Critically Ill > CKD > Flashcards

CKD Flashcards

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1
Q

What is CKD?

A

abnormalities of kidney structure or function present for >3 months with implications for health

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2
Q

How is CKD classified?

A
  1. Cause
  2. GFR category
  3. Albuminuria category
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3
Q

What is End Stage Renal Disease (ESRD)?

A
  1. GFR <15ml/min/1.73 m2
  2. pt requires dialysis
  3. renal transplant pts
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4
Q

What are risk factors for developing CKD?

A
  1. diabetes
  2. HTN
  3. obesity
  4. autoimmune disease
  5. systemic infections/UTIs
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5
Q

What are socioeconomic risk factors for CKD?

A
  1. older age
  2. AA, American indian, hispanic, pacific islander
  3. chemical exposure/environment
  4. low income/education
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6
Q

What are risk factors for progression of CKD?

A
  1. diabetes
  2. HTN
  3. proteinuria
  4. smoking
  5. obesity
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7
Q

When does CKD presentation usually occur?

A

asymptomatic until significant amount of renal function lost CKD stage 4/5

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8
Q

What are labs indicate CKD?

A
  1. BUN
  2. SCr
  3. urine albumin
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9
Q

What are signs of CKD?

A
  1. edema
  2. changes in urine output
  3. foaming of urine
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10
Q

What are the uremic symptoms associated with CKD?

A
  1. fatigue
  2. weakness
  3. SOB
  4. confusion
  5. itching
  6. cold intolerance
  7. peripheral neuropathies
  8. N/V/ loss of appetites
  9. bleeding
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11
Q

What are nonpharm treatments of CKD?

A
  1. exercise (30 min moderate intensity 5x weekly)
  2. weight loss if BMI >25 kg/m2
  3. <5g NaCl (2g Na) per day
  4. smoking cessation
  5. alcohol restriction (2 drinks/day for men and 1 drink/day for women)
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12
Q

What are pharm treatments for CKD?

A
  1. treat underlying conditions resulting in kidney damage
  2. vaccines (flu, pneumococcal, HepB)
  3. medications used to slow CKD
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13
Q

When should proteinuria (albuminuria) be treated?

A

stage A2 or higher

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14
Q

What is first line treatment for stage A2 or higher albuminuria?

A

low dose (2.5-5mg) ACEi or ARB

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15
Q

What patients should ACEs and ARBs be used in caution with?

A
  1. eGFR<30
  2. BP <110/70 mmHg
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16
Q

When should the dose of ACE/ARB not be titrated up in CKD?

A
  1. albuminuria reduced by 30-50%
  2. greater than 30% decrease in eGFR
  3. elevation in serum potassium
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17
Q

What should be added if patient is on max tolerated ACE/ARB and ARC>300?

A

SGLT2i:
Empagliflozin JARDIANCE 10mg QD
Dapagliflozin FARXIGA 10mg QD

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18
Q

What is first line treatment for stage A2 or higher AND HTN?

A

low dose (2.5-5mg) ACEi or ARB, once albumin excretion <30mg/24h or decreases 30-50% target a systolic BP of </=120mmHg

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19
Q

What is the BP goal for kidney transplant patients with stage A2 or higher AND HTN?

A

</=130/80

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20
Q

What can be added to achieve a BP goal of <120mmHg

A
  1. thiazides (loop if neccessary)
  2. aldosterone antagonists (especially if hypokalemic)
  3. non-DHP CCBs (Verapamil or Diltiazem)
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21
Q

What is the treatment for stage A2 and T2DM?

A
  1. SGLT2i +/- Merformin:
    Canagliflozin INVOKANA 100mg QD with the first meal of the day
    Empagliflozin Jardiance 10mg QD
    Dapagliflozin FARXIGA 10mg QD
  2. add on GLP-1 agonist if glucose target not met
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22
Q

When should Metformin regimens be reviewed and discontinued?

A

review: GFR 30-45 (lactic acidosis vs. A1c goal)
D/C: GFR <30

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23
Q

What can be used as an adjunctive agent for patients with persistently elevated albuminuria (ACR >30) and are receiving other preferred therapies?

A

Finerenone KERENDIA 10-20mg QD

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24
Q

What is the MOA of Finerenone?

A

non-steroidal selective mineralocorticoid receptor antagonist; mediates sodium reabsorption and over-activation in epithelial(kidney) and nonepithelial cells(vessels,heart)

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25
What lab must be checked before starting Finerinone?
potassium
26
What is a serious concern with Finerenone KERENDIA? What precautions should be taken?
1. reproductive warnings 2. patients who can become pregnant need a negative pregnancy test and use at least 2 methods of birth control
27
What is the A1c goal for patients with CKD and T2DM?
< 6.5-7%
28
What is a concern with A1c values in patients with CKD?
red blood cell life span is decreased so HbA1c values may be falsely low
29
What conditions lead to CKD that should be treated?
1. CV disease 2. dyslipidemia
30
Why should patients with CKD not continue ESAs if Hb >11-11.5?
increases risk of death, serious CV reactions, stroke
31
What is the KDIGO Hb goal for non-dialysis patients?
>10 g/dL
32
What is the Hb goal for dialysis patients CKD?
>9 g/dL
33
What Hb level indicates starting an ESA?
<10 g/dL
34
What is the transferrin saturation goal for CKD?
> 30%
35
What is the serum ferritin goal for CKD?
> 500 ng/dL
36
What are non pharm treatments for anemia of CKD?
1. diet (increase iron, folic acid, B-12) 2. water-soluble vitamin supplement for patients on dialysis
37
What are the pharmacologic options to treat anemia of CKD?
1. iron 2. ESA 3. Hypoxia-inducible factor prolyl hydroxylase inhibit
38
How is iron dosed for CKD?
200mg elemental iron PO QD for 1-3 months before assessing response
39
What can decrease the absorption of iron?
1. elevated stomach pH (PPIs) 2. food
40
What increases the absorption of iron?
Vitamin C
41
Which route of iron is preferred for hemodialysis patients?
IV
42
What are SEs of PO iron therapy?
1. nausea 2. constipation 3. cramping 4. false positive Hemoccult test
43
What are SEs of IV iron?
1. anaphylaxis 2. iron overload
44
Which IV iron requires a test dose due to the risk of anaphylaxis?
iron dextran
45
How long does it take for ESAs to start working?
onset of action ~10 days
46
What is an acceptable rate of increase in Hb per month?
1-2 g/dL/month
47
When should the ESA dose be decreased by 25-50%?
1. Hb increases >1 g/dL in 2 weeks 2. Hb increases >2 g/dL in 4 weeks
48
What should be done if Hb is >11 in a HD patient?
reduce the dose by 25% or temporarily discontinue
48
What should be done if Hb is >10 in a non-HD patient?
reduce the dose by 25% or temporarily discontinue
49
What should be done if ESA had to be temporarily D/C due to high Hb?
1. restart at 75% of the dose once Hb starts to decrease 2. increase ESA dose by 25% if Hb increases <1 g/dL in 4 weeks
50
What are SEs with ESAs?
1. HTN 2. seizures 3. thrombosis
51
What is the t1/2 of epoetin (EPOGEN)?
IV: 8.5 h SQ: 24 h
52
What is the t1/2 of darbepoetin (ARANESP)?
IV: 24h SQ: 48h
53
What is the t1/2 of methoxy polyethylene glycol-epoetin beta (MIRCERA)?
IV: 119h SQ: 124h
54
What agent is an Hypoxia-inducible factor prolyl hydroxylase inhibitor?
Daprodustat JESDUVROQ
55
What is a BBW with Daprodustat JESDUVROQ?
1. increases thrombotic vascular events and CV events 2. targeting Hb >11 is expected to further increase the risk of death and aterial venous thrombotic events 3. use the lowest dose possible to reduce the need for red blood cell transfusions
56
What are warnings and SEs with Daprodustat JESDUVROQ?
1. increased risk of death, MI, stroke, VTE 2. risk of hospitalization for HF 3. HTN 4. GI erosion 5. malignancy
57
How is Daprodustat JESDUVROQ dosed for adults on HD not receiving an ESA?
depends on Hb
58
How is Daprodustat JESDUVROQ dosed for adults on HD not switching from an ESA?
depends on the current dose of ESA
59
What is the generally accepted lowest Hb value that would prompt prescribers to administer packed RBCs?
Hb <7
60
Why do clinicians want to avoid giving PRBCs?
1. risks of infection 2. immunologic reactions 3. volume overload 4. hyperkalemia 5. iron overload 6. cost
61
How often should CKD patients be monitored for anemia?
every 3 months
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