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Most common cause of CKD

Hypertension and diabetes

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Factors affecting drug removal during dialysis

Molecular size, protein binding, volume of distribution, plasma clearance, and dialysis membrane

Drugs that are highly protein-bound such as warfarin are not usually removed during dialysis

Large drugs such as vancomycin are generally not removed unless a higher flux membrane with a large pore size is used

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A few examples of drugs not removed by hemodialysis

Amiodarone, ceftriaxone, insulin, vancomycin, and warfarin

Amiodarone is generally not removed due to its high volume of distribution

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Glomerulus

serves as a filter (if this filter is damaged protein can pass through) the level of albumin in the urine generally gauges the severity of kidney damage. Serum creatinine is also a determinate


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Proximal tubule

Large amounts of water sodium and chloride are absorbed here

Osmotic diuretics work in this area

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Loop of Henle

In the descending limb water is reabsorb but sodium chloride are not

In the ascending limb sodium and chloride are reabsorbed but water is not

Diuretics inhibit the sodium potassium pump in the ascending limb of the Loop of Henle

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Distal convoluted tubule

Regulates potassium, sodium, calcium, and pH

Dyazide diuretics work here by inhibiting the sodium chloride pump in the distal tubule

Thiazides also increase calcium absorption and have a long-term protective effect on bone

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Collecting duct

Aldosterone antagonist work here by blocking aldosterone, potassium increases

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Common drugs that require dose reductions or increased dosing intervals with decreased renal function

Acyclovir, allopurinol, amphotericin, aminoglycosides, Azole antifungal's, antiarrhythmics, aztreonam, beta-lactam, colchicine, cyclosporine, dabigatran, famotidine, ranitidine, gabapentin, pregabalin, and Noxapater in, macrolides, metoclopramide, morphine and codeine, penicillin's, quinolones, statins, Septra, vancomycin, venlafaxine

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Drugs that should not be used in severe renal impairment

Bisphosphonates, chlorpropamide, dabigatran, dofetilide, duloxetine, fondaparinux, foscarnet, glyburide lithium, my pyridine, metformin, nitrofurantoin, NSAIDs, potassium sparing diuretics, ribavirin, rivaroxaban, sotalol, tenofovir, tramadol, voriconazole

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Stages of CKD

Stage 1: >90 ml/min
Stage 2: 60 to 89
Stage 3: 30 to 59
Stage 4: 15 to 29
Stage 5: < 15 or dialysis dependent

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Gabapentin and metoclopramide

When used in severe renal impairment will have increased sedation drowsiness fatigue and with metoclopramide could have extrapyramidal symptoms

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Ace inhibitors and ARBs

Have been shown to prevent the progression of neuropathy in diabetic and nondiabetic patients with proteinuria

Goal blood pressure is less than 130/80

Note that when starting these agents you could notice a 30% rise in serum creatinine; do not need to stop unless greater than 30%

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What should you monitor and patients with kidney disease?

Serum creatinine, Albumin, phosphorus, calcium, vitamin D, and parathyroid hormone

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Phosphorus: phosphate binders

Agents used for hyperphosphatemia: aluminum-based agents, calcium-based agents, and aluminum free/calcium free agents

Aluminum-based agents: aluminum hydroxide (ALternaGEL, Amphogel)
Calcium-based agents: calcium acetate or PhosLo and calcium carbonate or tums
Aluminum free/calcium free agent: Sevelamer or renvela

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Common side effects associated with phosphate binders

Constipation, nausea, abdominal pain, diarrhea

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Contraindications for the use of renvela

Bowel obstruction

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Calcium binders

Cinacalcet (Sensipar)

Contraindication for use is hypocalcemia

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Treatment of vitamin D deficiency

30: normal

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Treatment of hyperkalemia

Normal potassium level is 3.5–5mEq/L

Drugs that raise potassium include potassium sparing diuretics, Ace inhibitors, ARBs, NSAIDs, oral contraceptives that contains drospirinone (yaz), cyclosporine, tacrolimus, heparin, invokana, potassium supplements, Septra

Treatment: next slide

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Treatment of hyperkalemia

1. Remove sources of potassium
2. Enhance potassium uptake via glucose administration and insulin administration
3. If metabolic acidosis give sodium bicarb: initiate if bicarb is <22 mEq/l
4. Consider beta agonist such as nebulized albuterol
5. Increase excretion with a loop diuretic such as furosemide
6. Kayexalate (SPS)
7. Dialysis
8. Calcium is almost always given to stabilize the cardiac tissue