What is a normal albumin to creatinine ratio? (ACR)
<2mg/mmol is normal
What can cause higher ACRs? (other than CKD)
UTI Febrile illness Exercise Decompensated CHF Menstruation Acute, severe elevation of blood glucose or blood pressure
What is the ACR range for microalbuminuria?
2-20
How do you test for microalbuminuria?
Several samples over 3 months, 2 samples have to be positive
What drug should diabetics with CKD or HTN receive? Why?
ACEi or ARB
Delay progression of CKD
When do you want to check bloodwork when you start an ACEi? What are you looking for?
Within 1-2 weeks
Make sure potassium levels within normal range
Make sure SCr does not raise more than 30%
Should you use an ACEi and ARB together??
no - more adverse outcomes
Is an ACEi contraindicated if CrCl <30?
NO - unless SCr increases above 30%, or increase K+, or dehydrated
How do you adjust calcium levels based on albumin?
For every 10g/L drop in albumin from 40g/L, calcium behaves like it’s 0.2 mmol/L higher
Explain what happens if someone with kidney disease eats too much phosphate
Too much phosphate will accumulate because the kidney is not filtering efficiently. Also not removed by dialysis.
Phosphate binds with calcium, forms deposits in body (coronary arteries, under skin).
How does the parathyroid react in regards to high phosphate levels?
Phosphate binds calcium, thus lowering calcium levels in blood. Parathyroid detects low calcium, releases PTH, takes calcium from bone.
= bone disease (osteitis fibrosa cystica)
What’s the best way to manage phosphate levels in CKD?
Decrease phosphates in their diets.
How do drugs that control phosphate levels work?
Drug binds to phosphate from food in stomach before getting absorbed, gets removed in stool
What are the 3 phosphate binders we were told to know about?
Calcium Carbonate
Sevelamer (Renagel)
Lanthanum (Fosrenol)
What’s a worry with taking calcium carbonate as a phosphate binder?
Hypercalcemia
Sometimes doesn’t control phosphates well enough
What’s a normal phosphate level? What is the target in CKD?
Normal 1.45 mmol/L
Don’t really have a target, not much evidence in trying to get close to normal, generally target around 1.8 mmol/L
Renagel… what is it, daily dose, when is it good
Sevelamer
800mg/day, given **with meals (titrate to adjust if needed)
Doesn’t have calcium
- Good if patient hypercalcemic with calcium carbonate
Really expensive
Fosrenol - what is it, dose, what about it
Lanthanum
250-1000mg/day, given TID **with meals
Causes nausea, doesn’t work much better than renagel or calcium
More expensive than renagel
How do you control high PTH levels?
Calcitriol (activated vitamin D – not OTC)
When do you start calcitriol?
When calcium and phosphate levels are in normal range
Why can’t you use regular OTC vitamin D to control phosphate levels?
Kidneys have to activate vitamin D first before it can work - if kidneys aren’t working, need to give activated vitamin D (calcitriol)
What is the normal range for PTH?
300-350
Side effects of calcium carbonate?
GI (N/V/D, constipation) Hypercalcemia Pruritis Xerostomia Muscle cramps
Side effects of sevelamer (Renagel)?
GI (N/V/D, abdominal pain, constipation) - high
Metabolic acidosis
Peritonitis
Side effects of lanthanum (Fosrenol)?
GI (N/V/D, constipation, dyspepsia) Hypercalcemia Muscle cramp Edema Myalgia Peritonitis
Calcium carbonate interactions?
Interferes with absorption of ASA, digozin, isoniazid, quinolone, tetracycline
Which phosphate binder should not be taken on an empty stomach?
Lanthanum (fosrenol) - can cause nausea and vomiting
Which phosphate binder should be taken just before eating, and can’t be cut or chewed?
Sevelamer (renagel) - contents expand in water, can cause choking
List some high phosphorus foods
Bran Basking powder Milk products Whole wheat bread Dried beans and peas Nuts Pizza Processed meats Colas Chocolate TV dinners
List some low phosphorous foods
Fresh meats Fish Plain cookie, soda crackers White rice, bread, noodles Cream of wheat Corn flakes Popcorn Pie Fresh fruit and vegetables Jam Coffee/tea/non-cola pop Original rice beverage