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NAPLEX PREP (RxPrep) > 4. Renal & Liver Disease > Flashcards

4. Renal & Liver Disease Flashcards

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1
Q

The _______ arteriole flows INTO the glomerulus, the _______ arteriole flows OUT of the glomerulus (where large, unfilterable substances stay in the blood)

A

Afferent = IN
Efferent = OUT

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2
Q

____ in the urine indicates kidney damage

A

Albumin

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3
Q

What drug works on the PROXIMAL tubule? What blood characteristic is regulated here?

A

SGLT-2is
Blood pH is regulated

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4
Q

What is reabsorbed in the descending limb of the loop of Henle? What is absorbed in the ascending limb?

A

Descending = WATER reabsorbed
Ascending = SODIUM reabsorbed

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5
Q

What is the mechanism of the DISTAL tubule of the nephron? What drug affects the distal tubule?

A

Regulates K, Na, Ca, and pH
Thiazide diuretics inhibit the Na-Cl pump, and increases Ca reabsorption

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6
Q

What drugs affect the COLLECTING DUCT (and distal tubule)?

A

**Potassium-sparing diuretics (including aldosterone antagonists [eg. spironolactone, eplerenone])
Decreased Na+ and water reabsorption, increased K+

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7
Q

What drugs can cause nephrotoxicity?

A

Aminoglycosides
Amphotericin B
Cisplatin
Cyclosporine + Tacrolimus
Loop diuretics
Contrast dyes
NSAIDs
Polymyxins
Vancomycin

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8
Q

What two lab markers can be used to estimate kidney function?

A

BUN
SCr

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9
Q

What is BUN?

A

Amount of nitrogen in blood from urea (waste of protein metabolism)

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10
Q

What is SCr? What is a normal range?

A

A waste product of muscle metabolism
Normal: 0.6 - 1.3 mg/dL

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11
Q

When is the Cockroft-Gault equation NOT PREFERABLE? (3)

A

Very young children
Kidney failure
Unstable, fluctuating renal function

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12
Q

What are two drugs dosed based on GFR?

A

SGLT2is
Metformin

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13
Q

Albumin in the urine is used to measure what?

A

Assess kidney disease
Albuminuria/proteinuria

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14
Q

What are the CKD guidelines?

A

KDIGO

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15
Q

What are the 2 criteria that confirms a CKD diagnosis?

A

eGFR < 60 mL/min/1.73 m2
Albumineria (AER ≥ 30)

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16
Q

What meds are used to delay CKD progression?

A

ACEi/ARBs SCr may increase up to 30%
SGLT2i
Finerinone

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17
Q

What drugs require dose reduction in CKD?

A

Anti-infectives (aminoglycosides, beta-lactams, fluconazole, quinolones, vanco)
Cardiovascular drugs (DOACs, enoxaparin)
GI drugs (H2RAs, metoclopramide)
Bisphosphonates
Lithium

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18
Q

What drug is contraindicated in CrCl < 60 mL/min?

A

Nitrofurantoin

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19
Q

What drugs are contraindicated in CrCl < 50 mL/min?

A

Tenofovir disoproxil
Voriconazole IV only

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20
Q

What drugs are contraindicated in CrCl < 30 mL/min?

A

Tenofovir alafenamide
NSAIDs
Dabigatran

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21
Q

What drug is contraindicated in CrCl < 30 mL/min?

A

Metformin

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22
Q

What some drugs that have CrCl limitations?

A

Meperidine
Rivaroxaban (Xarelto)
SGLT2i

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23
Q

What should be monitored in advanced kidney disease/CKD?

A

PTH (elevated)
Phosphorus (elevated)
Calcium (low)
Vitamin D (low)

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24
Q

What are some phosphate binders for CKD hyperphosphatemia?

A

Aluminum hydroxide
Calcium acetate/carbonate** (hypercalcemia risk)
Sucroferric oxyhydroxide
Ferric citrate
Lanthanum carbonate
Sevelamer (most common, may lower LDLs)

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25
What drugs should be separated from phosphate binders administration?
Levothyroxine Quinolones Tetracyclines
26
What is vitamin D3 and what is vitamin D2? What is the active form?
D3 = cholecalciferol (from UV of the sun) D2 = ergocalciferol (from diet) Calcitriol = ACTIVE form
27
What are some treatments for hyperparathyroidism
Vitamin D analogs (ie. Calcitriol) Calcimimetics (**cinacalcet**, etelcalcetide)
28
What are the treatments of anemia in CKD? What is needed for this medication to be effective? What is the Hgb limit?
Erythropoesis-stimulating agents (ESA) - epoetin alfa, darbapoetin alfa (Increased risk of HTN and thrombosis) **only for Hgb < 10!** [even though Hgb <13 is anemia]) Adequate **iron** necessary (can give IV iron)
29
What is a normal potassium level?
Normal K = 3.5 - 5 mEq/L
30
What drug causes an increase in intracellular shift of potassium?
Insulin (Pts w diabetes are at higher risk of hyperkalemia d/t lower insulin)
31
What is the most common cause of hyperkalemia?
Renal failure
32
What adverse events may occur in hyperkalemia?
Muscle weakness Bradycardia *Fatal arrhythmias*
33
What drugs raise K levels?
ACEi/ARBs Aliskerin Canagliflozin Drospirenone COCs K-sparing diuretics Bactrim Cyclosporine/tacrolimus
34
What drug may be given to prevent arrhythmias in the setting of hyperkalemia?
Calcium gluconate (preferred) or chloride
35
What medications can shift K intracellularly in the setting of hyperkalemia?
Insulin (regular) + dextrose Sodium bicarbonate Albuterol (nebulized)
36
What medications can be given to eliminate K from the body in hyperkalemia?
Loop diuretics [Potassium binders] **Sodium polystyrene sulfonate** Sodium zirconium cyclosilicate Patiromer Hemodialysis
37
What factors affect if/how much drug is removed during dialysis?
Molecular weight/size Vd (larger Vd = less removed by dialysis) Protein-binding Dialysis membrane Blood flow rate
38
Define hepatitis
Inflammation of the liver
39
Describe hepatitis A
Acute & self-limiting Transmission: fecal-oral - improper handwashing, contaminated food/water Sx: mild and non-specific
40
Describe hepatitis B and C (HBV, HCV). What is a preventative measure?
Acute + chronic illness Sx: chronic infection, cirrhosis, liver cancer, liver failure, death Transmission: blood (B+C), body fluids (B) **All adults should get the HBV vaccination**
41
Treatments for hep A? B? C?
Hepatitis A = supportive only Hepatitis B = Peg-interferon, NRTI (tenofovir, entecavir) Hepatitis C = Direct-acting antivirals combo
42
Treatment for naive hepatitis C patients w/o cirrhosis (2)
Glecaprevir/pibrentasa (Mavyret) x 8 weeks [with food! Avoid w statins] Sofosbuvir/velpatasvir (Epclusa) x 12 weeks [avoid amiodarone, PPIs] All DAAs = avoid strong CYP3A4 inducers
43
What is the MOA of NRTIs?
Inhibit HBV replication by inhibiting polymerase
44
What NRTIs are primarily used for hepatitis B treatment?
Tenofovir disoproxil fumarate (TDF) [renal tox, Falcons syndrome, weak bones] Tenofovir alafenamide (TAF) [renal tox, Falcons syndrome, weak bones] Entecavir (Baraclude) [take wo food] Lamivudine **do not use for HIV, since hep B dose is lower and may cause resistance**
45
Interferon alfa is used in hepatitis B treatment. What is the advantage of using pegylated interferon alfa (Pegasus)?
Pegylated = prolongs half life
46
Pegylated interferon alfa is used in hepatitis B treatment. What are its boxed warnings? Major AEs?
Boxed warnings: Neuropsychiatric disorders Autoimmune diseases Ischemic diseases Infectious diseases AEs: CNS effects, GI, increased LFTs, flu-like sx (**pretreat w APAP and antihistamine**)
47
Define cirrhosis
Advanced fibrosis/scarring of the liver, most commonly caused by **hep C and alcohol abuse**
48
What is the defining clinical presentation of cirrhosis
JAUNDICE
49
What are the lab values to look at for cirrhosis?
**Increased AST/ALT** (unless extremely advanced, then normal) Increased Alk phos Increased total bilirubin, lactate dehydrogenase *Increased PT INR* *Decreased albumin*
50
What assessment tool is used to assess severity of liver disease?
Child-Pugh
51
In alcoholic liver disease, is AST or ALT generally higher?
**AST** is generally 2x higher than ALT
52
What natural product is used for liver disease? Which natural product is a known hepatotoxins?
Treatment: Milk thistle Hepatotoxins: Kava,
53
What lab value limit indicates that a hepatotoxic medication should be D/Ced?
>3x ULN LFTs
54
What are some common hepatotoxic drugs? (10)
**APAP** Amiodarone Isoniazid Ketoconazole Methotrexate Nefazodone Nevirapine PTU Valproic acid Zidovudine
55
What is the treatment for alcohol-associated liver disease?
Alcohol cessation BZD = withdrawal Naltrexone, acamprosate, disulfiram = prevent relapses Thiamine = prevent Wernickes-Korsakoff
56
Portal hypertension can cause what secondary condition?
VARICEAL BLEEDING: portal HTN causes blood to back up and enlarge, with the risk of rupture
57
What non-pharm and pharm treatments can be used in variceal bleeding? What drug class can be used for prevention?
Non-pharm: Band ligation, sclerotherapy Pharm: octreotide, vasopressin (splanchnic vasodilation) Prevention: non-selective BB [nadolol, propranolol, carvedilol]
58
What are symptoms of hepatic encephalopathy?
Breath with musty odor Neuro changes (confusion, forgetfulness) Asterixis (hand flapping)
59
What are the treatments for hepatic encephalopathy?
Non-absorbable disaccharide (to flush out ammonia) + antibiotic **Lactulose + Rifaximin**
60
All patients with *cirrhosis* and *ascites* should be considered for….?
Liver transplant
61
What are the non-pharm ways of managing ascites due to portal HTN?
Restrict dietary sodium intake to <2g per day Paracentesis (if severe) with albumin replacement
62
What drugs may be used in patients with ascites?
Spironolactone monotherapy OR Spironolactone + furosemide *Furosemide alone is NOT effective*
63
What is the ideal ratio of furosemide to spironolactone dosing for ascites threat ent (to maintain K+ balance)?
40 mg furosemide : 100 mg spironolactone
64
How much albumin should be replaced per liter of fluid removed via paracentesis from a patient w ascites?
If removing >5 L fluid, give **6-8 grams albumin** per L removed
65
What is spontaneous bacterial peritonitis?
Acute infection of the ascitic fluid
66
What drug is used to TREAT SBP? What is used for secondary prophylaxis once a patient has had an episode of SBP?
Treatment: Ceftriaxone x 5-7 days Secondary prophylaxis: PO ciprofloxacin or Bactrim
67
What is hepatorenal syndrome?
Development of renal failure in patients with advanced cirrhosis as a result of renal vasoconstriction mediated by RAAS and sympathetic nervous system by the hepatorenal reflex.

NAPLEX PREP (RxPrep) (9 decks)

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