CKD, Hemodialysis, PD & CRRT

CKD Categories

• Diabetes

• Hypertension

• Glomerulonephritis

• Polycsystic CKD

2 factors that lead to Chronic Kidney Failure (CKD)

• HTN & Diabetes

• Can lead to irreversible loss of nephrons

Acute Renal failure

• Reversible

• Pre Renal cause & Post renal cause lead to:

  • Intrarenal cause

CKD is defined as…

• kidney damage

• Or GFR <60 mL/min/1.73m² for > 3 months

Kidney damage is defined as…

• pathologic abnormalities or markers of damage

• Includes abnormalities in blood or urine tests or imaging

Digoxin

• 90% protein bound

• Renally eliminated leading to INC serum levels

Antibiotics in CKD

• Most antibiotics are renally dosed

• Reduce the dose if GFR falls below a certain value

Anticoagulants in CKD

• Dabigatran is contraindicated in CKD

• 80% eliminated in kidneys

• Be careful w/ Rivaroxaban, Apixaban, Edoxaban & Enoxaparin

How to treat Hyperphosphatemia

• Sevelamer

• Dietary phosphate binders & dietary phosphate restriction

• Lanthanum carbonate (Fosrenol)

How to treat hypocalcemia

• Calcium Carbonate

  • Caltrate 600, TUMS

• Calcium Acetate

  • Phoslo, Eliphos, Phoslyra

• Ca supplements & possibly calcitrol

How to treat Anemia

• Iron Dextran

• Epoetin Alpha

• Daprodustat

What contributes to the high rates of mortality observed in CKD

Hyperphosphatemia

Hypocalcemia in Chronic renal failure is d/t 2 primary causes:

• ↑ serum phosphorus & ↓ renal production of Vit D

• ↑ serum phosphorus complexes w/ serum Ca & deposition into bone causing hypocalcemia

Hyperparathyroidism in CKD MOA

• Defect in activation of Vit D d/t CKD leads to hypocalcemia & hyperphosphatemia

• This leads to a compensatory ↑ in PT gland cellularity & PTH production causing secondary hyperparathyroidism

SGLT21 in CKD MOA

These agents prevent decline in kidney function thru reduction in glomerular HTN

Cacitriol

• Can alleviate hypocalcemia in CKD

• ↑ intestinal Ca absorption

• Prevents secretion of Ca in the kidneys

PO4 Scavenger

• Sevelamer (Renagel, Renvela)

• Indicated for the ↓ of serum phosphorus levels in pts w/ CKD on hemodialysis

Epoetin Alpha

• Stimulates division & differentiation of committed erythroid progenitor cells

• Induces release of reticulocytes from bone marrow into the bloodstream

Finerenone

• Indicated to reduce risk of sustained eGFR decline

• End-stage kidney Dz (ESKD)

• CV death

• nonfatal MI

• hospitalization for HF in adults w/ CKD associated w/ Type II diabetes

Dapagliflozin (Farxiga)

• Indicated to reduce risk of sustained eGFR decline

• ESKD

• CV death

• hospitalization for HF in adults w/ CKD who are at risk of progression

Canagliflozin (Invokana)

• Indicated to reduce risk of ESKD

• Doubling of serum creatinine

• CV Death

• hospitalization for HF in adults w/ Type II DM & diabetic nephropathy w/ albuminuria

How to treat Hyperkalemia in CKD

• Insulin

• High dose inhaled albuterol

• IV CaCl₂ / Ca gluconate

• Loop diuretics

• Emergency HemoD

• Sodium Bicarb

treatment for Plt abnormalities of CKD

• Desmopressin (DDAVP)

• Has been shown to ↑ Plt function w/in 1 hour of administration

Treatment for Glomerulonephritis

• Corticosteroids

  • Prednisone

• Immunosuppresants

  • Cyclophosphamide

Role of CRRT

• A type of blood purification therapy used w/ pt’s who are experiencing acute kidney injury (AKI)

• it is continuous

• pt’s blood passes thru a special filter that removes fluid & uremic toxins, returning clean blood to the body

Treatment for HTN in CKD

• Ace Inhibitors (ACEI)

  • Lisinopril or Ramipril

• Ace Receptor Blockers (ARB)

  • Valsartan or Candesartan

Drugs for Lipid management

• Atorvastatin

• Rosuvastatin

Drugs for HF

• Ace Inhibitors (ACEI)

  • Lisinopril or Ramipril

• Ace Receptor Blockers (ARB)

  • Valsartan or Candesartan

• Monitor Potassium

Beta Blocker drugs

• Carvedilol

• Bisoprolol

Spironolactone

Monitor K levels & best to use lowest dose (12.5 mg daily)

Drugs for CV Dz pt’s w/ CKD

• Aspirin

• ACEI

• Beta Blockers

• Statins

Diuretics in CKD

• Furosemide (Lasix)

• Chlorthalidone

Drugs for Hyperparathyroidism

• Calcitriol

• Cinacalcet (Sensipar)