CKD

Question 1

List in order the leading causes of CKD

Answer 1

1. DM
2. HTN
3. Glomerulonephritis

Question 2

What is first line therapy for Diabetes + CKD? What does the urine albumin need to be to indicates use of these drugs?

Answer 2

ACE-1 or ARB

urine albumin >30 mg/24 hrs

Question 3

When do you want to stop increasing the dose of an ACE-1 or ARB with DM + CKD?

Answer 3

1. Urine albuminuria reduced by 30-50% OR
2. Significant decrease in GFR OR
3. Hyperkalemia

Question 4

HTN + CKD treatment and its effects on CKD?

Answer 4

ACE-1 and ARBs

Limits disease progression

Question 5

Pathogenesis of Anemia in CKD

Answer 5

Deficiency of erythropoietin production by kidneys

Question 6

Anemia treatment in CKD

Answer 6

ESA (erythropoietin stimulating agent) + Iron supplementation

Question 7

What does ESA increase your risk of?

Answer 7

CV events

Question 8

When do you initiate ESA in Non-Dialysis CKD?

Answer 8

If HgB <10 g/dL

DO NOT initiate if Hb ≥10 g/dL

Question 9

When do you initiate ESA in Dialysis CKD?

Answer 9

HgB between 9-10 g/dL to avoid drop in HgB to <9 g/dL

Question 10

What HgB levels do you NOT want to use ESA for?

Answer 10

Increase HgB over 13 g/dL OR

to maintain HgB above 11.5

Question 11

Iron initiation indications in CKD

Answer 11

If TSat is ≤30% (≤0.30) and ferritin is ≤500 ng/mL

Question 12

What is the MOA of Erythropoietin Stimulating Agents (ESA)?

Answer 12

1. Induces erythropoiesis by stimulating division/differentiation of progenitor cells
2. Induces release of reticulocytes from bone marrow to blood stream

Question 13

ESA Box warning

Answer 13

Increased CV and CKD events with Hg > 11g/dL

Question 14

Other ADE’s of ESA

Answer 14

1. Cancer
2. Shortened survival/increased progression in certain CA’s when HgB >12 g/dL
3. Increase risk of DVT

Question 15

What is the net serum effect of PTH?

Answer 15

1. Increased serum Ca+

2. Decreased serum Phosphorus

Question 16

What is the net serum effect of Vitamin D

Answer 16

Both serum Ca/P increases

Question 17

What is the net serum effect of Firbroblast growth factor 23 (FGF23)

Answer 17

Decrease in serum Phosphorus

Question 18

Management of CKD-MBD

Answer 18

1. Dietary Phosphorous restriction
2. Phosphate-binding agents
3. Vitam in D supplementation
4. Calcimimetic therapy

Question 19

List the phosphate-binding agents for the treatment of hyperphosphatemia

Answer 19

1. Calcium-based binders
2. Resnin binders
3. Iron-based binders

Question 20

Calcium-based binders MOA

Answer 20

1. Binds dietary phosphate to form insoluble calcium-phosphate
2. Excreted through feces

Question 21

ADE’s of Calcium-based binders

Answer 21

1. Hypercalcemia
2. Hypophosphatemia
3. Milk-alkali syndrome: HA, nausea, weakness, irritability, renal impairment, alkalosis

Question 22

List a Resin binder

Answer 22

Sevelamer Hydrochloride

Question 23

Sevelamer Hydrochloride MOA

Answer 23

Binds phosphate in intestinal lumen to limit absorption

Question 24

Sevelamer Hydrochloride clinical indications

Answer 24

1. Tx of hyperphosphatemia in CKD pt’s

2. Patients @ risk of extra-skeletal calcification

Question 25

What does Sevelamer Hydrochloride lower?

Answer 25

LDL

Question 26

Sevelamer Hydrochloride ADE's

Answer 26

1. Metabolic acidosis 2. N/V/D 3. Dyspepsia

Question 27

What is unique about the Lanthanum Carbonate half life?

Answer 27

Half life in bones= 2-3.6 years | Potential for accumulation of lanthanum

Question 28

Lanthanum Carbonate ADE's

Answer 28

1. N/V 2. Abdominal pain 3. Constipation 4. Dyspepsia 5. Bowel obstruction 6. Fecal impaction

Question 29

Aluminum Hydroxide MOA

Answer 29

Binds phosphate in GI tract to prevent absorption

Question 30

Why isn't Aluminum Hydroxide a first line agent?

Answer 30

Risk of aluminum toxicity

Question 31

Who do we use Aluminum Hydroxide in?

Answer 31

Short-term (4 weeks) in patients w/ hyperphosphatemia that are not responding to other binders

Question 32

Aluminum Hydroxide ADE's

Answer 32

1. Constipation 2. Fecal impaction 3. Hypomagnesemia 4. Hypophosphatemia

Question 33

List the Vitamin D analogs used for ESRD

Answer 33

IV or PO: 1. Doxercalciferol 2. Paricalcitol * Already activated

Question 34

What would we use in a patient with hypocalcemia and chronic renal dialysis?

Answer 34

Calcitriol=active form of Vitamin D

Question 35

List Vitamin D agents and dosing

Answer 35

1. Ergocalciferol D2: daily doses, active metabolite D3 | 2. Cholecalciferol D3: higher doses, weekly or monthly

Question 36

Indications for Ergocalciferol D2 and Cholecalciferol D3

Answer 36

1. Hypophosphatemia | 2. Hypoparathyroidism

Question 37

Ergocalciferol D2 and Cholecalciferol D3 (Vitamin D agents) ADE's

Answer 37

Hypercalcemia

Question 38

What vaccines is recommended annually for CKD patients?

Answer 38

Influenza

Question 39

What vaccines are indicated in GFR <30?

Answer 39

1. Pneumococcal vaccine | 2. Hepatitis B vaccine

Question 40

Epoetin alfa dosing

Answer 40

3x/wk

Question 41

Darbopoetin alfa dosing

Answer 41

1x/month

Question 42

Methoxy PEG-epoetin beta dosing

Answer 42

Every 2 weeks | Once HgB stabilizes, double the dose and administer monthly

Question 43

List the Phosphate binders that lower LDL

Answer 43

Resnin Binders 1. Sevelamer Carbonate 2. Sevelamer Hydrochloride