SCOPE Objectives - kidneys

define CKD

abnormalities of the kidney structure/function for >3mo with implications for health

list criteria to be diagnosed with CKD

one of the following:

• albuminuria (ACR or AER >30mg/g)

• proteinuria (cat. A2-A3)

• urine sediment abnormalities

• electrolyte abnormalities due to tubular disorders

• abnormalities detected by histology or imaging

• history of kidney transplant

• decreased GFR (<60mL/min/1.72m2)

KDIGO stage 1 CKD

damage with normal or high eGFR

>90

KDIGO stage 2 CKD

damage with mildly decreased eGFR

60-89

KDIGO stage 3a CKD

mild to moderate decrease in eGFR

45-59

KDIGO stage 3b CKD

moderate to severe decrease in eGFR

30-44

KDIGO stage 4 CKD

severely decreased eGFR

15-29

KDIGO stage 5 CKD

kidney failure

<15

KDIGO stage 5D, 5-HD, 5-PD

on RRT

<15

KDIGO A1 albuminuria

normal or moderate increase of ACR/AER

<30

KDIGO A2 albuminuria

moderate increase (microalbuminuria)

30-300

KDIGO A3 albuminuria

severe increase (macroalbuminuria)

>300

what levels of ACR/AER signifies nephrotic syndrome

>2200

what labs to expect when a patient has CKD

increased levels = SCr, BUN, K, phos, PTH and ACR

decreased levels = eGFR and Hb (anemic)

iPTH goal for managing CKD-MBD

normal: <70pg/mL → want 2-9 x ULN

CKD 3 or 4 = monitor q 6-12 mos

CKD 5 or dialysis = monitor q 3-6 mos

phos goals for CKD-MBD

normal: 2.5-4.5mg/dL → want normal range

CKD 3 or 4 = monitor q 3-6mos

CKD 5 or dialysis = monitor q 1-3 mos

corrected Ca goals for CKD-MBD

normal : 8.5-10.5mg/dL → want normal range

CKD 3 or 4 = monitor q 3-6 mos

CKD 5 or dialysis = monitor q 1-3 mos

Ca x phos goal for CKD-MBD

CKD 3 or 4 = <55

CKD 5 or dialysis < 55

how to calculate a corrected Ca

serum Ca + [ 0.8 ( 4 - albumin ) ]

non-pharmacologic treatment for hyperphosphatemia in CKD-MBD

1st line = dietary restriction (avoid processed foods, sodas, caution with meat and dairy)

implemented once G3a and serum phos or iPTH is at the upper end of normal

pharmacologic treatment for hyperphosphatemia in CKD-MBD

• phosphate binders

• Ca-based phosphate binders

• vit. D therapy

• calcimimetics

when to start phosphate binders

persistent and progressive elevation in phos (usually G3 or G4 pts)

considerations for ca-based binders

• titrate q 2-3 wks until goal; may use combo agents

• counsel: take TID with meals to increase efficacy

• common ADRs = N/V/D/C and abdominal pain

types of Ca-based binders

• CaCO3 (Tums, Os-Cal, Caltrate)

• Ca-acetate (PhosLo)

resin/elemental based binders

• sevelamer carbonate (Renela)

• sevelamer HCl (Renagel)

• lanthanum (Fosrenol)

when to start vit. D therapy for hyperphos in CKD-MBD

if iPTH is increased, corrected Ca is normal, and 25(OH)D < 30

criteria to start active vit. D or analog forms for hyperphos

if iPTH is elevated, corrected Ca is normal and 25(OH)D is > 30

*usually pts with severe CKD → G4, 5 or dialysis)

inactive vit. D agents and dosing

ergocalciferol (D2) cholecalciferol (D3)

dosing depends on initial levels (i.e. QD, wkly, or monthly)

active vit. D agents and dosing

calcitrol (D3)

give po QD or IV 3 x wkly

analog vit. D agents and dosing

Paracalcitrol or Doxercalciferol

give po QD or IV 3x wkly

calcimimetics purpose and agents available

helps down reg Ca production in patients with increased Ca, iPTH, and phos and who cannot use vit. D

• cinacalcet (Sensipar)

• etelcacetide (Parsabiv)

monitor serum ca wkly after starting or adjusting dose then transition to monthly

cinacalcet dosing and other considerations

• 30mg QD with meal

• 2D6 substrate

• 3A4 inhibitor

• common ADRs = N/V

etelcalcetide dosing and other considerations

• 5mg IV 3 x wkly at end of IHD session

• common ADRs = N/V and may induce immunogenicity

define AKI

any of the following:

• increase in SCr by >0.3 within 48 hrs

• increase in SCr to >1.5 x baseline known or presumed to have occurred in last 7 days

• urine volume <0.5mL/kg/hr for 6 hrs

prerenal AKI

hemodynamic → sudden and severe decrease in BP or blood flow to kidneys

symptoms = blood loss, dehydration, HF, sepsis, vascular occlusion

intrinsic AKI

direct damage to kidney cells

• acute tubular necrosis (ATN): drugs, toxins, prolonged decrease BP

• glomerulonephritis

• small vessel vasculitis

management of prerenal AKI

correct hemodynamics

admin isotonic crystalloid fluid (NS or similar) = volume depletion (UOP >0.5mL/kg/hr)

vasopressor (i.e. NE) only if we need to maintain MAP >65

*DC offending agent

management of intrinsic AKI

manage fluids and electrolytes as needed

• drug induced = stop offending agent, start corticosteroids for immune response and inflammation

• ATN = stop offending agent

clinical presentation for iron deficiency anemia

• chronic and slow onset

• pica

• glossitis

• pagophagia

• glossal pain

• reduced salivary flow

labs indicative of IDA

• ferritin < 30mcg/L

• TSAT < 20%

oral therapy for IDA

starting dose = 50-100mg free iron taken every other day or QD

counseling: do not take with acid-reducing agents

D/D interactions: tetracyclines, quinolones, acid reducing agents, and levothyroxine

ADRs = dark stools and GI effects

parenteral IV therapy for IDA

• typically give 1000mg

• avoid in active systemic infections

how long to treat IDA

both methods treat for 3-6mo until anemia is resolved

clinical presentation of vit. B12 deficiency anemia

aka macrocytic anemia

similar to IDA but can also present neuro symptoms like bilateral paresthesia, ataxia, dementia-like, vision-loss and psychosis

labs indicative of vit. B12 deficiency anemia

• low Hb and MCV > 100

• serum B12 <200pg/mL

• elevated MMA

• elevated homocysteine

oral therapy for vit. B12 deficiency anemia

1st line = 1000mcg QD

don’t use first if neuro symptoms or severe

parenteral IV therapy for vit. B12 deficiency anemia

1st line for severe or neuro symptoms present

want to quickly saturate the B12 body stores

treatment duration for vit. B12 deficiency anemia

depends on resolution of symptoms and labs WNL and cause MUST be reversed

clinical presentation of folate deficiency

similar to other anemias

labs that are indicative of folate deficiency

• folate < 2ng/mL

• elevated homocysteine

• normal MMA

important to rule out B12

oral therapy for folate deficiency

oral folate 1-5mg QD

continue for at least 4mos and ensure labs are WNL and cause is reversed before DC

treatment options to prevent progression of proteinuria

if ACR > 30mg/g with DM or ACR >300mg/g w/o DM = start ACE or ARB

• titrate to BP and ACR goal (30-50% decrease or <30mg/g)

• monitor BP, SCr and K+ → esp 2-4wks after starting or dose adjust

• pregnant pts = use non-DHP CCB instead

treatment options to prevent progression of HTN associated with CKD

start ACE or ARB

common goal <130/80

treatment options to prevent progression of DM associated with CKD

anti-hyperglycemic meds (RENALLY DOSED)

1st line = SGLT2i (Jardiance or Farxiga) do not start if eGFR <20 and DC if on dialysis

*if SGLT2i is not tolerated = use metformin or GLP-1

identify secondary complications for CKD

• cardiovascular (atherosclerotic HD)

• HF

• hypertriglyceridemia

• uremic pruritis

primary cause of anemia of CKD and diagnosis levels

erythropoietin deficiency

men < 13g/dL Hb

women < 12g/dL Hb

when to treat anemia of CKD with iron agents

initiate when TSAT < 30% AND ferritin <500ng/mL

goals = minimize blood tranfusions, ESA use, and anemia-related symptoms

oral iron agents dosing and other considerations

200mg elemental Fe daily

ADRs = constipation, black stool, N/V, metallic taste

examples of oral iron agents

• ferrous sulfate

• ferric citrate

• ferrous gluconate

• ferrous fumarate

• ferric maltol

• iron polysaccharide

IV iron agent dosing and other considerations

initial 1g repletion and observe 1hr post infusion

• avoid in first trimester, active systemic infection

• ADRS = N/V, pruritis, headache, flushing, myalgia, arthralgia, back and chest pain

IV iron agents

• ferric gluconate (Ferrlicet)

• iron sucrose (Venofer)

• iron dextran (INFeD)

• ferumoxytol (Feraheme)

• ferric caarbocymaltose (Injetafer)

• ferric derisomaltose (Monoferric)

• ferric pyrophosphate citrate (Triferic)

monitoring parameters for iron agents

• at least q 3 mo if adequate iron stores

• every 1-2 mo → iron for repletion, initiation of ESA therapy or adjust ESA dose

• NOT within 1 wk of receiving iron dose

when to initiate ESA for anemia of CKD

when Hb <10g/dL

goal: use lowest possible dose to avoid transfusions

caution in pts with hx of stroke or active cancer

contraindicated in uncontrolled HTN

ESA agents

epoetin alfa (Epogen/Procrit) 3x a week

epoetin alfa-epbx (Retacrit 3x a week)

darbepoetin alfa (Aranesp once a week or q 2 weeks)

methoxy PEG-epoetin beta (Micera q 2 weeks or monthly)

monitoring for ESA

• evaluate Hb response wkly after starting, dose adjust then at least monthly

• do not exceed >1g/dL increase over 2 weeks

• adjustments occur in 25% increments not more than q 4 wks

BBW for ESA

increased risk of death, stroke, or cardiovascular events when Hb >11g/dL