State what the following indicate damage of

  1. Proteinuria
  2. Glucose in urine
  3. RBCs
  4. WBCS
  5. Leukocyte Esterases and nitrates
  6. Casts indicate ?
A
  1. glomerulus
  2. Diabetes or tubular injury
  3. glomerular injury
  4. infection or autoimmune disease
  5. confirm infection
  6. Damage in general (can be diff types)
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11
Q

For each dipstick category , state the corresponding Albumin Concentration

Trace
1+
2+
3+
4+

A

15-30 mg/dL

30-100 mg/dL

100-300 mg/dL

300-1000 mg/dL

> 1000 mg/dL

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12
Q

Proteinuria: For each classification, state the 24 hr urine collection value and Spot Urine Albumin : creatinine ratio

  1. Normal
  2. Mod incr
  3. Severely incr
A
  1. <30 mg , <30 mg/g
  2. 30-300 mg, 30-300 mg/g
  3. > 300 mg, > 300 mg/g
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13
Q

What’s the highest etiology incidence of CKD?

A

Diabetes 44% followed by HTN 27%

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14
Q
  1. Stage 1 Kidney Disease –> GFR is ____, but there’s evidence of ___
  2. Stage 2 ?
  3. Stages 3-5?
A
  1. Normal, kidney damage
  2. evidence of kidney damage AND a reduced GFR
  3. Reduction in GFR with OR WITHOUT evidence of damage to the kidneys
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15
Q

For diabetes, how can it cause CKD?

What’s the first sign of damage to the kidney from diabetes?

A

excessive filtration of glucose increases osmotic pressure and thickening of the capillary basement membrane

protein spilling into the urine

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16
Q

As kidney function declines… what does kidney do to the efferent and afferent arterioles?
What does this result in?
Causes progressive?

A
  1. constricts efferent and dilates afferent arterioles
  2. incr intraglomerular pressure to maintain GFR
  3. fibrosis, sclerosis, and nephron drop out
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17
Q

What are the sx’s and signs of each CKD stage? (Note as we progress to each further stage, GFR decreases)

  1. CKD stage 1
  2. CKD stage 2
  3. CKD Stage 3
  4. CKD Stage 4
  5. CKD Stage 5
A
  1. Sx’s : Asymptomatic
    Signs : HTN, abnormal urine test
  2. SX’s : Usually none, or edema
    Signs : HTN, abnormal urine test
  3. SX’s : None to fatigue, edema, nocturia
    Signs : Edema, anemia
  4. SX’s :None to loss of appetite, dyspnea, worsening fatigue, edema, pruritus
    Signs : MOD, electrolyte abnorms, onset of uremia
  5. SX’s : Weight loss, dyspnea, fatigue, altered mental status

Signs : Severe HTN, Pulm edema, acidosis, hyperkalemia, encephalopathy

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18
Q

Clinical Eval : Lab Work up for CKD

  1. Requires orders of ? (4)
  2. Serum creatinine is used to estimate ? Urinalysis used to estimate?
  3. These 2 important pieces of info allow u to do what 2 things?
  4. Fast progression of kidney disease is seen with?
A
  1. Serum chemistry, complete blood count, urinalysis, and urine chemistry for protein and creatinine
  2. The kidney function
    - determine if there are injury markers such as proteinuria or
    hematuria
  3. stage the severity of
    kidney disease using the GFR and determine how quickly the kidney disease will progress by
    quantifying proteinuria
  4. a greater amount of proteinuria
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19
Q

HTN Management

  1. Only 11% of pt’s with CKD have __ controlled
  2. Goals of therapy for BP for CKD pt’s ?
    - this is irrespective of ____ or ____
  3. More goals of therapy include reducing risk of ___ and slowing the progression of ___
  4. Goal for proteinuria is?
A
  1. BP
  2. BP should be <120/80 mmHg
    -proteinuria, diabetes
  3. CVD, CKD
  4. <1 gram/day
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20
Q

Management of CKD

  1. Address _____of CKD –> if autoimmune disease like lupus nephritis… tx with __
  2. Slow progression of the CKD
    -Use evidence based therapies such as ? (3)
  3. Estimate and reduce ____
    -Apply evidence based therapies such as ? (3)
  4. Treat co-morbidities and complications of CKD! List them! (8)
A
  1. Underlying cause
    - immunosuppression
  2. RAAS agents, SGLT2 Inhibitors, finerenone
  3. CV risk
    -RAAS, SGLT2I’s, statins
  4. HTN, Diabetes, hyperlipidemia, anemia, bone disease, electrolyte abnorms, metabolic acidosis, smoking cessation
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21
Q

Most
beneficial anti-hypertensives for patients with CKD and protein in the urine are ?

How do these drugs
slow the progression of CKD to end stage renal disease and slow the time to doubling of Scr?

Indicated for pt’s with proteinuria and these pt’s can be __ and __

A
  1. ACE’s and ARBS
  2. Dilate the efferent arteriole reducing intra-glomerular pressure and
    reducing proteinuria.

-reduce intraglom pressure will initially decr GFR but will stabilize! –> reduction in albuminuria –> renal protection

diabetic, non-diabetic

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22
Q

AE’s of ACEI’s and ARBS? (4)

A

-30% rise in Scr within the first two months of therapy
-Hyperkalemia
-Hypotension
-Worsening anemia and teratogenicity

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23
Q

When can you titrate ur pt’s dose of ACEI’s or ARBS?

A

Monitor Scr and and K within 1-2 wks –> if Scr within 30% of baseline and potassium is normal, u can titrate dose

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24
Q

DO NOT Initiate ACEIs and ARBS in CKD Stage ___ without ____?

A

5, consulting nephrology

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25
Q

CCB’s in Proteinuric CKD

  1. They are __ behind acei’s or arbs
  2. They dilate ____
  3. Non DHP CCBs associated with ___. Name the 2 drugs
  4. Don’t use DHP CCB alone without ___ or ___ in proteinuric pt’s bc they can ____
A
  1. second line
  2. afferent arteriole
  3. anti-proteinuric effects. Diltiazem or verapamil.
  4. ACEI , ARB , worsen proteinuria
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26
Q

Disadvantages of
CCBs ?

A

inhibit CYP 3A4 and interact with statins and calcineurin inhibitors used in
transplantation

27
Q

Diabetes Management and CKD :

  1. Goal of Blood sugar pre-prandial?
  2. Goal of blood sugar post prandial?
  3. A1C goal for early CKD Stages 2-3
  4. A1C Goal for stage 4 or 5 CKD or pt’s w/repeated hypoglycemia?
A
  1. 90-130 mg/dL
  2. <180 mg/dL
  3. 6.5%
  4. 8%
28
Q

First line agent for patients with Diabetes and CKD?

A

SGLT2I’s

29
Q

Technically, SGLT2I’s have shown benefit in which group of pt’s?
What are the drugs able to do?

A

Both diabetic and non diabetic CKD stages 2-4
for reducing proteinuria, GFR decline, and CV death

30
Q

In early stages of diabetic nephropathy what happens?

A

Hyperfiltration bc of upreg of SGLT2 receptors to absorb glucose and Na+ resulting in Afferent arteriole vasodilation and incr GFR
-bc of decr Na+ delivery to macula densa, u have impaired tubuloglomerulo feedback –> blunts afferent tone

SGLT2I’s –> restore TGF, allow for incr Na+ delivery to macula densa –> AA constriction –> normalization of GFR

31
Q

Eligible pt’s for SGLT2I’s with CKD :

  1. eGFR ?
  2. High priority features? (2)
  3. Potential CI’s? (4)
  4. Which SGLT2I’s have proven benefits? (3)
A
  1. egfr >= 20 mL/min/1.73 m^2
  2. ACR >= 200 mg/g or >= 20 mg/mmol
  3. Genital infection risk
    diabetic ketoacidosis
    foot ulcers
    immunosupression
  4. Canagliflo –> 100 mg
    Dapagliflo –> 10 mg
    Empagliflo –> 10 mg
32
Q

SGLT2I Dosing in CKD

  1. DAPA
    -dose?
    -eGFR by which dosing is approved?
  2. EMPA
    -Dose?
    -eGFR by which dosing is approved for pt’s with T2D + ASCVD for glucose control and for HF?
  3. CANA
    -Dose?
    -eGFR by which dosing is approved?
A
  1. 10 mg daily
    - >=25
  2. 10 mg daily. can incr to 25 mg daily prn for glucose control!

> = 30 for T2D and ASCVD for gluc control

> = 20 for HF

  1. 100 mg daily (high dose of 300 mg not rec for CKD)

> =30

33
Q

What Additional med for TX of Diabetes for pt’s with CKD (After metformin and SGLT2 INHIBITOR) would you add on?

A

GLP1 agonist

34
Q

GLP1RA Dosing in CKD : State dosing and CKD adjustment for each drug

  1. Dulaglutide
  2. Exenatide
  3. Exenatide ER
  4. Liraglutide
  5. Lixisenatide
  6. Semaglutide Injection
    7.Semag Oral
A
  1. A. 0.75 mg and 1.5 mg once weekly
    B. No dose adj. Use with eGFR > 15
  2. A. 10 microgram BID
    B. Use with CrCl > 30 mL/min
  3. A. 2 mg once weekly
    B. eGFR >45
  4. A. 1.2 mg and 1.8 mg once daily
    B. No dose adj

5.
A. 10 microg and 20 microg once daily
B. No dose adj. Not recc with eGFR < 15

  1. A. 0.5 mg and 1 mg once weekly
    B. N/A
  2. A. 3mg, 7mg, or 14 mg daily
    B. N/A
35
Q

Metformin is an excellent tx of diabetes in CKD but is CI if egfr< ___ due to risk of?

If GFR 30-44… WHAT do u do to the metformin dose?

A

30
lactic acidosis

Initiate at half the dose and titrate upwards to half of the max recc dose

36
Q

Third Tier Therapy for CKD Diabetes ?

It’s useful in CKD especially advanced CKD stage 5 when you cannot use an
SGLT2 inhibitor why?

Which one doesnt need dose adjustment for CKD pt’s?

A

DPP 4 Inhibs

Lack of hypoglycemia and neutral weight effects

Linagliptin

37
Q

Dyslipidemia and CKD

CKD is considered a ______
-Most pt’s w/dyslipidemia and CKD require a?
-DOC?
-Need to check ___
-DDI’s with ___
-High dose ___ associated with ___

-AVOID ___ due to INCR risk of ____

A

Cardiovascular risk equivalent

  • Mod intensity statin
  • HMG COA Reduct Inhib

-Renal dosing

-CCB’s Diltiazem and amlodipine

-Rosuvastatin , worsening proteinuria

-Fibrates. Myopathies

38
Q

ANEMIA and CKD

  1. What kind of anemia develops?
  2. Goals of therapy for HgB, TSAT and Ferritin?
  3. Ferritin goal for dialysis and nondialysis pt’s?
A
  1. normocytic, normochromic anemia
  2. 9.5-11 g/dL, rate of rise 1-2 g/dL per month
    TSAT 20-50% and Ferritin
    100-500 ng/mL
  3. > 200
    100
39
Q

ANEMIA : Oral Iron

  1. Dosing range?
  2. AE’s? (4)
  3. DDI’s? (4)
A
  1. 200 mg elemental iron /day
  2. constipation, nausea, abd cramping, food decr oral abs
  3. Antacids, H2 antags, PPI’s, quinolone antibiotics
40
Q

For each Oral Iron Product state the elemental iron and then the doses per day to reach the 200mg elemental iron requirement

  1. Ferr Sulfate
  2. Ferr Fumarate
  3. Ferr Gluc
  4. Polysach Iron (Niferex)
  5. Ferr Citrate (Auryxia)
A
  1. 65 mg per 325 mg
    tab. 3
  2. 99 mg per 300 mg
    tab. 2
  3. 36 mg per 325 mg
    tab. 6
  4. 150 mg per 150
    mg. 1
  5. 210 mg per 1 gram . 3
41
Q

When do you switch to IV Iron therapy?

A

If tx doesnt work after 3-6 months

42
Q

IV Iron

  1. Iron dextran has small risk of?
    -requires test dose of?
  2. Iron sucr or Gluc in sucrose release free iron much more ___ than ___. BUT They can cause ___ and large doses cannot be given by ___
  3. Ferumoxytol can be given in a ___ as IV push, convenient for ___
  4. Iron therapy associated with worsening of ___
A
  1. Anaphylaxis
    -25 mg to be administered
  2. rapidly, iron dextran.
    -Hypotension
    -IV push
  3. Large dose (510 mg)
    - outpt admin
  4. infections
43
Q

Kim : Refer to Outline for full dosing for each IV agent

  1. Total course of IV IRON should be ? (Loading Dose)
  2. For dialysis dep pt’s what’s the Iron gluconate in sucrose dose?
    -Iron sucrose/iron dextran?
  3. For non dialysis pt’s
    what’s the Iron Sucrose Dose?
    Ferumoxytol dose?
  4. DONT RE CHECK IRON INDICES FOR AT LEAST?
A
  1. 1 gram
  2. 125 mg IV push w/each dialysis session for 8 doses
  • 100 mg IV push w/dialysis session for 10 doses
  1. 500 mg over 3.5 hrs for 2 consec doses

510 mg IV push or intermittent infusion for 2 doses

  1. 2 weeks
44
Q

ESA Therapy

  1. 2 products?
  2. Which has longer half life and less freq dosing?
  3. For dialysis pt’s whats the dosing scheme?
  4. For non dialysis pt’s what’s dosing?
A
  1. EPO ALFA AND DARBEPOETIN
  2. Darbepoetin.
  3. Epo alfa 3x weekly w/each dialysis session
  4. Epo alfa SQ once monthly initially and adjusted to Hgb target (Can incr freq to once weekly depending on kidney function and rate of rise in Hgb)
45
Q

Most pt’s in CKD stage __ require ESA

ESA therapy is usually initiated if the Hgb
drops below?

ESA should be admined SQ why?

A

4

9.5 g/dL.

30% reduction in dose compared to IV admin

46
Q

AE/BBW for ESA?

A

AE : flu like symptoms, increased risk of malignancy in
patients with active cancers and worsening hypertension

BW : Mortality , serious cardio and thromboembolic events, INCR risk of tumor progression or recurrence

47
Q

Epo Alfa Dosing

  1. Hemodialysis
  2. CKD

Darbo Dosing
1. CKD?

In both cases, hold when HgB gets to more than ?

A
  1. 100 units/kg SC three
    times weekly
  2. 10,000 units SC qmonth
  3. 40-60 mcg SC q month
  4. 11
48
Q

As CKD progresses, what happens to urinary excretion of phosphorous?

What happens as serum phosphorous incr?

Decreased activation of 25-OH vitamin D leads to?

A

It diminishes –> increased serum
phosphorus.

It serves as a stimulus for PTH secretion, resulting in increased
PTH

It leads to decreased gut absorption of calcium and hypocalcemia. This also stimulates PTH secretion

49
Q

High PTH causes?

It increases ____ and causes impaired ____

A

bone resorption and an increased risk of fractures

osteoclastic activity, mineralization of bone

-

50
Q

For patients, you must assess the following aspects? (6)

A

serum calcium, calculate the corrected calcium if pt is hypoalbuminemic, assess serum
phosphorus, alkaline phosphatase, PTH and 25-OH vitamin D concentrations

51
Q

What’s the corrected calcium equation?

A

Corrected Ca = ((4-serum albumin)*0.8) + serum calcium

52
Q

Treatment of bone disease always targets what first?

TX algorithm :
1. Control phosphorous using ? (2)

  1. Replace Vitamin D
    -Check ___ level and replete vitamin ___ as necessary
    -If iPTH elevated, trend first and look at other markers such as ___ to determine if pt needs ___
A

Phosphorous control

  1. Dietary restriction (no dairy, dark colored soda, nuts, beans, chocolate) and BINDERS
  2. 25OH , D2
  • alkaline phosphatase
    -active Vitamin D replacement
53
Q

KIM : Print out Phosphorous Binders Table

  1. WHat is the first line binder?
A

Sevelamer

54
Q
  1. Sevelamer
    -What’s not systemically absorbed?
    -It also lowers?
A

Polymer resin

Total cholesterol and LDL

55
Q
  1. Lanthanum carb
    -How does it bind phosphorus?
    -Lack of?
A

Dissociates into trivalent cation which binds phos

long term safety data

56
Q
  1. Calcium based binders
    -No longer ___
    -What binds more phos for same amount of calcium as compared to calc carb?
A

first line for hyperphos

calcium acetate

57
Q
  1. Aluminum Hydroxide
    -Most ___ phos binder
    -Use is limited by?
    -Limit therapy to?
A

potent

accumulation and AE’s : encephalopathy, anemia, and bone disease

4 weeks

58
Q

Newer Phos Binders

  1. Ferric citrate (Auryxia)
    -Both a ___ and ___
    -Similar efficacy to __ and ___
    -AE’s ? (5)
    -Mg and dosage?
  2. Sucroferric Oxyhydroxide (Velphoro)
    -Same as?
    -Similar efficacy to?
    -___ binder
    AE’s ? (3)
    -Mg and dosage?
A

phos binder + iron replacement therapy

sevelamer + calc carb

N/V/D, constipation, ABD pain

210 mg tabs, 1-2 tabs po TID with meals

  1. iron sucrose
    sevelamer
    phosphate
    N,D,stool discoloration
    500 mg chew tabs, 1 tab PO TID w/meals
59
Q

Phosphate Binder Counseling

  1. Take at ___ of meal
  2. Carry a small pill box in case of?
    3.___ is a problem
A
  1. Start
  2. unplanned snacks or small meals where u’ll need extra tabs
  3. adherence
60
Q

Routine use of Vitamin D analogs is not recommended in CKD stage ___

Vitamin D analogs should be reserved for ?

A

3-5 not on dialysis

CKD stage 4-5 w/severe and progressive hyperparathyroidism

61
Q

What are the 3 Vitamin D analogs?

How does Calcitriol work?

Calcitriol is associated with?

A

Calcitriol, paricalcitol, doxercalciferol

Interacts with Vitamin D receptors in gut to increase intestinal absorption of calcium and correct hypocalcemia

Greater incidence of hypercalcemia compared to other agents

62
Q

KIM : print/look at vit D analogs on outline

What are the AE’s of Vit D analogs?

Drug interactions?

A

HYPER calcemia, phosphatemia, adynamic bone disease

Cholestyramine (decr absorption)

Paricalcitol (with 3A4 inhibs)

63
Q

DOSING

  1. Calcitriol
  2. Doxercalciferol or paricalcitol
  3. pulse dosing 3 times weekly associated with?
  4. To reduce risk of hypercalcemia, admin oral vit D analogs on __
A
  1. 0.25 mcg po daily to 3 times weekly
  2. 1 mcg po daily to three times weekly
  3. Less hypercalcemia than daily dosing
  4. empty stomach
64
Q

Calcimimetics -Cinacalcet

MOA?

Used when?

A

Calcium sensing receptor on surface of parathyroid gland
-mimics extracellular ionized Ca

Feedback between serum calcium concentration and parathyroid gland is disrupted (i.e hypercalcemia and high PTH)

Therapeutics (15 decks)

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