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Module 6: Mali: Renal > Pharm Cases > Flashcards

Pharm Cases Flashcards

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1
Q

Case #1: a 74 year old has dysphagia and hypokalemia and HTN. H&H 11/34. HCTZ. Amlodipine. Atorvastatin. 3 DOC considerations?

A

DOC1: stop HCTZ since that can cause hypokalemia
DOC2: start KCl IV since she has dysphagia and the pills are about the size of waffles
DOC3: eythropoetin for low H&H since used for anemia in CKD

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2
Q

what are the most two common SE associated with K loss?

A

nausea/diarrhea

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3
Q

if someone has hypokalemia what are the 4 diuretics would you consider?

A

K sparing:

  1. spirolactone
  2. eplenerone
  3. amiloride
  4. tiamterene (adjunct)
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4
Q

if someone has hyperkalemia….what should you do?

A

get a EKG to check for T wave changes

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5
Q

what is the name of the drug that can increase risk of gyneocomastic in men?

A

spirolactone

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6
Q

which two drugs are thought to decrease myocardial remodeling secondary to aldosterone?

A

k sparing

  1. spirolactone
  2. eplenerone
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7
Q

what is a weak diuretic usually combined with others as adjunct?

A

tiamterene, adjunct k+ sparing

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8
Q

Case#2: 60 year old with stage 4 CKD who needs to reduce his serum phosphate levels. HTN. T2DM. Hyperlipidemia. Lisinopril. Atorvastatin 20 mg. two DOC considerations?

A

elevated serum phosphate level secondary to stage 4 CKD

DOC: sevelamer TID with every meal
DOC2: consider uping atorvastatin to 40mg since stage 4 CKD, he may do ok on just the 20 mg

benefit of sevelamer: this drug reduces LDL by 30% which is good because this pt has hyperlipidemia

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9
Q

what is a benefit of taking sevelamer? how must it be taken?

A

benefit: reduces LDL by 30% as benefit to lowering phosphorus levels (good for people with high phosphate AND dyslipidemia)

must be taken WITH meals!!

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10
Q

can you crush, break, chew or break the sevelamer tablets?!

A

NO….DONT DO IT!!!

just dont.

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11
Q

where does selvelamer bind phosphate?

A

BINDS PHOSPHORUS IN THE INTESTINAL TRACT

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12
Q

if you have high phosphate levels, what 3 foods should you avoid?

A

red meds, nuts, seeds

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13
Q

what is one major side effect of sevelamer that you want to be aware of before prescribing to patients because it is common?

A

ask the pt if they have a hx of chronic constapation because this can be a side effect of this medication and can lead to a BOWEL OBSTRUCTION!!

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14
Q

Case #3: a 70 year old pt with CKD that has progressed from 45 to 30 ml/min. HTN. COPD. Osteoarthritis. Ibuprophen 800 mg BID. Lisinopril 20 mg. Advair. 3 DOC considerations?

A

DOC: take off ibuprophen since that increase HTN
DOC 2: give corticosteroid injections for pain instead of Ibuprophen
DOC 3: lower the dose of linsinopril in eGFR is less than 30 (2.5 mg)

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15
Q

what effect do NSAIDS have on BP and how do they accomplish this? (2 things and causes 1 thing)

A
  1. NSAIDS inhibit prostaglandins that cause dilation so you get renal artery constriction which activates RAAS
  2. increased retention of Na/H2O

Get decreased profusion to renal afferent arterioles

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16
Q

what is a risk of taking tramadol?

A

seizure

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17
Q

case #4: 65 y/o patient with gout, HTN, osteoarthritis, angina. At his follow up his eGFR is 34 ml/min. uric acid is fine. Allopurinol. Amlopdipine. Atenolol 50 mg. NTG. Acetaminophen. what are the four drug choices to take into consideration?

A

DOC1 stop atenolol because 50% of active drug is renally excreted so if CKD progresses, the metabolism of atenolol decrease so more will remain in his system
DOC2: SWITCH ATENOLOL TO ACE
DOC3 try decreasing the dose of allopurinol because it accumulates in CKD and is nephrotoxic
DOC4: HD statin because of CKD
DOC5: clopidogrel antiplatelet therapy due to gout because of angina

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18
Q

allopurinol is toxic to the _____

A

KIDNEYS! consider this when patients are taking it for gout!

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19
Q

what do you need to keep in mind about atenolol and CKD?

A

50% of this drug are renally excreted in the ACTIVE form, so if your kidney is shot, the active form stays in the body which is NOT GOOD!

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20
Q

ACE inhibitors exert their force on what part of the kidney SPECIFICALLY?

A

dilate the EFFERENT arteriole and decrease pressure in the glomerulus, this is what its good for CKD

exert their effect on ARTERIOLES

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21
Q

case #5 65 y/o patient with gout, HTN, ANGINA and now has been diagnosed with T2DM with a A1c of 11. eGFR of 25 ml/min. uric acid ok. allopurinol. amlodipine. atenolol 50mg. NTG. Ibuprofen 800 mg. what are the four DOC considerations for this?

A

stage 4 CKD with end organ damage

DOC1: switch atenolol for ACE 2.5 mg because his eGFR is below 30
DOC2: STOP IBUPROPHEN, increases BP
DOC3: atorvastatin because CKD
DOC4: clopidogrel antiplatelet because of gout for AV nicking from HTN

  • consider decreasing allopurinol because of CKD*
  • if angina wasn’t controlled consider adding amlodipine*
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22
Q

ASA can cause a increase in _______, so you should use clopidigrel in patients with gout instead!

A

ASA can cause a increase in URIC ACID, so you should use clopidigrel in patients with gout instead!

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23
Q

what is the only loop dieuretic that is ALSO K sparing!

wow thats crazy

A

ethacrynic acid

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24
Q

what is a benefit of ethacrynic acid and why it might be a good option for a patient with gout?

A

it can decrease UA levels so might be a good option for someone with gout

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25
case #6 72 y/o pt with HTN, angina, stage 4 CKD and has just developed herpes zoster. eGFR 25 ml/min. what are the 3 DOC consideration?
DOC1: acyclovir 800 mg 3x daily instead of 5x times daily because of CKD DOC2: follow up in a week when her rash is gone and change BB to lisinopril 2.5 mg because eGFR is less than 30 DOC3: put on ASA because of angina *order a lipid panel*
26
what is the dosing for acyclovir in a CKD pt vs a regular pt?
herpes zoster acyclovir since stage 4 800 mg x3 times a day, instead of 800 mg 5x a day
27
what is a good pain control source for herpes zoster?
lidocaine pain patch
28
case#7 30 y/o who was hiking in the dessert and became lost. he was found 2 days later and brough to the ED. his uring output over the last 2 hours has been 12 ml. he lost 20 pounds over the last two days. he is disoriented. BUN 70. what is the DOC? what are 3 tests to do?
elevated BUN indicates dehydration DOC1: IV fluids and electrolytes so pt will need to be admitted **get UA, BUN, and CrCl and watch BUN and CrCl**
29
case #9 35 y/o patient with persistent BP 180/110 range with mild reduction in BP taking HCTZ, lisinopril, amlodipine atorvastatin 20 mg. you are concerned she has renal artery stenosis. renal artery stenosis without organ damage primary cause of HTN. 2 test, 2 medication considerations?
1. DUPLEX SCAN/ultrasound of renal arteries 2. CT ANGIOGRAM SCAN WITH DYE…..PT WITH CKD INCREASES THE RISK SINCE THERE IS DYE DOC1: increase atorvastatin 40 mg DOC2: discontinue lisinopril since contraindicated in renal artery stenosis *REFER NEPHROLOGIST*
30
case #11 a 75 y/o pt with HF and dependent edema that is not responsive to 80 mg furosemide. Angina is well controlled. A-V nicking with muffled heart sounds. eGFR 45 ml/min. HTN, angina, hyperlipidemia. Amlodipine, ASA, atovastatin 20 mg daily, FeSO4, furosemide 80 mg BID. what are three DOC considerations? diet?
DOC1: Add metolazone for 3 days short term 5 mg; thiazide use for quick burst that doesn’t lose effectiveness until less than 20 ml/min DOC2: Add ACE since patient not on one and they have HF DOC3: increase atorvastatin to 40 mg because of HF DOC4: DASH DIET
31
are loops and thiazides often used together?
yes they are
32
of the thiazides which one has been show in studies to be more effective in decreasing periphreal edema?
metalozone
33
case 12 65 y/o with CKD and anemia that is not controlled on iron supplement. HTN, CKD, COPD, dyslipidemia. Lisinopril, amlodipine, FeSO4, formoterol/budesonide inhaler, atorvastatin 20 mg daily. eGFR 30 ml/min. H+H 9/27. what are 2 DOC considerations? what are they right on the line of?
DOC1: SQ erythropoetin 3x week to bring up H+H DOC2: increase atorvastatin to 40 mg **keep in mind eGFR is 30ml/min so right on the line of needing ACE reductions**
34
a major side effect of statins is______ so you need to check a ________ value
a major side effect of statins is MYOPATHY so you need to check a CREATINE KINASE (CK) value
35
case #8 70 year old with hearing loss, HTN, and HF. She went to rage and ate a ton of salty food and presents to your office with 2+ pitting edema bilaterally. She has gained 10 pounds. Muffled heart sounds. GFR 20 ml/min down from 45 ml/min. Linsinopril 20 mg. Atorvastatin 20 mg. ASA 81 mg. three DOC considerations?
progression of HF and CKD to stage 4 DOC1: torsemide because it takes high doses to cause hearing loss DOC2: lower lisinopril dose to 2.5-5mg since below
36
which loop diuretic has the longest half life and the highest availability?
torsemide... ...yes more so than furosemide
37
what does furosemide cause in high doses?
OTOTOXICITY IN HIGH DOSES
38
what is the ratio of dosing between the IV and oral dosing of furosemide? If they are getting 20 mg IV, what is the oral dose?
1:2 if giving 20 mg IV in the hospital then they need 40 mg oral dose to go home with?
39
what is the ratio of dosing for torsemide IV and oral?
1:1 the IV and oral doses are the same!!
40
what is the goal daily weight loss with loops?
2 lbs per day
41
what is the bioavailability and half life of torsemide?
80-100% bioavalibility, 3-4 hour halflife (longest of the loops)
42
what is the bioavalibility and half life of furosemide?
50% oral bioavalibilty, .3-3.4 H hour halflife (shorter of the loops)
43
what part of the nephron do loop diuretics work on?
the ascending loop of henle
44
what loop diuretic is not effected by food intake?
torsemide!!
45
case #10 68 y/o with stage 4 eGFR, with metabolic bone disease, anemia, and secondary HPT. HF. Hyperlipidemia. lisinopril, FeSO4, atorvastatin 20 mg, furosemide PRN, ASA. ELEVATED PHOSPHATE, ELEVATED CALCIUM, ELEVATED Ca-P. eGFR 25 ml/min.iPTH elevated. what are the 3 DOC considerations?what do you want to restrict? what should you consider checking this patient for?
Elevated phosphate, calcium with secondary hyperthyroidism Restrict phosphate to 90 mg a day consider screening for malignancies DOC1: selevemer DOC2: decrease lisinopril to 2.5 mg daily DOC3: increase atorvastatin to 40 m
46
cinacalcet is approved for which patients?
approved for use in patients on DIALYSIS with Bone mineral disease
47
DECREASE IN CALCIUM INCREASE IN PHOSPHORUS CAN LEAD TO.....
metabolic bone disease!
48
PTH goes up with ______ calcium and ____phosphorus
PTH goes up with DECREASED calcium and INCREASED phosphorus
49
Secondary hyperparathyroidism means the issue originates from the______ because_____
KIDNEYS!!! as kidneys fail, the phosphorus levels rise which causes the calcium levels to drop. when calcium levels drop, the posterior pituitary gland is stimulates PTH release which causes resorption of the bone (breakdown) to equal out the calcium levels!
50
what are 5 diet things you should avoid if you have high phosphorus?
avoid excessive beans, nuts, seeds, cheese & dark beverage
51
if a patient is on a ACE and has a eGFR less than 30 ml/min what do you need to do?
you decrease the dose because CKD it is a independent and significant RF for CVD
52
should people with CKD be put on a statin even though it has nothing to do with any of the rules we learned about?
YES ALWAYS because CKD is a serious RF for CVD so they need to be on a statin! usually high dose!!
53
who should you not use ASA in so what should you use instead?
don't use ASA in a gout patient because it can increase UA levels.....use clopidigrel
54
when is it appropriate to use ASA in a CKD patient?
you use ASA in CKD patients who have a sign of CVD disease like angina/HTN, AV nicking, claudications, loss of pulses...need actual presentations besides HTN for ASA.......think CKD + symptom (angina, claudication, AV nicking, loss of pulses)
55
why do you use ASA in patient with CKD with symptoms/presentations?
use it because CKD is a risk factor for CVD A SERIOUS ONE!!! so used in patient who have a presentation of CVD progression (angina, AV nicking, loss of pulses, claudication)
56
CKD is a CVD risk _______
CKD is a CVD risk EQUIVALENT they most likely die from CVD not CKD
57
admission to the hospital is based on what 3 characteristics?
age, symptoms, O2 levels
58
if starting a patient on lisinopril and they have CKD with eGFR less than 30 ml/min, what dose should you start at?
2.5-5 mg
59
if someone has CKD and is taking lisinipril and their eGFR decreases below 30 ml/min how do you know how much to decrease the dose?
depends on the person, the point is you need to know that you decrease it!!
60
case 13: 70 year old man with HF who has 2+ pitting dependent edema to mid tibulas. He now has to sleep sitting upright in a chair with persistent dry cough. HF. CKD3. COPD. Anemia chronic disease. HTN. Allergies Sulfa (anaphylaxsis), ACEI (cough).Atorvastatin 20 mg. Losartan 50 mg. eGFR 40 ml/min. H+H 11/34. O2: 87%! 1 DOC?
HF and pitting edema DOC: ethacrynic acid since prophylaxis to sulfa
61
what loop diuretic should you use if someone has anaphylaxsis to sulfa?
ethacrynic acid
62
Case 14: 55 y/o on routine follow up for CKD, HTN. eGFR had decreased from 40 to 25 ml/min. CKD. HTN. hyperlipidemia. HCTZ 25 mg. Lisinopril 20 mg daily. atorvastatin 40 mg. 2 DOC?
DOC1: switch HCTZ to INDAPAMIDE since eGFR is less than 30-40 DOC2: decrease lisinopril since eGFR less than 30
63
can thiazides increase UA levels?!
yes they can! thiazides can cause hyperurecemia
64
what eGFR do HCTZ and chlorthiadone loose effectiveness?
30-40 ml/min
65
Case 15: 75 y/o traveled across country in a hot car without AC. He didn’t drink any water and takes furosemide for his HF. He finally stopped at ED from dizziness and nausea and disorientation. Urinating small amounts. HF. HTN. Osteoarthritis. Fursemide 20 mg. Lisinopril 40 mg. Chlorithiadone 12.5 mg. OTC ibuprophen 400 mg TID. BP 90/50. Skin and mucous membranes dry. Creatinine, BUN, K, NA, elevated. eGFR 27.9. 4 DOC? 2 considerations?
Admit him! hes sick! DOC1: isotonic saline DOC2: take off ibuprohfen from eGFR DOC3: decrease lisinopril dose DOC4: take off chlorthiadone, not effective if eGFR is 30-40 ml/min * **since he has hypovolemia and HF, need to hydrate and diuress him at the same time so he does not get 3rd spacing fluid*** * **this case is interesting because pt is 75 and in crisis, if this pt was 35 could give him fluids and discharge after 24 hours***
66
in patients with HYPOVOLEMIA, what do ACE inhibitors do?
they further decrease eGFR **this is why we lower the lisinopril dose in CKD...I think***
67
NSAIDS cause________ (2 things)
1. Na retention/H20 water retention | 2. vasoconstriction (from inhibiting prostaglandins)
68
Case 16: 65 y/o comes to clinic with acute onset of left great toe pain. CKD stage 3 and recent angina onset. CKD3, angina, hyperlipidemia. ASA 81 mg. Metoprolol 100 mg daily angina. Atorvastatin 40 mg. Lisinopril 20 mg daily. eGFR 32 ml/min. 2 DOC?
acute onset gout NSAIDS and COLCHINE are contraindicated DOC: oral prenisone with taper up and down for 14 days, more likely to come back since first attack DOC: switch ASA to clopidigrel since gout
69
what do you need to monitor when taking prenisone?
glucose levels
70
Why do you take a patient off ASA if they have gout? what do you put them on instead?
ASA can increase UA so put them on clopidigrel instead
71
what percent of patients who have gout have some sort of renal disease?
40%
72
Case 17: 78 y/o notices more bruising that usual. CKD4, anemia of CKD, HTN, elevated cholesterol, and HF. Lisinopril 20 mg. Atorvastatin 40 mg. Furosemide 40 mg. ASA 81 mg. H+H 9.5/27. BUN 32 (8-25), eGFR: 23 ml/min 3 DOC options
**identify the source of anemia, CBC, TIBC, transferring, B12, folate** DOC: NO TREATMENT AT THIS TIME DOC: HOLD ASA SINCE BLEEDING DOC: decrease lisinopril since eGFR less than 30 ml/min DONT PUT PT ON ERYTHROPOEITIN SINCE HEMO IS 9.5 AND ISN'T HAVING HF EXACERBATION
73
What is the max hemoglobin target on erythropoetin?
11-12 is the max you should raise with eryhropoetin
74
when do you use erythropoetin?
don’t use erythropoietin unless hemoglobin below 10, but must consider other symptoms esp HF, if they are stable and have a hemoglobin of 9.5 don’t put them on it! must always figure out the cause of anemia anemia of chronic disease increase HF symptoms, only put on erythropoetin if Hemoglobin around 8
75
what must you do before putting a pt on erythropoetin?
must always work up the cause of anemia before putting the pt on erythropoetin, if folate or B12 deficiency this won’t help it
76
Case 18: 60 y/o developes 2+ pitting dependent edema in the past 24 hours. she is scheduled to have abdominal aorta aneurysm repair in a week. She had a CT done. AAA. HTN. CKD3. Hyperlipidema. Lisinopril 40 mg. Amlodipine 5 mg. chlorithiadone 12.5 mg. Atorvastatin 80 mg daily. BUN 40 (8-25). eGFR 35 ml/min.BP 170/110. 2 DOC? what must you do?
need to get this BP down ASAP because you don't want the aneurysm to rupture ***need to determine if from constast dye from CT or something else is going on*** DOC: stop amlodipine, can cause periphreal edma DOC: clonidine-drops BP reliably and fast in SMALL dose, don’t want her to drop too much contact the surgeon because she may need to delay in surgery until this is figured out!
77
CT dye is ____________ and will wear off after _______
CT dye is nephrotoxic and will wear off after 1 week
78
cyclosporine causes:
renal vasoconstriction and decreased blood flow to the kidney causing renal injury
79
what CCB can cause dependent edema?
amlodipine DHCCS
80
Case 19: 59 y/o developed dependent edema and gained 5 lbs and is more out of breath then usual. she is unable to go upstairs currently without getting out of breath. CKD3. HF. OA. HTN. Furosemide 40 mg. ASA 81 mg. amlopdipine 10 mg. OTC analgesic for OA. amlodpine 10 mg. Lisinopril 20 mg. BUN 40 (8-25). eGFR 25 ml/min. Na 150 (135-145). Bp 180/110. 3 DOC?
DOC1: STOP OTC analgesic DOC2: decrease lisinopril dose since eGFR below 30 ml/min DOC3: consider amlodipine if that doesn’t work since causes periphreal edema need to determine what is causing her HTN and kidney dysfunction
81
Case 20: 59 y/o with hx of solitary kidney following a motor vechicle accident where the other one was damaged. On exam she has new HTN. solitary kidney. COPD. 30 pack smoking hx. CKD3. Albuterol. Salmeterol. BP 170/110. sCR 1.5 (.6-1.1). eGFR=45 ml/min. 1 DOC? if this didn't work?
DOC: indapadine since she has a low GFR and this can be used in any GFR. DOC: if no luck: consider starting Lisinopril **chlorthiadone could be used here, but if her eGFR decreased to 40 ml/min (5ml/min decrease) then you would have to switch her to indapadine, so it is just easier to start her on this instead in case her GFR decreases*
82
Case 21: 70 y/o african american presents with HF comes in with three says days of muscle weakness and paresthesias. HF, HTN, CKD3. Furosemide 40 mg. Lisinopril 40 mg. spirolactone 25 mg. Peaked T weaks, wide QRS, shortened QT. Na 140. K 5.9 (3.3-4.9). eGFR=38 ml/min.
Hyperkalemia CKD3. Hyperkalemia caused by spirolactone. DOC: hold spiralactone then start at ½ the dose DOC: Switch lisinopril to amlodipine because lisinopril can increase K levels and these are already elevated ***keep in mind this person would have originally been started on a HCTZ or CCB because he is black, however, he may have been started on this before the rules came out. this drug was started for learning purposes only. ***
83
hyperkalemia increases the risk for:
QT and ventricular arrhythmia so get a EKG
84
if someone has hyperkalemia....what must you avoid!?!?
k sparing diuretics spirolactone eplenerone amiloride triametrene
85
Case 22: 63 y/o in your practice for follow-up for long term HTN and you ask about her increasing dependent edema.she has had poorly controlled HTN for about 20 years but since four years ago her BP has been controlled. Amlodipine 10 mg. Lisinopril 40 mg. chloriathiadone 12.5 mg. BP 140/90. Fundi show A-V nicking bilaterally with papilledema. 1+ pitting edema bilaterally to tibia. BUN 30 (8-25). sCR 1.5 (.6-1.1). eGFR: 43 ml/min 2 DOC? why do you do this?
chronic kidney disease stage 3 HTN with AV nicking suggest end organ damage DOC: lower dose of amlodipine (since dependent edema) DOC: Diltaizem 1 tablet at bedtime once daily for 30 days **need to add diltiazem because her BP has been hard to control in the past and your are now decreasing her amlodipine so you need to make sure you add something to lower her BP without causing peripheral edema**
86
Case 23: 70 y/o with CKD, CKD-MBD (metabolic bone disorder), HTN, and anemia with chronic anemia. Lisinopril 20 mg daily. BP 150/90. Ca low. PTH increased. H+H 11/33. DOC? what test do you need to get on this person?
- HYPOCALCEMIA - DOC: calcitrol **Need to get a phosphate level because if it was elevated along with hyperparathyroidism then we would need to start her one a calcium-binding agent**
87
if phosphorus is high, what are the rules for using the phoshate binding agent?
Phosphorus elevated..... then if Ca is high, use sevelamer then if Ca is low, use CaCO3, because it can help raise Ca levels a little since it
88
what drug do you use if Ca is low with increased PTH (and phosphorus is normal)?
then go to calcitrol, activated vitamin D
89
CKD can cause.....
metabolic bone disorder
90
what is the primary reason we see SECONDARY metabolic bone disease?
CKD which causes hyperparathyroidism
91
what is the primary drug used to increase calcium levels? how does this do this?
calcitrol, activated vitamin D promotes Ca absorption in the intestines
92
cinacelcenet is what drug class? what it is used for?
calcemimenetic lowers Ca primarily used in dialysis patients
93
what are the two drugs that are primarilly used to lower phosphorus levels?
CaCO3 | selvemer
94
what is the maximum Ca intake in 24 hour period if you are taking CaCO3 to decrease phosporus levels?
1,500 mg in 24 hours
95
Case 24: 65 y/o male with low serum K which is not responding to tx with K supplement. CKD3. HTN. K supplement 20 twice daily. amlodipine 10 mg daily. BP 150/90. eGFR 40 ml/min. Low K. Mg low.
HYPOKALEMIA regardless of K+ supplement with hypomagnesium. DOC: just replenish Mg SLOW and K should go up take home: magnesium level goes hand in hand with K
96
what does Mg deficiency do?
increase K secretion
97
don’t use K sparing and K retaining drugs together like ACE linsinopril (retaining) and K sparing spirolactone
FUN FACT!
98
if someone isn’t responding to K+ supplement, what should you do?
check Mg
99
what should you not take if you are taking lisinopril?
no K+ sparing diuretics or K+ supplement because lisinopr lisinopril can cause hyperkalemia on its own, so by combining with these you increase the risk

Module 6: Mali: Renal (4 decks)

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