Kidney related shit PEBC

CKD staging:

1. Name the eGFR ranges for each stage from G1-G5

2. name the albuminuria stage from A1-A3

G1 >90

G2 60-89

G3a 45-59

G3b 30-44

G4 15-29

G5 <15, on dialysis

A1 <3

A2 3-30

A3 >30

CKD changes to bloodwork

Decreased

• Hgb, Hct, ferritin

• Ca

• Bicarb - more likely for metabolic acidosis

Increased

• phosphate

• potassium

Progressive Risk factors for development of CKD

• unctrl DM

• unctrl HTN

• autoimmune disorder (glomerulonephritis, lupus nephritis, IgA nephropathy)

• CVD (incl HF)

• Smoking

• obesity

Susceptibility risk factors for CKD

age >60

low SES

low birth weight

fam hx of CKD

drug induced nephrotoxicity

exposure to nephrotoxins

prior AKi

kidney fialure

hx of kidney stone

Polycystic kidney disease

systemic inflammation

dyslipidemia

tubular cell toxicity drugs - impair mitochondrial function and transport

Aminoglycoside

Amphotericin B

antiretrovirals

cisplatin

contrast dye

fascarnet

zolendronate

Drugs that cause glomerulonephritis - inflammation of flomerulus, leads to fibrosis or scarring (proteinuria >3.5g/day)

gold

hydralazine

interferon alfa

lithium

nsaid

PTU

pamidronate (high dose or prolonged course)

drugs that lead to Acute interstitial nephritis AIN - inflammation in renal tubules and intersititium = fibrosis and scarringDrugs that lead to Acute interstitial nephritis AIN - inflammation in renal tubules and intersititium = fibrosis and scarring

acyclocir

allopurinol

abx - beta lactam, rifampin, sulfonamide, vanco

diuretics - loop and thiazide

indinavir

nsaid

phenytoin

PPI

ranitidine

drugs that lead to chronic interstitial nephritis

acetaminophen (high doses chronically)

calcineurin inhibitors - cyclosporin, tacrolimus

chemotherapy

chenese herb with aristolochic acid

lithium

nsaid

drugs that cause rhabdomyolysis muscle injury, release more CK into blood and damage kidney, change GFR

AD: amitriptyline, doxepin, fluoxetine

diphenhydramine, doxylamine

Etoh, BZD, heroin, cocaine, ketamine, methadone, Methamphetamine

Li

statin

drugs that cause crystal nephropathy insoluble in urine = block urine flow

Abx ampicillin, cipro, sulfonamides

antiviral

chemo that cause tumour lysis syndrome (release uric acid and Ca)

indinavir

methotrexate

triamterene

when does someone have CKD

GFR<60 for over 3 months

ACR >3 over 3 months

and or some markers of kidney dmg for over 3 months with or without decreased GFR

When do people get symptoms in CKD

once at stage G3a - fatigue, poor appetite, itching

G4 signs of edema in lower extremities

G5 poor sleep, SOB, vomiting

Recommended therapy for CKD no DM

ACE/ARB

Statin

SGLT2i

optional

• Antiplatelet (if hx of heart event)

Recommended therapy for CKD with DM

SGLT2i until dialysis or transplant

ACE/ARB

statin

optional

• Antiplatelet (if hx of heart event)

• GLP-1 if needed

• nsMRA - finerenone!!

• CCB, MRA if not at SBP target of 120

IBW in males

50kg + 2.3kg(inches over 5ft)

IBW in females

45.5kg + 2.3kg(inches over 5ft)

AdjBW calculation

IBW + 0.4(Actual BW- IBW)

when to use adjusted BW and IBW

IBW used UNLESS patient is obese (30% over IBW) OR if less than IBW

• less than IBW = use actual body weight

• if 30% over IBW use adjusted BW

nonpharm tx for CKD

smoking cessation

healthy diet <2g Na, SBP <120, avoid hyperkalemia

• meats 0.8g/kg/day CKDG3-5

• dietary phosphate CKD3-5

phys acitivity

weight BMI 18.5-24.9

prevent depression

A1c<7

amount of elemental iron in each

iron polysacc

ferrous fumarate

ferrous sulfate

ferros gluconate

FeraMax dose 150 / Fe 150mg

ferrous fumarate dose 300 / Fe 100mg

ferrous sulfate dose 300 / Fe 60mg

ferros gluconate dose 300 / 35mg

when to initiate erythropoiesis stim agents ESA

initate if Hbg 90-110

note that it does not improve mortality or CV outcomes in CKD and anemia but improves QoL (like furosemide in HF)

AE of ESA

Thromboembolism

Hypertension

allergic rxn

myalgia, flulike symptom

injection site pain

Complications of ESA

abx production

Al toxicity

pure red cell aplasia

Darbepoetin vs erythropoetin

Darbo has dosing of 1-2wk vs EPO of 1-3 times weekly, arget Hgb 115

IV Fe infusions considered

if oral failed.

• target is hgb 115

• monitor every 3 months

What is the definition of AKI

• scr that increases over 26.5unol/L in 2 days

• SCr that increases 1.5x baseline within last 7 days

• urine volume <0.5mL/kg/hr for 6 hours

Risk factors for AKi

CVD, hx of cardiac sx

DM

multiple myeloma

hepatorenal syndrome

CKD

hypovolemia

sepsis

male

african american

advanced age

Pre renal AKI / functional (common 70%)

hypo perfusion of kidney - increases BUN and SCr

Intrinsic structural AKI 10%

Post renal AKI 20%

Severe AKI symptoms

confusion

fatigue

anorexia

flank pain

weight gain, edema

oliguiria <400mL/day or anuria <100mL/day

pre renal and intrinsic AKI treatment

fluid resus - isotonic crystalloid (NS or ringers lactate)

NaCO3 IV for metabolic acidosis and alkinizing urine

vasopressor if shock

diuretic for fluid overload

stop offending agents

post renal aki tx

removal of offending agent

renal replacement tx - dialysis to remove toxins

nonpharm tx for AKI

monitoring really

caloric intake 20-30kcal/kg/day

Allopurinol is also used in what?

prevention of AKI - cancer chemotherapy with risk of tumor lysis

prevents uric acid nepropathy - taken a few days prior to chemo

what is bad hyperkalemia? (ranges)

mild 5-5.9

mod 6-6.4

severe >6.5

What is used to shift K into cells?

sodium bicarbonate - used in acidosis

insulin

salbutamol

what is used to eliminate K from body?

furosemide

sodium polystyrene sulfonate

dialysis

When is metformin CI

CrCl <30

hepatic failure incl AUD

severe dehydration

hx lactic acidosis

When is acorbose CI

IBD

intestinal obstruction

intestinal diseases

ulceration

severe hepatic diesease

AE of acarbose

flatulence

diarrhea

abdominal pain

hepatitis

AE SU - gliclazide and glyburide and meglitide repaglinide

hypoglycemia (SU more, esp gliclazide)

weight gain (SU more)

HA

dizzy

GI

when are SU CI

T1DM

pregnancy

breastfeeding

ketoacidosis

severe liver or renal impairment

when is repaglinide CI

clopidogrel - clopidogrel inhibits repaglinide metabolism → higher change of hypoglycemia

gemfibrozil - same as above

same CI as SU.

MOA of SU and repaglinide

stimulate insulin release from beta cell

MOA Thiazolidindiones (TZD) - pioglitazone, rosiglitazone

increasing insulin sensitivity and decreasing liver glucose production

DPP4 inhibitors MOA

increase in incretin levels

Thiazolidinediones (TZD) AE

WORSEN HF → fluid retention and weight gain

fractures

URI

HA

Macular edema

TZD CI

HF

liver failure

bladder cancer - pioglitazone

Myocardial infarction - rosiglitazone

caution with DPP4 inhibitors

hx of pancreatitis or pancreatic cancer

GLP1RA CI

pregnancy

family hx of MTC or MENS2

causion in pancreatitis pancreatic cancer hx

GLP1RA AE

NVD

inj rxn

acute pancreatitis

gallbladder dx

weight loss

SGLT2i AE

UTI

yeast infx

hypotension

hyperkalemia

wt loss

DKA

fracture, amputation - canagliflozin

orlistat MOA

wt reduction - inhibit absorption of dietary fats

orlistat AE

NVD

more bowel mvt (not abs fat)

flatuence

steatorrhea (fat in poo)

ab pain

Rapid acting insulin is taken when because

right before eating (bolus)

• short onset 4-15min

• peak in 30-120min

• lasts 3-5h

Fiasp is fastest.

SA insulin is taken when because

30 min prior to eating

• onset 15-30min

• peak 2-8h

• duration 6.5-24h

RA insulin

Lispro

Aspart

Glulisine

SA insulin

Humulin R

Novolin ge Toronto

Entuzity

Longest acting insulin

Degludec - Tresiba

• onset 90min

• no peak

• duration 42h

Second longest acting insulin

Glargine Lantus, Basaglar, Toujeo

• onset 90 min

• no peak

• duration 24h (toujeo 30)

Intermediate acting insulin

NPH numullin N novolin ge NPH

• onset 1-3h

• peak 5-8h

• duration 18h

• ITS CLOUDY

• TAKEN QHS or BID

Detemir/levemir

onset 90min

peak none

duration 6-24hr

has short duration - may need BID

General summary of DM drugs

microvascular complications DM

eye, kidney, nerves

macrovascular complications

brain, heart, extremeties

diagnosis of DM - must be acle to repeat test to confirm diagnosis unless symptomatic hyperglycemia

FPG >7

Random PG >11.1 (anytime of day)

2hPG with 75g OGTT >11.1

A1c >6.5%

how to treat hypoglycemia

15 rule - 15g PO fast acting glucose - 4 glucose tabs, 3 tsp sugar, 1 tbsp honey, 150ml juice/soft drink → check BG in 15 min again → if <3.9, repeat, if >3.9 and next meal over one h away, take carb + protein

< 4, 40 minute rule for driving

Causes of T2DM - drugs

Glucocorticoids

atypical antipsychotics

FQ

Tiazides

protease and calcineurin inhibitors

HAART

Hyperglycemia inducing agent

Risk factors for T1DM

fam hx

genetics

finnish

younger age 5-14

risk factors for T2DM

non-modifiable

• >40 yo

• SEA, Latin american, FN

• fam hx 1st degree relative

• gestational DM, macrosomic infant

targets for A1c

<7 for most

<6.5 if low risk for hypoglycemia

7-8.5 if older, dementia, etc

non pharm DM recs

dietary

• can effect A1c by 1-2%, less fat, more protein, less than 2 drinks a week or less

Exercise

• 150min /week mod aerobic exercise

• resistance training 2 days a week

Weight loss

• anything over 5% improve sugar ctrl and CVD risk

If pt has high CV risk and DM

GLP1RA, SGLT2i to decrease MACE

• liraglutide

• dulaglutide

• semaglutide

• empa

• cana

If pt has HF and DM

SGLT2i decrease HF hosp and CV death

• dapa

• empa

If pt has CKD and DM

SGLT2i and GLP1RA, nsMRA

initiating insulin dosing

1. basal insulin first at 0.1-0.2u/kg/day, titrate by 1u to target (consider stopping Su, meglitinide, TSD bc hypoglycemia)

2. consider adding SGLT2i, GLP1RA/DPP4,

3. bolus insulin starting with 1 meal a day

Total insulin dose if using both basal and bolus is a 40% basal / 60% bolus (divided by how many meals)

how to change insulin doses

usualy adjust by 10% each time

target lows first then first elevated blood glucose of day

How to administer insulin

How to initiate insulin in T2DM

What is the somogyi effect

what is the dawn phenomenon

Medications that DM patient should be on

Statin - macrovasc dx, over 40, if less than 40 had DM over 15yr or microvasc complications

ACE/ARB for HTN if have CVD, CKD risk factors (if no risk factor can consider DHPCCB, Thiazide/like diuretic)

Aspirin if 2ndary prevention CVD (MI/STroke)

sick day management DM SICK and SADMANS

Pregnancy and DM

insulin and breastfeeding

breastfeeding increases risk of hypoglycemia and insulin is secreted in breastmilk - not risk to infant

how to monitor blood glucose in DM

Monitoring complications in diabetes

Agents for neuropathy DM

pregabalin, gabapentin, 1st line

duloxetine, valproate, amitriptyline, venlafaxine

topical nitrate spray and casaicin

1. If patient’s A1c is >1.5% then start…

2. If patient’s A1c is <1.5% then start…

1. lifestyle plus metformin

2. lifestyle only