CKD anemia

Question 1

what alterations in RBC indices are expected for CKD of anemia

Answer 1

RBC decreased
Hgb decreased
MCV normal
MCHC normal
reticulocyte count decreased

Question 2

what is the primary cause of CKD anemia

Answer 2

decreased erythropoietin production

Question 3

goal level for Hgb in CKD

Answer 3

10-11.5

Question 4

when is PRBC transfusion indicated

Answer 4

Hgb<7

Question 5

when is ESA indicated

Answer 5

Hgb<10 or 9-10 on dialysis

Question 6

when is iron supplementation indicated

Answer 6

Tsat <30%
serum ferritin <500

(peds: Tsat <20%, serum ferritin <100)

Question 7

when to give PO vs IV iron

Answer 7

IV: patient on ESA, or PO iron inadequate
PO: patient not on ESA

Question 8

definition of anemia

Answer 8

Males: Hgb<13
females: Hgb<12

Question 9

CKD anemia is _____ and ______ anemia

Answer 9

normocytic, normochromic
(cells are normal in size and color)

Question 10

counseling for PO iron supplements

Answer 10

absorption is improved when taken on an EMPTY stomach

Question 11

when to administer IV iron products

Answer 11

after dialysis session
monitor for ~30 mins for infusion reaction

Question 12

when to monitor iron therapy

Answer 12

1-3 months
discontinue when iron stores are consistently above goal:
TSat>30%
Serum ferritin >500

Question 13

what are the actions of the erythropoiesis stimulating agents (ESAs)

Answer 13

stimulate division & differentiation of erythroid progenitor cells; increase release of reticulocytes from bone marrow into blood stream

Question 14

black box warning for ESAs

Answer 14

for CKD: increased risk of death and CV events with Hgb target> 11 g/dL- USE LOWEST DOSE POSSIBLE

Question 15

what are the ESA names?

Answer 15

Epoetin alfa (Epogen, Procrit)
Epoetin alfa-epbx (biosimilar- Retacrit)
Darbepoetin alfa (Aranesp)
Methoxy PEG-epoetin beta (Mircera)
ALL ARE EQUALLY EFFECTIVE THEY JUST HAVE DIFFERENT ADMINISTRATION

Question 16

when to monitor ESA therapy?

Answer 16

1 month
might take 4-6 weeks to see complete response
if iron stores are adequate, Hgb increases by 0.2-0.5 per week
HOLD ESAS WHEN HGB> 11.5

Question 17

what are hypoxia-inducible factor (HIF-PH) inhibitors?

Answer 17

HIF is a transcription factor for EPO production, produced in response to hypoxia. HIF is degraded by enzyme HIF-prolyl-hydroxylase 2.
Daprodustat (Jesduvroq) inhibits this enzyme to stabilize HIF so effects are increased Hgb, physiologic EPO levels, improves iron absorption and improves iron deficiency

Question 18

when is daprodustat indicated and what are the black box warnings

Answer 18

indications: anemia of CKD in adults receiving dialysis for >4 months
boxed warnings: thrombosis and CV events; targeting Hgb > 11 increases death and arterial thrombosis- use lowest dose possible

Question 19

what are the hormones involved in calcium and phosphorus regulation

Answer 19

parathyroid hormone
vitamin D
fibroblast growth factor-23

Question 20

effects on calcium and phosphorus regulation when GFR<60 in CKD?

Answer 20

Net effects: Phos levels can be maintained initially, Ca levels usually decrease

Question 21

effects on calcium and phosphorus regulation when GFR<30 in CKD?

Answer 21

net effects: Ca levels decrease, Phos levels increase

Question 22

what is the effect of hyperparathyroidism in CKD

Answer 22

BONE DISEASE!

Question 23

osteomalacia

Answer 23

low burn turnover with low bone mineralization

Question 24

adynamic bone disease

Answer 24

very low bone turnover

Question 25

osteitis fibrosa cystica

Answer 25

high bone turnover

Question 26

what happens as phosphorus continues to rise, that impacts the heart?

Answer 26

phosphorus likes to bind to calcium: calcification in the heart

Question 27

goals for phosphorus Stages G3-G5D

Answer 27

near normal (2.5-5)

Question 28

goals for calcium Stages G3-G5D

Answer 28

avoid hypercalcemia

Question 29

goals for PTH G5D

Answer 29

2-9x normal (cannot get it down to normal)

Question 30

options for management of hyperphosphatemia in CKD

Answer 30

Non pharm: dietary phos restriction (dairy, dark cola, chocolate) Dialysis Pharmacologic: Phosphate binders -Non-calcium containing -Iron containing -Calcium containing -Aluminum and magnesium containing -

Question 31

general actions of phosphate binders

Answer 31

decrease phos decrease pth no effect on vitamin d

Question 32

counseling for all phosphate binders (def exam question)

Answer 32

give just before or with meals (phos comes from food!)

Question 33

what are the non-calcium containing phosphate binders and their pros/cons

Answer 33

first line agents; best for hypercalcemia or soft tissue calcifications Sevelamer/sevelamer carbonate: also has favorable effect on cholesterol. carbonate preparation also has effect on bicarb. CONS being may require high doses. ADEs are nausea vomiting diarrhea lanthanum carbonate: PRO being few reported drug interactions. CONS are palatability, cost, GI effects

Question 34

what are the iron containing phosphate binders and their pros/cons

Answer 34

can be first line; best for concomitant anemia Sucroferric oxyhydroxide-- PROS: insoluble form of iron, lower pill burden. CONS: GI effects, can't take with Synthroid, take 1 hr after doxycycline and alendronate. Ferric citrate-- PROS: each tab contains 210 mg iron so good for iron deficiency, can increase serum ferritin and TSAT levels. CONS: GI EFFECTS, constipation

Question 35

what are the calcium containing phosphate binders and their pros/cons

Answer 35

calcium carbonate: 40% of tablet strength is calcium; 20-30% calcium absorbed may require high doses calcium acetate: less calcium absorption than calcium carbonate; binds twice as much phosphorus. PROS: cheap, lots of products available CONS: constipation, disrupts calcium balance in CKD current guidelines: restrict dose of calcium-containing phosphate binders

Question 36

what are the aluminum and magnesium containing phosphate binders and their pros/cons?

Answer 36

very limited role in CKD; best agents for AKI Aluminum hydroxide-- PROS: increased phosphorus binding capacity compared to calcium products. CONS: aluminum toxicity, constipation, bone mineral effects Magnesium carbonate-- PROS: increased phosphorus binding capacity compared to calcium products. CONS: increased magnesium accumulation; should only be used in CKD patients receiving hemodialysis, ADEs are hypermagnesemia and diarrhea.

Question 37

what are the options for management of hyperparathyroidism in CKD

Answer 37

1. phosphate binders (elevated phos stimulates the parathyroid glands to release PTH) 2. vitamin D analogs 3. calcimimetics 4. vitamin d supplementation

Question 38

indications for vitamin D analogs and what are the options

Answer 38

To inhibit PTH release in patients with evidence of bone disease. Calcium and phosphorus must be at goal before starting vitamin D analogs. Calcitriol, paricalcitol, doxercalciferol

Question 39

what are the calcimimetics

Answer 39

cinacalcet etelcalcetide can cause hypocalcemia; do not start if corrected Ca<8.4