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Critically Ill > CKD > Flashcards

CKD Flashcards

1
Q

What is CKD?

A

abnormalities of kidney structure or function present for >3 months with implications for health

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2
Q

How is CKD classified?

A
  1. Cause
  2. GFR category
  3. Albuminuria category
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3
Q

What is End Stage Renal Disease (ESRD)?

A
  1. GFR <15ml/min/1.73 m2
  2. pt requires dialysis
  3. renal transplant pts
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4
Q

What are risk factors for developing CKD?

A
  1. diabetes
  2. HTN
  3. obesity
  4. autoimmune disease
  5. systemic infections/UTIs
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5
Q

What are socioeconomic risk factors for CKD?

A
  1. older age
  2. AA, American indian, hispanic, pacific islander
  3. chemical exposure/environment
  4. low income/education
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6
Q

What are risk factors for progression of CKD?

A
  1. diabetes
  2. HTN
  3. proteinuria
  4. smoking
  5. obesity
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7
Q

When does CKD presentation usually occur?

A

asymptomatic until significant amount of renal function lost CKD stage 4/5

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8
Q

What are labs indicate CKD?

A
  1. BUN
  2. SCr
  3. urine albumin
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9
Q

What are signs of CKD?

A
  1. edema
  2. changes in urine output
  3. foaming of urine
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10
Q

What are the uremic symptoms associated with CKD?

A
  1. fatigue
  2. weakness
  3. SOB
  4. confusion
  5. itching
  6. cold intolerance
  7. peripheral neuropathies
  8. N/V/ loss of appetites
  9. bleeding
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11
Q

What are nonpharm treatments of CKD?

A
  1. exercise (30 min moderate intensity 5x weekly)
  2. weight loss if BMI >25 kg/m2
  3. <5g NaCl (2g Na) per day
  4. smoking cessation
  5. alcohol restriction (2 drinks/day for men and 1 drink/day for women)
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12
Q

What are pharm treatments for CKD?

A
  1. treat underlying conditions resulting in kidney damage
  2. vaccines (flu, pneumococcal, HepB)
  3. medications used to slow CKD
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13
Q

When should proteinuria (albuminuria) be treated?

A

stage A2 or higher

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14
Q

What is first line treatment for stage A2 or higher albuminuria?

A

low dose (2.5-5mg) ACEi or ARB

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15
Q

What patients should ACEs and ARBs be used in caution with?

A
  1. eGFR<30
  2. BP <110/70 mmHg
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16
Q

When should the dose of ACE/ARB not be titrated up in CKD?

A
  1. albuminuria reduced by 30-50%
  2. greater than 30% decrease in eGFR
  3. elevation in serum potassium
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17
Q

What should be added if patient is on max tolerated ACE/ARB and ARC>300?

A

SGLT2i:
Empagliflozin JARDIANCE 10mg QD
Dapagliflozin FARXIGA 10mg QD

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18
Q

What is first line treatment for stage A2 or higher AND HTN?

A

low dose (2.5-5mg) ACEi or ARB, once albumin excretion <30mg/24h or decreases 30-50% target a systolic BP of </=120mmHg

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19
Q

What is the BP goal for kidney transplant patients with stage A2 or higher AND HTN?

A

</=130/80

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20
Q

What can be added to achieve a BP goal of <120mmHg

A
  1. thiazides (loop if neccessary)
  2. aldosterone antagonists (especially if hypokalemic)
  3. non-DHP CCBs (Verapamil or Diltiazem)
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21
Q

What is the treatment for stage A2 and T2DM?

A
  1. SGLT2i +/- Merformin:
    Canagliflozin INVOKANA 100mg QD with the first meal of the day
    Empagliflozin Jardiance 10mg QD
    Dapagliflozin FARXIGA 10mg QD
  2. add on GLP-1 agonist if glucose target not met
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22
Q

When should Metformin regimens be reviewed and discontinued?

A

review: GFR 30-45 (lactic acidosis vs. A1c goal)
D/C: GFR <30

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23
Q

What can be used as an adjunctive agent for patients with persistently elevated albuminuria (ACR >30) and are receiving other preferred therapies?

A

Finerenone KERENDIA 10-20mg QD

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24
Q

What is the MOA of Finerenone?

A

non-steroidal selective mineralocorticoid receptor antagonist; mediates sodium reabsorption and over-activation in epithelial(kidney) and nonepithelial cells(vessels,heart)

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25
Q

What lab must be checked before starting Finerinone?

A

potassium </= 5mEq/L

26
Q

What is a serious concern with Finerenone KERENDIA? What precautions should be taken?

A
  1. reproductive warnings
  2. patients who can become pregnant need a negative pregnancy test and use at least 2 methods of birth control
27
Q

What is the A1c goal for patients with CKD and T2DM?

A

< 6.5-7%

28
Q

What is a concern with A1c values in patients with CKD?

A

red blood cell life span is decreased so HbA1c values may be falsely low

29
Q

What conditions lead to CKD that should be treated?

A
  1. CV disease
  2. dyslipidemia
30
Q

Why should patients with CKD not continue ESAs if Hb >11-11.5?

A

increases risk of death, serious CV reactions, stroke

31
Q

What is the KDIGO Hb goal for non-dialysis patients?

A

> 10 g/dL

32
Q

What is the Hb goal for dialysis patients CKD?

A

> 9 g/dL

33
Q

What Hb level indicates starting an ESA?

A

<10 g/dL

34
Q

What is the transferrin saturation goal for CKD?

A

> 30%

35
Q

What is the serum ferritin goal for CKD?

A

> 500 ng/dL

36
Q

What are non pharm treatments for anemia of CKD?

A
  1. diet (increase iron, folic acid, B-12)
  2. water-soluble vitamin supplement for patients on dialysis
37
Q

What are the pharmacologic options to treat anemia of CKD?

A
  1. iron
  2. ESA
  3. Hypoxia-inducible factor prolyl hydroxylase inhibit
38
Q

How is iron dosed for CKD?

A

200mg elemental iron PO QD for 1-3 months before assessing response

39
Q

What can decrease the absorption of iron?

A
  1. elevated stomach pH (PPIs)
  2. food
40
Q

What increases the absorption of iron?

A

Vitamin C

41
Q

Which route of iron is preferred for hemodialysis patients?

A

IV

42
Q

What are SEs of PO iron therapy?

A
  1. nausea
  2. constipation
  3. cramping
  4. false positive Hemoccult test
43
Q

What are SEs of IV iron?

A
  1. anaphylaxis
  2. iron overload
44
Q

Which IV iron requires a test dose due to the risk of anaphylaxis?

A

iron dextran

45
Q

How long does it take for ESAs to start working?

A

onset of action ~10 days

46
Q

What is an acceptable rate of increase in Hb per month?

A

1-2 g/dL/month

47
Q

When should the ESA dose be decreased by 25-50%?

A
  1. Hb increases >1 g/dL in 2 weeks
  2. Hb increases >2 g/dL in 4 weeks
48
Q

What should be done if Hb is >11 in a HD patient?

A

reduce the dose by 25% or temporarily discontinue

48
Q

What should be done if Hb is >10 in a non-HD patient?

A

reduce the dose by 25% or temporarily discontinue

49
Q

What should be done if ESA had to be temporarily D/C due to high Hb?

A
  1. restart at 75% of the dose once Hb starts to decrease
  2. increase ESA dose by 25% if Hb increases <1 g/dL in 4 weeks
50
Q

What are SEs with ESAs?

A
  1. HTN
  2. seizures
  3. thrombosis
51
Q

What is the t1/2 of epoetin (EPOGEN)?

A

IV: 8.5 h
SQ: 24 h

52
Q

What is the t1/2 of darbepoetin (ARANESP)?

A

IV: 24h
SQ: 48h

53
Q

What is the t1/2 of methoxy polyethylene glycol-epoetin beta (MIRCERA)?

A

IV: 119h
SQ: 124h

54
Q

What agent is an Hypoxia-inducible factor prolyl hydroxylase inhibitor?

A

Daprodustat JESDUVROQ

55
Q

What is a BBW with Daprodustat JESDUVROQ?

A
  1. increases thrombotic vascular events and CV events
  2. targeting Hb >11 is expected to further increase the risk of death and aterial venous thrombotic events
  3. use the lowest dose possible to reduce the need for red blood cell transfusions
56
Q

What are warnings and SEs with Daprodustat JESDUVROQ?

A
  1. increased risk of death, MI, stroke, VTE
  2. risk of hospitalization for HF
  3. HTN
  4. GI erosion
  5. malignancy
57
Q

How is Daprodustat JESDUVROQ dosed for adults on HD not receiving an ESA?

A

depends on Hb

58
Q

How is Daprodustat JESDUVROQ dosed for adults on HD not switching from an ESA?

A

depends on the current dose of ESA

59
Q

What is the generally accepted lowest Hb value that would prompt prescribers to administer packed RBCs?

A

Hb <7

60
Q

Why do clinicians want to avoid giving PRBCs?

A
  1. risks of infection
  2. immunologic reactions
  3. volume overload
  4. hyperkalemia
  5. iron overload
  6. cost
61
Q

How often should CKD patients be monitored for anemia?

A

every 3 months

Critically Ill (20 decks)

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