CKD - Heeter

Susceptibility Factors for CKD:

• aging

• low kidney mass

• low birth weight

• ethnicity, family history, low income, low education

• systemic inflammation

• dyslipidemia

Initiation Factors of CKD:

• DIABETES MELLITUS

• HYPERTENSION

• GLOMERULONEPHRITIS

• drug toxicity

• UTIs

• Kidney stones

Progression factors of CKD:

• Hyperglycemia

• Uncontrolled HTN

• Proteinuria

• Smoking

• Obesity

Stage 1 CKD GFR:

≥ 90 ml/min

Stage 2 CKD GFR:

60-89 ml/min

Stage 3 CKD GFR:

30-59 ml/min

Stage 4 CKD GFR:

15-29 ml/min

Stage 5 CKD GFR:

≤ 15 ml/min

A1/ Normal protein in the urine:

<30 mg

A2/ Microalbuminuria in the urine:

30-300 mg

A3/ Macroalbuminuria in the urine:

>300 mg

CKD Symptoms start to show during what stages:

late stage IV, stage V

CKD most important signs:

• CV

• GI

• Endocrine

• Hematologic

• Fluid/Electrolytes

Think: Fluid Retention Symptoms

• CV- HTN, Edema

• GI- GERD, weight loss

• Endocrine- sHPT, gout

• Hematologic- anemia, Fe deficiency-

• Fluid/Electrolytes- hyper/hyponatremia, hyperkalemia, metabolic acidosis

KDIGO recommendations for protein intake w/ a GFR <30ml/min

0.8/kg/day

KDIGO recommendations for protein intake w/ a GFR >30 ml/min

1.3/kg/day

Normal A1c value is around…

5

The A1c goal for Diabetic CKD is based on…

life expectancy

• old elderly ppl= higher goal

• younger, healthier= lower goal

1st line therapy for Diabetic CKD:

• metformin

• SGLT2 Inhibitor

If the GFR <45 what do you do w/ Metformin?

reduce dose

If the GFR <30 what do you do w/ Metformin?

discontinue

If on dialysis, what would you do to the 1st line therapies for Diabetic CKD?

discontinue

If the GFR <30 what would you do w/ SGLT2 Inhibitor?

• do not initiate

• if already on SGLT2 Inhibitor, continue taking

Systolic goal for HTN in CKD:

120

Treatment of choice for HTN in CKD:

• ACEi or ARBs

What ADR should be watched for with ACEi and ARBs?

hyperkalemia

For ACEI/ ARB you want to titrate until proteinuria is reduced by _____-____%

30-50%

What is a possible add on therapy to ACEi/ARBs?

CCBs

Nonpharm treatment for HTN in CKD:

• maintain healthy weight

• smoking cessation

• minimize salt intake

• exercise

• limit alcohol

What is level of Hgb is classified as anemia in males and females?

males: <13g/dL

females: <12g/dL

In iron deficiency anemia, is macrocytic anemia or microcytic anemia presented?

microcytic anemia

Hemoglobin goal on ESA therapy is…

10-11 g/dL

What do we want out TSAT and Ferritin to be above for anemia:

TSAT ≥30%

Ferritin ≥500 ng/mL

If we have low Hgb, what would be our 1st choice of treatment?

iron replacement therapy

We start ESA therapy when Hgb is between…

9-10 g/dL

What MUST we do before starting ESA therapy?

have normal TSAT and Ferritin levels

What is our iron goal per day?

200 mg/day

Ferrous sulfate (325mg) contains _____ elemental iron.

65mg

Polysaccharide iron/Hytinic (150mg) contains ______ elemental iron.

150mg

Examples of some IV Iron preparations:

• Iron Dextran

• Ferric Gluconate

• Iron Sucrose

• Ferric Carboxymaltose

• Ferumoxytol

With oral iron replacement therapy you should take the supplements with ________.

food

Examples of ESAs:

1. Epoetin

2. Darbepoetin

3. Methoxy PEG-epoetin-beta

Frequency of Administration for each ESA:

1. Epoetin

2. Darbepoetin

3. Methoxy PEG-epoetin-beta

• Epoetin

  • 3 times a week

• Darbepoetin

  • on dialysis: every 1-2 weeks

  • not on dialysis: every 4 weeks

• Methoxy

  • monthly

With ESA therapy, are you more likely to see changes in Hgb immediately or over time?

over time

Most common ADR of ESAs:

HTN

If my Hgb increased from 1 g/dL to 2.1 g/dL over 2 weeks I would…

decrease dose by 25%

If after 4 weeks my Hgb only increased by 0.4 g/dL, I would…

increase dose by 25%

Dosing Adjustment rules for ESA:

• Hgb increases <1 g/dL over 4 weeks

  • increase dose by 25%

• Hgb increases >1 g/dL over 2 weeks

  • decrease dose by 25%

• STOP WHEN HIT GOAL

sHPT in CKD does what to Ca and P?

• low Ca

• high P

Corrected Ca equation:

CC= Serum Ca + 0.8(4- albumin)

K/DOQI recommendations for phosphate intake in CKD:

800-1000mg/day

Should Phosphate binders be taken with food?

yes

what is the preferred Phosphate Binding Agent?

calcium acetate or carbonate

What is a good benefit of using Sevelamer as a Phosphate-Binding agent?

can use if you also have high Ca

What is a good benefit of using Auryxia as a Phosphate-Binding Agent?

if you also have anemia

What forms of Vitamin D are used in Stage II, III CKD and need converted to the active form?

• ergocalciferol

• cholecalciferol

What forms of Vitamin D are used in Stage IV, V CKD and are already the active form?

• Calcitriol

• Paricalcitol

• Doxercalciferol

ADRs of Vit D therapy:

hypercalcemia and hyperphosphatemia

What is used last line if patients PTH, Ca, and P are still not controlled used max doses of other medications?

Calcimimetics- Cinacalcet

If we can balance _______, we can control metabolic acidosis.

bicarbonate

Treatments for metabolic acidosis:

• sodium bicarbonate

• citrate/citric acid preps

  • Bicitra, Polycitra