Renal Exam 2

kidney damage or GFR < 60mL/min for 3 months

definition of chronic kidney disease

g1

GFR > 90 AND markers of kidney disease

g2

GFR 60-89 AND markers of kidney disease

g3a

GFR 45-59

g3b

GFR 30-44

g4

GFR 15-29

g5

GFR < 15

cystatin c

alternative to creatinine to calculate GFR

hypertension and diabetes

the two most common causes of CKD

protein in the urine - can cause decline in renal function and cardiovascular disease

< 30

normal albumin to creatinine ratio

30-300

moderately increased albumin to creatinine ratio

> 300

severely increase albumin to creatinine ratio

no

is dietary protein restriction recommended?

RAAS inhibitors

best pharmacotherapy option for proteinuria

up

does serum creatinine go up or down when using ACEs/ARBs?

reduces rate of GFR decline

reduction in proteinuria with ACEs/ARBs reduces what?

ACR > 30

when should ACE/ARB be initiated in proteinuria patient with hypertension?

ACR > 300

when should ACE/ARB be initiated in proteinuria patient with no hypertension?

ACR > 30

when should ACE/ARB be initiated in proteinuria patient with no hypertension but has diabetes?

aldosterone receptor antagonists

what class of drugs can reduce proteinuria in combination with an ACE/ARB?

chronic kidney disease with type 2 diabetes

what is finerenone indicated for?

ACE/ARBs

what is aliskiren contraindicated with?

binds to potassium in the blood

patiromer mechanism of action

binds to potassium in the blood

sodium zirconium cyclosilicate mechanism of action

lowers GFR

increase in systolic blood pressure does what to GFR?

< 130/80

goal blood pressure in chronic kidney disease

salt

what “chemical” should be restricted in hypertension?

diuretic or CCB

what are the two medication classes that should be used in a patient with CKD and hypertension (no proteinuria)

beta blocker

what medication class should be used in patients with CKD and hypertension and comorbidities such as heart failure

chlorthalidone

which diuretic shows ability to lower BP in stage 4 CKD?

stages 4-5

which CKD stages are loop diuretics most effective?

dihydropyridines

which CCBs have a neutral or negative effect on proteinuria (but are superior for hypertension/CKD management)?

non-dihydropyridines

which CCBs have a potential to improve proteinuria?

6.5-8.0

reasonable HgA1C goal for a patient with CKD and diabetes

reduces albumin in the urine, reduces intraglomerular pressure (these are not effective in glucose lowering in patients with CKD)

effects of SGLT-2 inhibitors in CKD

thiazide or loop diuretics

what medication classes should be decreased (or eliminated) before starting SGLT-2 inhibitors?

cardiovascular, mineral/bone disorders, anemia, acidosis

what 4 complications can be caused from CKD?

dyslipidemia

biggest risk factor for cardiovascular disease in a patient with cardiovascular disease caused by CKD

moderate intensity statin (with or without ezetimibe)

how to treat dyslipidemia in a patient with cardiovascular disease caused by CKD

dialysis

when should moderate-intensity statins NOT be used in a patient with cardiovascular disease caused by CKD?

increased PTH

how does decreased calcium affect PTH?

replace vitamin D

what is the first treatment for hypocalcemia?

0.8 x (4.0-albumin) + serum calcium

corrected calcium equation

reduce dietary phosphate, phosphate binders (includes calcium binders)

two treatments for hyperphosphatemia

hyperphosphatemia

what are aluminum-containing binders used to treat?

neurotoxicity

adverse effect of aluminum-containing binders

calcium acetate and calcium carbonate

which calcium based binders (for hyperphosphatemia) are best?

calcium citrate

which calcium based binder (for hyperphosphatemia) should not be used?

take with meals

counseling point for sevelamer carbonate (for hyperphosphatemia)

take with each meal (taken TID)

counseling point for lanthanum carbonate (for hyperphosphatemia)

hyperphosphatemia

what does sevelamer carbonate treat?

hyperphosphatemia

what does lanthanum carbonate treat?

hyperphosphatemia

what does ferric citrate treat?

hyperphosphatemia (affects calcium levels as well)

what do calcium based binders treat?

hyperphosphatemia (iron is not absorbed in the body)

what does sucroferric oxyhydroxide treat?

phosphorus, TSAT, ferrin

what has to be monitored with ferric citrate?

to avoid artery calcification

why should calcium based binder dose be reduced?

calcium

what does active vitamin D help absorb?

> 30 ng/mL

sufficient level of vitamin D

ergocalciferol weekly for 8 weeks until > 20ng/mL, then switch to daily vitamin D supplement

treatment approach for < 20 ng/mL vitamin D

hyperparathyroidism in CKD in stage 3 and 4 (vitamin D < 30)

rayaldee indications

fix underlying issue (hyperphosphatemia, low vitamin D, hypocalcemia)

first treatment plan for hyperparathyroidism

vitamin D analogs (only stage 4 and 5 CKD)

second line treatment for hyperparathyroidism (after trying to fix underlying problem)

calcitriol

what is the most common oral form of vitamin D?

calcitriol

which vitamin D analog has the highest risk of hypercalcemia?

hypercalcemia

vitamin D analogs increase the risk of what?

tricks body into thinking there is more calcium than there is (stops PTH from being synthesized)

cinacalcet mechanism of action (calcimimetic agent)

injectable calcimimetic agent (lowers PTH)

what is etelcalcetide?

TSAT < 30% or ferrin < 500ng/mL

when should anemia be treated with iron?

oral iron (usually taken three times a day)

first line therapy for anemia in non-dialysis CKD

IV iron

first line therapy for anemia in dialysis CKD

anaphylaxis

safety concern for high molecular weight iron dextran

Hb < 10

when should you initiate ESA in non-dialysis or dialysis CKD?

13 (or above)

the TREAT trial showed that there was a greater risk of stroke when target Hb to what?

hypertension, CVD, clot risk

ESA can cause what?

hyperkalemia

low serum bicarbonate in CKD can lead to what?

yes

end of fravel material

greater than 75 years old

survival advantage of starting dialysis disappears in patients in what age?

over half (54.5%)

1 year mortality rate in patients over 65 that start dialysis

dependence for basic activities, age over 85, dialysis initiation, having 4 or more comorbidities

what are the 4 risk factors for 1 year mortality?

conservative care

interventions to delay progression of kidney disease and minimize risk of adverse effects or complications

dialysis

what does conservative care NOT include?

decreases hospitalization rates, increases home death rates

how dose conservative care affect hospitalization rates and home death rates?

dialysis

does dialysis or conservative care have higher symptom burden?

yes

is acetaminophen safe in CKD?

no

is salsalate safe in CKD?

yes

is topical diclofenac safe in CKD?

no

are systemic NSAIDs safe in CKD?

yes

is buprenorphine safe in CKD?

yes

is fentanyl safe in CKD?

yes

is methadone safe in CKD?

no

is oxycodone safe in CKD?

no

is hydrocodone safe in CKD?

no

is oxycodone safe in CKD?

no

is hydromorphone safe in CKD?

no

is morphine safe in CKD?

yes

is tramadol safe in CKD?

no

is tramadol ER safe in CKD?

yes

are IR gabapentinoids safe in CKD?