Renal Therapeutics Flashcards by Stephanie Flint

how long does an AKI last?

7 days or less

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when does AKD occur?

7 to 90 days after AKI

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AKI Dx

1) SCr 1.5-1.9 x baseline over 7 days
or
2) SCr increase greater than or equal to 0.3 mg/dL over 48 hours

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monitoring for AKI loop use?

dec intravascular volume
dec BP
inc HR
alkalosis

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nephrotoxins

aminoglycosides (gentamicin, …)
amphotericin
iodinated contrast
vancomycin

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drugs to avoid in AKI prevention

sodium bicarbonate
vitamin C
dopamine
fenoldapam

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pre-renal AKI Dx

FeNa < 1%
or
if on loop, FeUrea < 35%

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what kidney assessment measure do you avoid in AKI?

SCr –> lags 1-2 days behind GFR

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drugs to temporarily hold in hemodynamic AKI?

ACEi
ARB
SGLT2i
calcineurin inhibitors
NSAIDs

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drugs to temporality hold in pre-renal AKI?

loop diuretic
thiazide diuretic (HCTZ, chlorthalidone)

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dialysis modalities

hemodialysis
peritoneal dialysis
continuous kidney replacement therapy

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HD access points

1) arteriovenous fistula
2) arteriovenous graft
3) central venous catheter

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which HD access is highest risk of infection, thrombosis, inadequate dialysis?

central venous catheter

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HD fistula characteristics

preferred long-term access, takes 6-12 weeks to mature after surgical creation, lowest infection/thrombosis risk

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HD graft characteristics

plastic tube outside of body

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HD catheter characteristics

last-line option, used short-term (while bridging to fistula), highest infection/thrombosis risk

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what are the risk factors associated with HD access?

thrombosis
infection
inadequate dialysis (slower blood flow)

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peritoneal dialysis complications

infection of peritoneal membrane
- can occur from site of entry and tip of catheter infection
- ensure aseptic technique

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when to do HD TDM?

prior to HD
- bc after HD there is 4-6 hours of redistribution and fluid shifts, therefore fluctuating drug concentrations

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when to do PD TDM?

random

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when to do CRRT TDM?

random

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HD complications

hypotension
cramping
fatigue
infection
thrombosis
bleeding

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PD complications

peritonitis
fluid overload
hyperglycemia

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midodrine indication

HD hypotension complication

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midodrine MoA

alpha-1 agonist --> stimulates peripheral vasoconstriction (pro-drug) -> inc BP

midodrine dosing

2.5-10mg po 30 min before HD

midodrine AE

bradycardia, hypertension, peripheral ischemia, urinary retention

midodrine CI

severe PVD

midodrine DDI

MAOIs, sympathomimetics

vitamin E indication

HD cramping symptom improvement

vitamin E dose

400 IU po qhs

what to avoid to treat HD cramping

quinine

HD thrombosis treatment and dose

alteplase (cathflo) 2mg/2mL instilled for 30-120 min

HD hypotension and cramping treatment

100-250mL 0.9% NaCl

vancomycin efficacy failure vs toxicity for dialysis

toxicity: ototoxicity, nephrotoxicity, red man's syndrome (puritis, ...) efficacy failure: infection mortality and morbidity

what drug characteristics allow for no renal dosing?

large therapeutic index and fraction excreted unchanged in urine 30% or less and inactive or no metabolites

which kidney assessment do you use for CKD staging?

eGFR (CKD-EPI)

which kidney assessment do you use for drug dosing?

eCrCl (cockcroft-gault)

opioids safe in kidney disease

fentanyl methadone

opioids caution in kidney disease

hydromorphone oxycodone hydrocodone

opioids avoid in kidney disease

morphine codeine (pro-drug of morphine) meperidine

loading dose most impacted by

digoxin LD consideration

lower Vd --> cut LD by 50%

hydrophilic antibiotics LD considerations

higher Vd --> inc dose

hydrophilic antibiotics

aminoglycosides (gentamicin) beta lactams carbapenems linezolid colistin glycopeptides (vancomycin)

maintenance dose most impacted by

antimicrobials that do not require kidney dosing

metronidazole azithromycin nafcillin tigecycline oxacillin linezolid doxycycline moxifloxacin erythromycin quinupristin/dalfopristin clindamycin ceftriaxone

normal SCr

around 1.2 mg/dL

normal BUN

24 mg/dL ish

DOAC with lowest percent kidney CL

apixaban

LMWH with lowest percent kidney CL

tinzaparin

metformin CI

eGFR < 30

SU bad for kidneys

glyburide

SU preferred for kidney

glipizide (no beers too)

DPP4i without renal adjustment

linagliptin

thiazide renal impact

not effective for HTN when CrCl < 30

K sparing and aldosterone antag CI

CrCl <30 bc hyperkalemia

loop dietetic starting dose

40 mg furosemide po ???

how does loop dose change with renal impairment

CrCl 25-50: 2x dose CrCl < 25: 4x dose

analgesic to avoid kidney dysfunction

- NSAIDs (inc progression of CKD, can use ESRD bc no progression to prevent against -- already happened) - gabapentin/pregabalin (falls, altered mentation)

preferred analgesic in kidney dysfunction

APAP 1000mg po tid

duloxetine CI

CrCl < 30

anemia Dx

male: Hgb < 13 g/dL female: Hgb < 12 g/dL

anemia treatment labs

Hgb 10-11 g/dL --> o2 carrying capacity serum ferritin > 500 ng/mL --> storage form iron transferrin saturation (Tsat) > 30% --> functional form iron

most common cause of erythropoeitin resistance?

iron deficiency

when to hold IV iron

Tsat > 50% ferritin > 1200 ng/dL

oral iron characteristics

10-15% F (low) slow replenishment of iron

iv iron characteristics

high F rapid replenishment of iron risk of iron overload

oral iron AE

**GI upset --> nausea, cramp, constipation dark stool DDI

iv iron AE

infusion reactions (itching, hypotension, edema, chest pain) anaphylactic **infection

IV iron CI

active systemic infections

oral iron tid dosing AE

more iron --> inc hepcidin --> dec iron absorption --> need more iron to dec risk of this: qd or every other day dose

oral iron CI (ish)

PPI, H2RA --> need low gastric pH to absorb

oral iron DDIs

drugs that are impacted by iron and therefore need 2 hr separation - fluoroquinolones - levothyroxine - tetracyclines - mycophenolate - methyldopa - levodopa

ferric gluconate brand, dose

iv ferrlecit 125 mg tiw 8 doses

iron sucrose brand, dose

iv venofer 100mg 1-3x weekly, total 1g

what is the marker of good ESA response

2.5% inc in reticulocytes in 1-2 weeks

longest acting ESA

methoxy polyethylene glycol epoetin beta (Mircera)

cheapest ESA

epoetin alfa epbx (Retacrit)

epoetin alfa

Epogen

darbapoetin alfa

Aranesp

dialysis ESA goals

initiate: Hg < 9-10 target: Hg < 10-11

non-dialysis ESA goals

initiate: Hg < 10 target: Hg < 10

how long does it take for ESA to improve Hg?

4-6 weeks

goal ESA Hg change

1-2 g/dL/month

when to lower ESA dose

by 25% if - Hg approach 12 - Hg inc by > 1 g/dL in 2 weeks for AE

causes of ESA resistance

#1: iron deficiency ACEi hyperparathyroidism aluminum toxicity folate or b12 deficiency infection malignancy trauma inflammation

ESA AE

hypertension hypercoagulability HA progression of malignancy

ESA CI

active malignancy with anticipated cure high risk CVA (stroke) Hgb > 11 g/dL

blood transfusion indication

Hgb < 7 - 1 unit PRBC = 200mg elemental iron, inc Hgb 1 g/dL

consequences of CKD MBD

cv disease bone disease calciphylaxis

MBD labs

calcium 8.5-10.2 mg/dL phosphorus 3.5-5.5 mg/dL iPTH 2-9X ULN (150-600 pg/mL)

how to take phosphate binders

with food

renvela

sevelamer carbonate

ca based phosphate binders AE

stones, bones, abdominal groans nephrolithiasis calciphylaxis bone pain abdominal discomfort

phoslo

calcium acetate (first line)

which ca based phos binder has mire binding capacity

calcium acetate (renvela)

which ca based phos binder has mire binding capacity

calcium acetate (renvela

which non-ca phos binder do you have to chew

lanthanum carbonate (Fosrerol)

cinacelcet dose

30mg/day start --> titrate q2-4 weeks up to MDD 180mg

cinacalcet consideration

need to treat Ca if Ca < 8.4

top ckd causes in us

1. DM 2. HTN 3. glomerulonephritis 4. polycystic kidney disease

Renal Therapeutics Flashcards

(102 cards)