Kidney Disease

Question 1

SGLT2 inhibitors inhibit glucose reabsorption in the…

Answer 1

proximal tubule

Question 2

Loop diuretics inhibit the Na-K-Cl pump, causing more excretion and less Na and Ca reabsorption in the…

Answer 2

ascending loop of henle (25% of Na is reabsorbed here)

Question 3

Thiazide diuretics inhibit the Na-Cl pump, causing less Na reabsorption, and increase Ca reabsorption at the Ca pump in the…

Answer 3

distal convoluted tubule (DCT)

Question 4

Aldosterone works in the DCT and collecting duct to increase Na/water reabsorption and…

Answer 4

decrease K reabsorption

Question 5

Aldosterone antagonists block aldosterone so more Na/water is excreted in the urine and serum K…

Answer 5

increases

Question 6

Drugs that cause kidney disease include…

Answer 6

aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAIDs, polymyxins, radiographic contrast dye, tacrolimus, vancomycin

Question 7

Risk factors for drug-induced kidney disease include…

Answer 7

taking multiple kidney toxic drugs, existing kidney disease, decreased blood flow to the kidneys, elderly age

Question 8

CKD is defined as a GFR…

Answer 8

<60 mL/min

Question 9

Albuminuria is defined as an ACR greater than or equal to…

Answer 9

30

Question 10

C/I (CrCl <60 mL/min)

Answer 10

Nitrofurantoin

Question 11

C/I (CrCl <50 mL/min)

Answer 11

TDF-containing products (e.g. Stribild, Complera, Atripla, Symfi, Symfi Lo), voriconazole IV (due to vehicle)

Question 12

C/I (CrCl <30 mL/min)

Answer 12

TAF-containing products, NSAIDs, dabigatran, rivaroxaban

Question 13

C/I (CrCl <30 mL/min)

Answer 13

SGLT2 inhibitors, metformin, meperidine

Question 14

C/I (CrCl <30 mL/min): Others

Answer 14

Avanafil, bisphosphonates, duloxetine, fondaparinux, K-sparing diuretics, tadalafil, tramadol ER, dofetilide, edoxaban, glyburide, sotalol

Question 15

Complications of CKD include:

Answer 15

Increased PO4 (phosphate), decreased vitamin D and calcium, decreased EPO

Question 16

Hyperphosphatemia must be treated and leads to chronically elevated…

Answer 16

parathyroid hormone (PTH) levels

Question 17

Three types of phosphate binders include:

Answer 17

1) Aluminum-based
2) Calcium-based (first-line)
3) Aluminum-free, calcium-free drugs

Question 18

Vitamin D cannot be activated by the kidney, causing dietary calcium absorption to decrease. Ca is pulled from the bone, causing…

Answer 18

bone demineralization and increased fractures

Question 19

Treatment for hyperphosphatemia includes restricting dietary phosphate (e.g. dairy products, cola, chocolate, nuts) and using…

Answer 19

phosphate binders. Counsel patients to take doses right before or with meals.

Question 20

Phosphate binders interact with many drugs including…

Answer 20

levothyroxine, quinolones, tetracyclines, oral bisphosphonates, others

Question 21

Healthy kidneys hydroxylate vitamin D to its active form…

Answer 21

1,25- dihydroxy vitamin D

Question 22

In CKD patients, anemia can be treated using…

Answer 22

Erythropoietin stimulating agents (ESAs) and iron

Question 23

ESAs have risks and should only be used when…

Answer 23

Hbg <10 g/dL

Question 24

ESAs are only effective if…

Answer 24

adequate iron is available to make Hbg (supplement if needed)

Question 25

A normal K level is...

Answer 25

3.5-5 mEq/L. Higher than this may lead no symptoms, or muscle weakness, bradycardia, and fatal arrhythmias.

Question 26

Drugs that may raise K levels include...

Answer 26

ACE inhibitors, aldosterone receptor antagonists, ARBs, aliskiren, canagliflozin, drospirenone-containing COCs (Yaz), K-containing IV fluids, K supplements, SMX/TMP, transplant drugs (cyclosporine, everolimus, tacrolimus), glycopyrrolate, heparin, NSAIDs, pentamidine

Question 27

Risk factors for hyperkalemia include:

Answer 27

diabetes (insulin deficiency reduces the ability to shift K into the cells) and hospitalized patients

Question 28

Steps for treating severe hyperkalemia:

Answer 28

1) Stabilize the heart to prevent arrhythmias (IV Calcium gluconate) 2) Move K intracellularly with IV regular insulin + IV dextrose, IV Na bicarb, if metabolic acidosis is present, and nebulized albuterol. 3) Remove K using IV furosemide, rectal SPS, patiromer, sodium zirconium cyclosilicate, HD.

Question 29

As CKD progresses, bicarbonate reabsorption decreases, leading to..

Answer 29

metabolic acidosis

Question 30

When serum HCO3 < 22 mEq/L, treat metabolic acidosis using...

Answer 30

sodium bicarbonate, sodium citrate/citric acid solution. Monitor sodium levels.

Question 31

Which factors affect drug removal during dialysis?

Answer 31

1) MW/size: smaller molecules are more readily removed 2) Vd: drugs with a large Vd are less likely to be removed 3) Protein-binding: highly protein-bound drugs are less likely to be removed by dialysis 4) Dialysis membrane: high-flux and high-efficiency HD filers remove more substances 5) Blood flow rate: higher dialysis blood flow rates increase drug removal over a given time

Question 32

JS has been using famotidine 20 mg BID for 5 years. His renal function has worsened over time from 78 mL/min to 26 mL/min. Which statement is true regarding his famotidine use?

Answer 32

Famotidine could accumulate and cause adverse effects. Same is true of other drugs that are renally cleared.

Question 33

Where would bumetanide exert it's MOA?

Answer 33

thick ascending limb of the loop of Henle

Question 34

Which drugs can require a decrease in dose or an increase in dosing interval with impaired renal function?

Answer 34

``` Antibiotics 1) Aminoglycosides (increase interval) 2) Beta-lactams (except antistaph pencillins and ceftriaxone) 3) Fluconazole 4) Quinolones (except moxifloxacin) 5) Vancomycin CV drugs 1) LMWHs (enoxaparin) 2) rivaroxaban, apixaban, dabigatran GI drugs 1) H2RAs (famotidine, ranitidine) 2) Metoclopramide Others: bisphosphonates, lithium, topiramate ```

Question 35

Which drugs can require a decrease in dose or an increase in dosing interval with impaired renal function? (continued)

Answer 35

``` Antibiotics 6) amphotericin B 7) anti-TB meds (ethambutol, pyrazinamide) 8) antivirals (acyclovir, valacylovir, ganciclovir, valganciclovir, oseltamivir) 9) aztreonam 10) NRTIs, including tenofovir 11) polymyxins 12) SMX/TMP CV drugs 3) antiarrhythmics (digoxin, disopyramide, dofetilide, procainamide, sotalol) 4) most statins Pain/Gout 1) allopurinol 2) colchicine 3) gabapentin, pregabalin 4) morphine, codeine 5) tramadol ER Transplant 1) cyclosporine 2) tacrolimus ```

Question 36

What is the primary dietary source of vitamin D?

Answer 36

Vitamin D2 (ergocalciferol)

Question 37

Calcitriol (Rocaltrol) is the active form of vitamin D3. Tri= 3. Newer vitamin D analogs, like paricalcitol and doxercalciferol, are associated with less...

Answer 37

hypercalcemia than calcitriol

Question 38

CrCl (mL/min) =

Answer 38

[140- (patient age)]/(72 x SCr)* weight (kg) * 0.85 (if female)

Question 39

SC has lupus-related renal disease. Her serum creatinine today is 2.7 g/dL and the K is 6.2 mEq/L. In order to reduce the potassium, the physician has prescribed SPS. When can the physician expect the effects to start?

Answer 39

hours to days

Question 40

Aluminum hydroxide, suspension

Answer 40

Al-based phosphate binder, rarely used due to risk of accumulation (expect short term). S/E: Al intoxication, "dialysis dementia", osteomalacia, constipation, nausea Monitoring: Ca, PO4, PTH, ss of Al toxicity

Question 41

Calcium-based phosphate binders: first-line.

Answer 41

1) Calcium acetate (Phoslyra, PhosLo) 2) Calcium carbonate (Tums) S/Es: hypercalcemia, constipation, nausea Monitor: Ca, PO4, PTH Total daily dose of elemental Ca be <2,000 mg (from diet and supplements) Note: Calcium acetate binds dietary phosphorus on an elemental calcium basis than Tums Hypercalcium is especially problematic with concomitant use of vitamin D (due to increased calcium absorption)

Question 42

Al and Ca- free binders: more $.

Answer 42

1) Sucroferric oxyhydroxide (Velphoro), chewable tablet. 2) Ferric citrate (Auryxia), tablet. Warnings: iron absorption occurs with ferric citrate; dosage reduction of IV iron may be necessary; store out of reach of children to prevent accidental OD. S/Es: diarrhea, constipation, discolored (black) feces Monitoring: iron, ferritin, TSAT (only with ferric citrate), PO4, PTH Notes: Absorption is minimal with sucroferric oxyhydroxide

Question 43

All phosphate binders should be divided TID and taken...

Answer 43

with meals

Question 44

Lanthanum carbonate (Fosrenol); chewable tablet, powder

Answer 44

C/Is: GI obstruction, fecal impaction, ileus S/Es: N/V/D, constipation, abdominal pain *Must chew tablet thoroughly to reduce risk of severe GI adverse effects. Use powder if unable to chew. Monitoring: Ca, PO4, PTH

Question 45

sevelamer carbonate (Renvela); sevelamer HCl (Renagel)

Answer 45

*Not systemically absorbed C/I: bowel obstruction Warnings: can reduce dietary absorption of vitamins D, E, K and folic acid (consider supplementation) Tablets can cause dysphagia and get stuck in the esophagus; consider powder if unable to swallow. S/Es: N/V/D (all >20%), dyspepsia, constipation, abdominal pain, flatulence Monitoring: Ca, PO4, HCO3, Cl, PTH Notes: can lower total cholesterol and LDL by 15-30%. Sevelamer carbonate can maintain bicarbonate concentrations.

Question 46

Separate phosphate binders from...

Answer 46

levothyroxine and antibiotics that chelate (e.g. quinolones, tetracycline)

Question 47

Vitamin D analogs: increase intestinal absorption of Ca, which provide negative feedback to parathyroid

Answer 47

1) calcitriol (Rocaltrol) 2) calcifediol (Rayaldee), ER capsule (prodrug of calcitriol). Taken with food or after a meal. 3) doxercalciferol (Hectorol) 4) paricalcitol (Zemplar) C/Is: hypercalcemia, vitamin D toxicity Warnings: digitalis toxicity potentiated by hypercalcemia S/Es: hypercalcemia, hyperphosphatemia, N/V/D (<10%) Monitor: Ca, PO4, PTH, 25-hydroxy vitamin D

Question 48

Calcimimetics: | Cinacalcet (Sensipar); etelcalcetide (Parsabiv) IV only

Answer 48

*Only use in dialysis patients MOA: Increases sensitivity of the calcium-sensing receptor on the parathyroid gland, which causes decreased PTC, Ca, PO4 C/Is: hypocalcemia Warnings: caution in patients with seizure history S/Es: hypocalcemia, N/V/D, paresthesia, HA, fatigue, depression, anorexia, constipation, bone fracture, weakness, arthralgia, myalgia, limb pain, URTIs

Question 49

Sodium polystyrene sulfonate (SPS, Kayexalate); | powder, oral suspension, rectal suspension

Answer 49

Warnings: electrolyte disturbances (hypernatremia, hypokalemia, hypomagnesemia, hypocalcemia, fecal impaction, GI necrosis (increased risk when given with sorbitol; do not use together) Can bind other oral meds (separate) S/Es: N/V, constipation or diarrhea Monitoring: K, Mg, Na, Ca Notes: do not mix oral products with fruit juices containing K

Question 50

Patiromer (Veltassa); powder for oral suspension Instructions: measure 1/3 cup of water and pour half into an empty cup; empty packet contents into the water and stir well; add the remaining water and stir well; drink the mixture right away.

Answer 50

Warnings: can worsen GI motility, hypomagnesemia Binds to many oral drugs; separate by at least 3 hours before or after Monitor: K, Mg Notes: delayed onset of action (~7 hours); not for emergencies Store powder in fridge (must be used within 3 months if stored at room temperature)

Question 51

Sodium zirconium cyclosilicate (Lokelma); powder for oral suspension Instructions: empty packet contents into a cup with at least 3 tablespoons of water; stir well and drink immediately (if powder remains in the cup, add additional water and drink; repeat as needed)

Answer 51

Warnings: can worsen GI motility, edema, contains sodium (may need to adjust dietary Na intake. S/Es: peripheral edema Notes: Can bind other drugs; separate by at least 2 hours before or after Delayed action (~1 hour); not for emergency use Store at room temperature

Question 52

Metabolic acidosis; treat when serum bicarbonate <22 mEq/L. Drugs to replace bicarb are:

Answer 52

1) Sodium bicarbonate (Neut). Monitor Na, can cause fluid retention 2) Sodium citrate/citric acid solution (Cytra-2, Oracit, Shohl's solution). Note: metabolized to bicarb b the liver; may not be effective in patients with liver failure. Monitor Na.