Chronic Kidney Disease: Management of Complications

Dr. Glaze, Exam 1

13

• anemia diagnosis hemoglobin < __ in men

12

• anemia diagnosis hemoglobin < __ in women

TSAT and ferritin

• lab values to evaluate iron status

KDIGO normal iron levels

• TSAT > 30%

• Ferritin level > 500 ng/mL

iron deficiency

• before ESA therapy initiated, ___ must be corrected

30, 500

• all CKD patients with TSAT </=___ % and or ferritin </= _ should receive iron therapy (even if currently on ESA)

KDIGO guideline treatment targets for iron therapy

• transferrin saturation > 20%

• serum ferrtin: CKD-HD (>200 ng/mL), or CKD-ND (>100 ng/mL)

oral iron

• iron supplementation

• 200mg of elemental iron daily

• Non-HD CKD

IV iron

• preferred over PO in HD patients

• preferred if patient does not repsond/cannot tolerate oral iron

maybe

ESA __ started in non-HD patients with Hgb <10g/dL

should

ESA ____ be started in HD patients when Hgb < 10 g/dL

stage CKD on HD

• ESA and IV iron generally used in combination in ____

11

treatment target for Hgb ESA </= ___ g/dL

iron deficiency

• most common ESA hypo-responsiveness

diagnosis of anemia in CKD

• Men: Hgb < 13

• Women: Hgb < 12

when to treat iron deficiency

• TSAT </= 30%

• Ferrtin </= 500

iron replacement options

• oral (non-HD)

• IV (HD or non-repsonders)

iron treatment goals

• TSAT > 20%

• ferritin level

  • >200 (HD)

  • >100 non-HD

when to use ESA

• non-HD CKD: may if Hgb <10g/dL

• HD: should if Hgb <10

treatment target for anemia

Hgb </= 11g/dL

2.5-4.5

target phosphorous levels

8.5-10.5

target calcium levels

PTH normal range

10-65 ng/L

phosphate binders

• approach to lower PO4

• not for prevention

• reduces phosphorous absorption and serum levels

• forms insoluble complexes that are excreted in stool

• must be taken with meals

calcium phosphate binders

• calcium carbonate, calcium acetate

• phosphate binder used in hyperphosphatemia from CKD

• not recommended in patients with 2 consecutive measurements: calcium > 10.2, PTH <150

when calcium containining phosphate binders are not recommended

• Calcium > 10.2

• PTH < 150

sevekaner/lanthanum

• non calcium containing phosphate binders used to treat hyperphosphatemia

calcium based phosphate binders

• effective in lowering serum phosphorous levels and may be used as the initial binder

CKD G3a-G5D

• in adult patients with ___ receiving phosphate lowering treamtent, we suggest restricting the dose of calcium based phosphate binders

phosphate

• manage ___ first when patient has calcium and phosphate issues with CKD

1,25D

• in a CKD patient the ability to convert 25D to ___ is lost as kidney function declines

hypocalcemia treatment

• vitamin D

• CKD patients require active form of vitamin D

• activated vitamin D suppresses PTH

• direct effect on parathyroid gland

• stimulation of calcium and phosphorous absorption in intestines

• shown to decrease PTH levels, improve bone histology, increase BMD

• should not be given until PO4 levels are controlled

inactive vitamin D

• vitamin D precursor (PO)

• ergocalciferol (D2)

• cholecalciferol (D3)

• calcifediol ((D3)

activated vitamin D

• PO or IV

• calcitriol

• paricalcitol

• doxecalciferol

vitamin D (D2 or D3)

• in stages CKD 3-5 ND

• when:

• serum levels of 25(OH)-vitamin D are low (<30)

• severe and progressive hyperparathyroidism

• calcium is low < 9.5 and phosphorous < 4.6

• dose adjust based on: PTH, calcium, and phosphorous levles

• consider active vitamin D if PTH remains elevated despite adequate 25(OH)D levels

active vitamin D

• PTH > 300 should receive this

• during stage 5 CKD

calcimimetic

• cinacalcet

• attaches to calcium receptor in parathyroid gland and increases the sensitivity of receptors to serum calcium concentration, reducing PTH

• useful in patients with high calcium/phosphate concentrations and high PTH concentration

• CKD stage 5 (usually)

high phosphate

• use phosphate binders if ____

low phosphate

• avoid/reduce if phosphate binders if ___

high PTH, low Ca

• when to use calcitriol

low PTH, high Ca, high Phos

• when to avoid calcitriol ___

high PTH, high Ca, high phos

• when to use cinacalcet ____

low Ca, low Phos

• when to avoid cinacalcet ____

phosphate lowering therapies

• __ should be based on progressive or persistent elevated serum phosphate (start with calcium based)

hypercalcemia

• avoid ___ in CKD linked to increase mortality and nonfatal CV events (restrict dose of calcium based phosphate binders)

calcitriol/vitamin D analog (active vitamin D)

• in CKD G3-5 with severe, progressive hyperparathyroidism

calcimimetic and or calcitriol

• 1st line for lowering PTH in CKD 5 HD