Chapter 18: Renal Disease Flashcards
(97 cards)
1
Q
What are the most common causes for Chronic Kidney Disease?
A
Diabetes, Hypertension
2
Q
What is the functional unit of the kidney?
A
The Nephron
3
Q
How does nephrons work?
A
Controls concentrations of Na and H2O [regulates Blood Volume, BP, and pH]
4
Q
What does the afferent arteriole do?
A
Brings blood in to the glomerulus
5
Q
What does the efferent arteriole do?
A
Takes blood out of the glomerulus
6
Q
What happens to proteins or protein-bound drugs in a healthy kidney?
A
They are NOT filtered and go back into blood
7
Q
What indicates kidney damage in terms of protein loss?
A
Albumin leaves in urine
8
Q
What does the presence of albumin in urine show?
A
Severity of kidney disease
9
Q
What substances are filtered back into the blood in the proximal tubule?
A
Na, Ca, Cl, H2O
(blood pH regulation)
10
Q
Where do SGLT-2 transporters function in the nephron?
A
In the proximal tubule
11
Q
What is reabsorbed in the Descending Loop of Henle?
A
H2O is reabsorbed
12
Q
What is reabsorbed in the Ascending Loop of Henle?
A
Na/Cl is reabsorbed
13
Q
Where do Loop Diuretics work in the nephron?
A
Inhibit Na-K pump in the Ascending Loop of Henle
14
Q
What effect do Loop Diuretics have on urine?
A
They increase H2O in the urine
15
Q
What does the distal tubule in the nephron help regulate?
A
K, Na, Cl, pH
16
Q
Where do thiazide diuretics work in the nephron?
A
Distal tubule
17
Q
What is the effect of thiazide diuretics on calcium?
A
Keeps Ca, providing bone protection
18
Q
What are potassium sparing diuretics?
A
Diuretics that help retain potassium while promoting the excretion of sodium and water.
19
Q
Where do potassium sparing diuretics primarily act?
A
In the distal convoluted tubule and collecting duct.
20
Q
What is the primary effect of potassium sparing diuretics?
A
Decrease sodium and water reabsorption and increase potassium retention.
21
Q
What are some of the risk factors associated with Drug-induced nephrotoxicity?
A
- Decreased Renal Flow
- Nephrotoxic Medications
- Age
22
Q
What are some of the medications that are considered to be Nephrotoxic?
A
- Aminoglycosides
- Amp B
- Cisplatin
- Cyclosporine
- Loop Diuretics
- NSAIDS
- Polymixin
- Contrast Dye
- Tacrolimus
- Vancomycin
23
Q
What are the 2 most common lab values that we look at when estimating kidney function?
A
- BUN (measures nitrogen in the blood)
- Serum Creatinine
24
Q
What is the equation that we use to find the CrCl?
A
CrCl = [(140 - Age) / (72 x SCr)] x weight (kg) x 0.85 if female
25
When should the Cockcroft-Gault equation not be used for finding CrCl?
* In frail elderly patients,
* Children,
* Those with Kidney Failure, Those with unstable renal functions
26
What is the criteria in confirming that someone does have CKD?
* eGFR < 60,
* Albuminuria > 30
27
Who is recommended to use ACE inhibitors and ARBs?
Patients with hypertension and albuminuria
28
Why are ACE inhibitors and ARBs used in patients with albuminuria?
To prevent kidney disease progression
29
How do ACE inhibitors and ARBs function in the body?
They inhibit the renin-angiotensin-aldosterone system (RAAS), causing efferent arteriolar dilation
30
What are the effects of ACE inhibitors and ARBs on the kidneys?
They reduce pressure in the glomerulus, decrease albuminuria, and delay progression to ESRD
31
What are common scenario related to medications and kidney disease?
* The drug is eliminated through the kidneys.
* The drug is nephrotoxic.
* Drugs may become less effective as kidney function declines
32
What may be required for drug dosing in patients with kidney impairment when drug is eliminated renally?
The dose may require reduction and/or the dosing interval is extended.
33
List some key anti-infectives that require dose adjustments in CKD
* Aminoglycosides (increase interval)
* Beta-lactam antibiotics (except nafcillin, oxacillin, ceftriaxone)
* Fluconazole
* Quinolones (except moxifloxacin)
* Sulfamethoxazole/Trimethoprim
* Vancomycin
34
Which cardiovascular drugs require dose adjustments in CKD?
* Rivaroxaban (for AF)
* Apixaban (for AF)
* Dabigatran (for AF)
* LMWHs (enoxaparin)
35
What gastrointestinal drugs require dose adjustments in CKD?
* H2RAs (famotidine, ranitidine)
* Metoclopramide
36
List some pain/gout drugs that require dose adjustments in CKD
* Allopurinol
* Colchicine
* Gabapentin, pregabalin
* Morphine and codeine
* Tramadol
37
What is recommended for drugs when CrCl is ≤ 60 ml/min?
Dose adjustments may be necessary.
38
What does CrCl ≤ 30 mL/min indicate regarding kidney function?
Severely reduced kidney function.
39
Which drugs are contraindicated in CKD with CrCl < 30 mL/min?
Metformin
40
Which drug is contraindicated with CrCl < 60 mL/min?
Nitrofurantoin.
41
What is the significance of Tenofovir disoproxil fumarate containing products in CKD?
Contraindicated with CrCl < 50 mL/min.
42
What is the recommendation for metformin in CKD?
Do not start treatment if eGFR ≤ 45 mL/min/1.73 m².
43
For Stribild:
- Do not start if CrCl ____
- CI if CrCl ____
* Do not start if CrCl < 70
* D/C if CrCl < 50
44
What is hyperphosphatemia and its significance in CKD?
Hyperphosphatemia contributes to chronically elevated PTH levels (secondary hyperparathyroidism) and must be treated to prevent bone disease and fractures.
45
What dietary restrictions are recommended for patients with hyperphosphatemia?
Patients should avoid:
* Dairy products
* Cola
* Chocolate
* Nuts
46
What is the role of phosphate binders in CKD?
Phosphate binders block the absorption of dietary phosphate by binding to it in the intestine and are taken just prior to each meal.
47
What should a patient do if they miss a dose of phosphate binder?
If a dose is missed and the food is absorbed, the phosphate binder should be skipped, and the patient should resume normal dosing at the next meal or snack.
48
What are the three types of phosphate binders?
The three types of phosphate binders are:
* Aluminum-based
* Calcium-based
* Aluminum-free, calcium-free
## Footnote
Ferric citrate is systemically absorbed, while other aluminum-free, calcium-free products are not.
49
What are the treatments for low serum calcium in CKD?
Treatments include:
* Vitamin D
* Calcimimetic to lower PTH
50
What causes anemia in patients with CKD?
Anemia is caused by decreased erythropoietin (EPO) production by the kidneys, resulting in decreased red blood cell production in the bone marrow.
51
What side effects are associated with aluminum-based phosphate binders?
Side effects include:
* Aluminum intoxication (CNS and bone toxicity)
* Osteomalacia
* Constipation
* Nausea
52
What is the recommended dosage for aluminum hydroxide suspension?
300-600 mg PO TID with meals.
53
What are the side effects of Calcium-based binders?
Hypercalcemia, constipation, nausea
54
What should be monitored when using Calcium-based phosphate binders?
Ca, PO4, PTH
55
What must be done to Lanthanum carbonate tablets before swallowing?
Must chew tablet thoroughly
56
Sevelamer carbonate
Renvela
57
What are common side effects of Sevelamer products?
* Nausea/vomiting/diarrhea (all ~20%)
58
Sevelamer hydrochloride
Renagel
59
Separate the administration of Phosphate binders with ____
* levothyroxine.
* Quinolones and tetracyclines
* Oral bisphosphonates
60
What can sevelamer carbonate lower in patients?
Total cholesterol and LDL by 15-30%
61
What is vitamin D deficiency?
Occurs when the kidney is unable to hydroxylate vitamin D to its final active form, 1,25-dihydroxy vitamin D.
62
What are the two primary forms of vitamin D?
* Vitamin D3 (cholecalciferol)
* Vitamin D2 (ergocalciferol)
63
When should vitamin D analogs be reserved for use?
For the later stages of CKD (e.g., stages 4 and 5) with severe and progressive hyperparathyroidism.
64
What effects do vitamin D analogs have?
* Increase calcium absorption from the gut
* Increase serum calcium concentrations
* Inhibit PTH secretion
65
What is calcitriol?
The active form of vitamin D3.
66
What are some newer vitamin D analogs?
* Paricalcitol
* Doxercalciferol
67
How does cinacalcet function?
It mimics the actions of calcium on the parathyroid gland, causing a reduction in PTH.
68
In which patients is cinacalcet used?
Only in dialysis patients.
69
What is warning for vitamin D analogs?
Hypercalcemia
70
What should be monitored when using vitamin D analogs?
* Calcium (Ca)
* Phosphate (PO4)
* PTH
* 25-hydroxy vitamin D (calcifediol)
71
Calcitriol
Sensipar
72
What are warning for calcimimetics?
Hypocalcemia.
73
What side effects are associated with etelcalcetide?
* Muscle spasm
* Paresthesia
74
What happens to EPO production as kidney function declines?
EPO production decreases
75
What are erythropoiesis-stimulating agents (ESAs)?
Agents that work like EPO to produce more RBCs
76
Name two examples of ESAs.
* Epoetin alfa (Procrit, Epogen, Retacrit)
* Darbepoetin alfa (Aranesp)
77
What are the risks associated with ESAs?
* Elevated blood pressure
* Thrombosis
78
When should ESAs be used based on Hgb levels?
When the Hgb is < 10 g/dL
79
What should be done if Hgb exceeds 11 g/dL while using ESAs?
The dose should be held or discontinued
80
What is necessary for ESAs to be effective?
Adequate iron must be available to make Hgb
81
What is the normal range for potassium levels?
3.5 - 5 mEg/L
82
What is hyperkalemia?
Potassium level > 5 mEg/L
83
What hormone increases renal potassium excretion?
Aldosterone
84
Which type of diuretics is more effective in increasing renal potassium excretion?
Loops > thiazides
85
What effect does insulin have on potassium levels?
Causes potassium to shift into the cells
86
What is the most common cause of hyperkalemia?
Decreased renal excretion due to kidney failure
87
Why are patients with diabetes at higher risk for hyperkalemia?
Insulin deficiency reduces the ability to shift potassium into the cells
88
What symptoms can be present with hyperkalemia?
* Muscle weakness
* Bradycardia
* Fatal arrhythmias
89
List drugs that can cause hyperkalemia
1. ACE inhibitors
2. Aliskiren
3. ARBs
4. Canagliflozin
5. Drospirenone-containing COCS
6. Potassium-containing IV fluids (including parenteral nutrition)
7. Potassium-sparing diuretics (e.g., triamterene, spironolactone)
8. Potassium supplements
9. Sulfamethoxazole/Trimethoprim
10. Transplant drugs (cyclosporine, tacrolimus)
90
What is the first step in treating hyperkalemia?
All potassium sources must be discontinued
91
What is the urgent clinical need in severe hyperkalemia?
Stabilize the myocardial cells to prevent arrhythmias
92
What is the preferred medication for stabilizing the heart in hyperkalemia?
Calcium gluconate
93
What is the onset time for calcium gluconate administration?
1-2 minutes
94
Which medications are used to shift K into the cells?
1. Regular insulin + Dextrose
2. Sodium bicarbonate
3. Albuterol
95
Which medication is used to eliminate potassium in the urine?
1. Loop diuretics
2. sodium polystyrene sulfonate
3. Patiromer
4. Sodium Zirconium cyclosilicate
5. Hemodialysis
96
What is the onset time for loop diuretics administered IV?
5 minutes
97
What is the main adverse effect associated with sodium polystyrene sulfonate?
Gastrointestinal necrosis
