pharm 2: renal rx

Drug classes that slow CKD progression

- ACEi/ARB

- SGLT2i

- loop diuretics

MOA of ACE/ARB

dilate Eff arteriole -> dec. intraglomerular pressure

MOA of SGLT2i

dec glucose + Sodium reabsorption-> hyperfiltration

MOA of Loop diuretics

- inh NA/K/2Cl in loop of henle

- when GFR <30

in CKD, what goes up

- phosphate

- potassium

- magnesium

in CKD, what goes down

- vit d.

- calcium

potassium is regulated by the

kidney

K excretion increases with...

aldosterone, high tubular flow

what affects K levels

- meds (ace, arbs, k sparing)

- acid base disorders

- renal dysfunction

HYPOkalemia, first check

- Magnesium level

- needs Mg absorption to occur to help absorb K

oral tx for hypokalemia

- oral potassium cl

- 10mEq raises 0.1 mEq/mL to 3.5mEq/L

- mild deficiency

When is IV potassium indicated?

Severe deficiency or when the patient cannot take PO

What is the recommended infusion rate for IV potassium?

- SLOW 10-20 mEq/hr

- never exceed 20mEq/hr

What type of monitoring is required during IV potassium administration?

Cardiac monitoring.

How should IV potassium be administered?

Given as dilution rather than IV push.

What is a common adverse effect of IV potassium?

Irritation of the GI tract.

What should be monitored during IV potassium treatment?

Potassium levels, renal function, and EKG

what causes CKD to cause hyperK

kidney cant excrete K

things that can cause hyperK

- bactrim

- bananas

- spirinolactone

Tx for HYPERkalemia consequence

disruption of the electrical act. of heart

treatment steps for hyperK

- stabilize cardiac membrane

- shift the K into cell

- get it out of the body

mneumonic for hyperK

C BIG K DR(OP)

C-

calcium fluconate 1g IV push

B-

beta2 agonist/bicarb shift from blood to cell

I-

- insulin shift (quickest)

G-

glucose/dextrose to counter the insulin if blood sugar is < 250

K-

kayexalate- exit

D-

diretics- exit

R-

renal unit for dialysis Of Patient

potassium binders help with

exit

Kayexalate (sodium polystyrene sulfonate)

increase fecal K

Lokelma (sodium zirconium cyclosilicate)

increase fecal K

Veltassa (patiromer)

dec absorption of K by binding K within the GI tract

use for Veltassa

- chronic hyperkalemia

- drugs that affect RAAS with CKD

HypoMg seen in

alcoholism, diabetes and pancreatitis

oral tx for hypoMg

- Magnesium oxide

- mild cases

- 400-800mg PO daily

- causes diarrhea

IV tx for hypoMg

- mag sulfate

- severe

Hyperphosphatemia definition

- serum phosphate > 4.5 mg/dL

- d/t calcium phosphate imbalance

tx to hyperphosphatemia

- limit dietary phosphate (anabolic diet)

- phosphate binders

MOA of phosphate binders

bind to phosphorus to reduce intestinal absorption

types of phosphate binders

- aluminum based (aluminum hydroxide)

- iron based (ferric citrate)

- calcium based

aluminum (calcium acetate, calcium carbonate)

- sevelamer (no aluminum or ca)

- metallic based (lanthanum)

first line for hyperPhos

calcium based unless hypercalcemia

Hypocalcemia causes

vit D deficiency, CKD , hypoPTH

Tx for hypoCalcemia

- servere= IV calcium fluconate/chloride

- asxs= oral

- vit d supplementation

Calcium salts indication

- mild hypocalcemia

- prevention of osteoporosis

PK calcium salts

- oral or IV

- look at elemental calcium levels (600mg BID)

above 600mg calcium

doesnt get absorbed

ADE for calcium salts

- hypercalcemia

- GI disturbances (constipation)

- renal dysfunction

- lethargy

Drug interactions calcium salts

- glucocorticoids decrease absorption of Ca

- decrease absorption of tetra, fq, thyroid hormones, biphosphonates (bc cation)

in CKD, vit D is

low, not converting to active form

Low vit D causes

low calcium and phosphorus

indication for vit D supplementation

- calciferol

- vit D deficiency

- prevention of osteoporosis

main vit D supplementation

- ergocalciferol D2

- cholecalciferol D3

PK for vit D

- oral

- 25-OHD

give ___ in CKD

- calcitriol

- doesnt need to be broken down

Anemia in CKD cuase

erythropoietin deficiency

Tx for Anemia

- if hgb <10g/dL

- epo stimulating agents

epoetin alfa

- first gen

- short duration

- 1-3x weekly

darbapoetin alfa

- second gen

- long duration

- every 2-4 weeks

what to monitor during anemia tx?

- hgb monthly

- target 10-12g/dL

ESA black box warning

- risk of death

- risk of MI

- risk of stroke

- risk of VTE/ thrombosis

benefits of iron supplementation

avoid transfusions and minimize ESA therapy

Risk with iron supplementation

anaphylaxis

oral iron- most common

ferrous sulfate

administration for oral iron

- empty stomach

- 2 hours from cations

- taken with Vit C to increase absorption

ade with oral iron

- n/v

- constipation

- metallic taste

- dark stool

- heart burn

IV iron indications

- IDA

- oral iron intolerance

- blood loss

- CKD malabsorption

IV iron dextran requires

test dose d/t anaphylactic risk

IV iron sucrose used in

dialysis

IV ferric fluconate, ferumoxytol, ferric carboxymaltose have ___ doses

larger and faster

ADE with IV iron

- flushing

- headache

- hypotension