1
Q
CKD is classified based on what 3 things?
A
- Cause of kidney disease
- assessment of GFR
- extent of proteinuria
2
Q
What are frequent complications of advanced CKD?
A
- altered Na and water balance
- hyperkalemia
- metabolic acidosis
- anemia
- CKD related mineral and bone disorder (CKD-MBD)
- cardiovascular disease
3
Q
What is the 1st, 2nd, and 3rd leading causes of CKD leading to ESRD?
A
- DM
- HTN
- Glomerulonephritis
4
Q
Besides the top 3 (DM, HTN, and glomerulonephritis), what other 4 diseases cause CKD?
A
- Polycystic Kidney Disease
- Wegener’s granulomatosis
- Vascular Diseases
- HIV nephropathy
5
Q
1st line therapy for CKD caused by DM?
A
ACEI or ARB
6
Q
Tx for CKD caused by DM:
- ACEI or ARB
- Dose is usually increased until what 3 things happen?
A
- Albuminuria is reduced by 30-50% (1st goal!)
- Significant drop in eGFR
- Hyperkalemia
7
Q
Therapy for CKD caused by HTN?
A
ACEI and ARB
(effect on renal hemodynamic and reduction of BP)
8
Q
Deficiency in the production of endogenous erythropoietin by the kidney (iron deficiency as a contributing factor)
A
Anemia
9
Q
2 ways to manage anemia
A
- erythropoietic stimulating agents (ESAs) (epoetin alfa, darbepoetin alfa)
- Regular iron supplementation (oral or IV administration)
10
Q
What are the “administartion limits” of treating anemia? (2)
A
- Higher risk of cardiovascular events
- When hemoglobin is targeted to greater than 11 g/dL
11
Q
At which stage of CKD should you send to nephrology based on the GFR?
A
Stage 2 CKD (mildly decreased) = 60-89
12
Q
At what stage of CKD do you need adjust dose?
A
Stage 3 CKD, GFR of 50-60
(most common GFR is at 30)
13
Q
What stage of CKD is ESRD?
A
Stage 5
14
Q
KDIGO recommendations for initiation of Erythropoiesis Stimulating Agents and Iron in Anemia of CKD
- If Hb is <___ g/dL, consider the ____ of Hb prior to initiating ESA.
- DO NOT initiate if Hb is ___g/dL or greater
A
- 10 / rate of fall
- 10
15
Q
- Do not use ESAs to intentionally increase Hb above ___ g/dL
- Do not use ESAs to maintain Hb above ___g/dL
A
- 13
- 11.5
16
Q
Initiate Iron therapy when TSat is ___% or less and ferritin is ___ or less
A
- 30
- 500
17
Q
Use ESAs to avoid drop in Hb to <9 by starting an ESA when Hb is between ___ and ___ g/dL
A
9 and 10
18
Q
What are the 3 Erythropoiesis-Stimulating Agents in CKD?
A
- Epoetin alfa
- Darbepoetin alfa
- Methoxy PEG-epoetin beta
19
Q
Which ESA?
- Adults: 50-100 units 3x/week
A
Epoetin alfa
20
Q
Which ESA?
- Once every 4 weeks
A
Darbepoetin alfa
21
Q
Which ESA?
- Every 2 weeks, once Hb stabilizes, double the dose and administer monthly
A
Methoxy PEG-epoetin beta
22
Q
MOA of which drug?
- Induces erythropoiesis by stimulating the division of differentiation of committed erythroid progenitor cells
- Induces release of reticulocytes from the bone marrow into the blood stream
A
Erythropoetin Stimulating Agents (ESA)
23
Q
2 clinical indications for ESAs
A
- Anemia due to myelosuppression
- Anemia due to CKD
24
Q
ESA half lives
- Are half lives longer in IV or SQ?
A
SQ
25
3 Adverse Effects of ESAs
* Boxed warning: increased CV and CKD events w/ Hb \>11 g/dL
* Cancer
* Increase risk of DVT
26
What is the Hb goal / change for management of anemia in adults?
1-2g/dL in 4 weeks
27
What are the 6 abnormalities in Chronic Kidney Disease-Mineral & Bone Disorder?
* Parathyroid hormone (PTH)
* Calcium, phosphorus
* The calcium-phosphorus product
* Vit D
Bone turnover
* Soft tissue calcifications
28
What effect does PTH have in regards to CKD-MBD?
* **Serum Ca increased\*\***
* **Serum Phosphate decreased\*\***
## Footnote
**(Net effect on serum levels)**
29
What effect does Vit D have in regards to CKD-MBD?
* **Serum Ca increased\***
* **Phosphate increased\***
## Footnote
**(net effect on serum levels)**
30
What effect does FGF23 have in regards to CKD-MBD?
* **Decreased serum phosphate\***
## Footnote
**(Net effect on serum levels)**
31
4 ways to manage CKD-MBD?
* Dietary phosphorus restriction
* Phosphate-binding agents
* Vit D supplementation
* Calcimimetic therapy
32
Give examples of foods high in phosphorus
* Pumpkin seeds
* Ground mustard seeds
* Parmesan cheese
* Brazil nuts
* Cocoa powder
* Edamame
* Baker's yeast
* Bacon
* Beef liver
* Canned sardines
33
What 2 drugs are Calcium Based Binders used to tx Hyperphosphatemia in CKD patients?
* Calcium acetate (PhosLo)
* Calcium carbonate (Tums)
34
What 2 drugs are Iron-based binders used to tx Hyperphosphatemia in CKD?
* Ferric citrate (Auryxia)
* Sucroferric oxyhydroxide (Velphoro)
35
What are 2 Resin binders used to tx Hyperphosphatemia in CKD pts?
* Sevelamer carbonate (Renvela)
* Sevelamer hydrochloride (Renagel)
36
What are 2 "other elemental binders" used to tx hyperphosphatemia in CKD pts?
* Lanthanum carbonate (Fosrenol)
* Aluminum hydroxide (AlternaGel)
37
**Which drug?**
* **MOA:** Binds w/ dietary phosphate to form insoluble calcium phosphate: excreted in feces
* **Clinical indication:** CKD hyper-phosphatemia
Calcium Based Phosphate-Binding Agents for tx of Hyperphosphatemia in CKD pts.
* Calcium acetate (PhosLo)
* Calcium carbonate (Tums)
38
**Adverse effects of which drug?**
* Hypercalciumia
* Hypophosphatemia
* Milk-alkali syndrome
**Calcium Based Phosphate-Binding Agents for tx of Hyperphosphatemia in CKD pts.**
* Calcium acetate (PhosLo)
* Calcium carbonate (Tums)
39
**These sxs are apart of which adverse effect for which drug?**
* HA
* Nausea
* Irritability
* Weakness or Alkalosis
* Hypercalciumia
* Renal impairment
**Milk-Alkali Syndrome**
(from Calcium based Phosphate Binding agents for tx of hyperphosphatemia in CKD pts)
* Calcium acetate (PhosLo)
* Calcium carbonate (Tums)
40
**Which drug?**
* **MOA:** binds phosphate within intestinal lumen limiting absorption and decreasing serum phosphate concentrations
* **Clinical indications:** Hyperphosphatmia tx, lowers low-density lipoprotein cholesterol, consider in pts at risk for "extraskeletal calcification"
Sevelamer Hydrochloride (Renagel)
| (Resin Binder to tx hyperphosphatemia)
41
**Adverse effects of which drug?**
* Metabolic acidosis (greater in children)
* N/V/D
* Dyspepsia
Sevelamer hydrochloride (Renagel)
(Resin Binder to tx Hyperphosphatemia)
42
**Which drug?**
* **MOA:** binds dietary phosphate resulting in insoluble lanthanum phosphate complexes with net decreases in phosphate and Ca levels
* **Clinical indications:** hyperphosphatemia tx, bone half life is 2 - 3.6 yrs, potential for accumulation of lanthanum
Lanthanum carbonate (Fosrenol)
"other elemental binder)
43
**Adverse Effects of which drug?**
* N/V
* Abd pain
* Bowel obstruction
* Constipation
* Dyspepsia
* Fecal impaction
* Ileus
Lanthanum carbonate (Fosrenol) to tx hyperphosphatemia
"other elemental binders"
44
**Which drug?**
* **MOA:** binds phosphate in GI tract preventing absorption of phosphate
* **Clinical indications:** not a first line agent, reserve for short term use (4 weeks) in pts w/ hyperphosphatemia not responding to other binders
**Aluminum Hydroxide (AlternaGel)**
Used to tx hyperphosphatemia in CKD
"Other elemental binders"
45
**Which drug?**
* Risk of aluminum toxicity
* Constipation, fecal impaction
* Hypomagnesemia
* Hypophosphatemia
**Aluminum hydroxide (AlternaGel)**
Used to tx hyperphosphatemia in CKD
"Other elemental binders"
46
What are the 2 "nutritional Vitamin D" drugs?
* Ergocalciferol (Drisdol)
* Cholecalciferol
47
What are the 3 "Vitamin D & Analogs?"
* Calcitrol (Rocaltrol)
* Doxercalciferol (Hectorol) - analogs
* Paricalcitol (Zemplar) - analogs
48
Production of Vitamin D requires what?
Conversion of 7-dehydrocholesterol to cholecalciferaol (vit D3) by sunlight
49
* The first hydroxylation step of Vitamin D occurs where?
* The final conversion step of Vitamin D occurs where?
* 1st: Liver, to form 25-hydroxyvitamin D3
* Final: Kidney, to form 1,25-dihydroxyvitamin D3 or calcitriol
50
Recommendations for CKD
* Adjust med doses for kidney function
* Seek pharmacist or medical advice before using OTC meds / nutritional supplements
* Are herbal medicines recommended?
* ___ is suggested for pts at risk for atherosclerotic events unless there is an increased bleeding risk
* Avoid ______ in people w/ a GFR \<60 or in those known to be at risk of phosphate nephropathy
* Herbal meds NOT recommended
* ASA
* oral phosphate-containing bowel preparations
