2026 NAPLEX Renal and Hepatitis/Liver Disease

Common Causes of Renal Disease

- uncontrolled DM

- HTN

Types of AKI

Pre-renal:

Intrinsic:

Pre-renal: volume depletion (e.g. dehydration) , presents with BUN:SCr ration >20:1

Intrinsic: caused by tubular damage

Functional unit of the Kidneys

Nephron

Afferent arteriole delivers ___ into the ___

blood

glomerulus

Small molecular weight substances (most drugs), pass through glomerular capillaries into filtrate and are ___

excreted in the urine

Larger substances (e.g. albumin, protein-bound drugs) are not filtered in glomerulus, stay in the blood and exit via the ___

efferent arteriole

The first place the filtrate travels after exiting the glomerulus is the ____ ____.

Proximal tubule

At the proximal tubule ____, ___, and ___ are ____

Na, Cl, Ca ; reabsorbed

What is blood pH regulated by

exchanged hydrogen and bicarbonate ions

As the filtrate moves through descending limb of loops of Henle, ____ is reabsorbed back into blood, ____ and ____ ARE NOT

H20 ; Na and Cl ARE NOT

As filtrate moves through ascending limb of loop of Henle,

Na and Cl are reabsorbed, but water is NOT (unless ADH or vasopressin is present)

1. Thiazides

2. Potassium-sparring diuretics (including aldosterone antagonists)

3. SGLT-2 inhibitors

4. Loops

1. Recognize electrolyte changes associated with different diuretics (i.e. potassium, magnesium, calcium).

1. Thiazides:

   • (-)

   • (+)

2. Loops:

   • (-)

   • (+)

3. Potassium sparring:

1. Loops:

   • (-) K/Mg, Na, Ca

   • (+) uric acid

2. Thiazides:

   • (-) Na, K/Mg

   • (+) Ca, glucose, uric acid

3. Potassium sparring: Hyperkalemia, hyper uricemia

Loop diuretics MOA

Inhibit Na/K/Cl in the ascending loop → decreasing Na reabsorption into blood, less water is reabsorbed, and less Ca is reabsorbed *(can lead to hypocalcemia and loss of bone density long-term)*

Thiazide Diuretics MOA

inhibit Na-Cl pump in distal convoluted tubule, increasing Ca reabsorption *(protective to bones long-term)*

Potassium-sparing Diuretics MOA

work in DCT and distal convoluted tubule to ↓ Na and H20 reabsorption and ↑ K reabsorption

Drugs that are Nephrotoxic

abx (5)

immunosuppressant (2)

other (3)

Aminoglycosides, Amphotericin B, Cisplatin, Polymyxins, Vancomycin

Cyclosporine, Tacrolimus

Loop diuretics (due to excessive vol loss), NSAIDs, Radiographic contrast dye

BUN

increases as kidney function declines

Scr normal range

0.6-1.3 mg/dL ; as GFR declines, SCr increases

Accuracy of Cockgrauft-Gault Equation decreased when ___

LOW muscle mass

*over-estimates CrCl*

When is Cockgrauft-Gault Equation not preferred

- young children

- ESRD or unstable renal function

- very low muscle mass patients

CKD Confirming Criteria

presence of either for ≥ 3 months:

1. eGFR < 60 mL./min

2. Albuminuria (AER ≥ 30 mg/24 hours)

Medications for Delaying Progression of CKD

1___ or ___

• (3 pearls)

2. if eGFR _____, use SGLT-2 inhibitor

3. if eGFR_____, use finerenone in patients with (1)_____ and (2) _____, and max (3) _____ and ____

1. ACE or ARB

• expect initial up to 30% inc SCr ; do NOT stop

• SCr and K monitored 2-4 weeks after initiation

• avoid potassium and salt substitutes

2. if eGFR ≥ 20 mL/min, use SGLT-2 inhibitor

3. if eGFR ≥25 mL/min, use finerenone in patients with persistent albuminuria and TD2M on max ACE/ARB and SGLT-2 already

ACE/ARB's help Albuminuria by inhibiting _______, results in efferent arteriolar _____which reduces glomerulus pressure and decreases filtration of albumin into urine

inhibit RAAS (production/activity of angiotensin II) ; dilation

Select Drugs that are Contraindicated in CKD

CrCl <60: _____

CrCl <50: TDF-containing HIV treatment (e.g. _____, _____, _____) and _____IV (d/t vehicle)

CrCl <30: TAF-containing HIV treatment (e.g. _____, _____, _____, _____, _____), _____, _____, _____

GFR <30: _____

others: _____

CrCl <60: Nitrofurantoin

CrCl <50: TDF-containing HIV treatment (e.g. Complera, Delstrigo, Stribild) and voriconazole IV (d/t vehicle)

CrCl <30: TAF-containing HIV treatment (e.g. Biktarvy, Descovy, Genvoya, Symtuza, Odefsey), NSAIDS, Dabigatran, potassium-sparing diuretics

GFR <30: metformin

others: meperidine

Select Drugs that Require ↓ Dose or ↑ Interval in CKD that Increase Risk of ADE d/t ↓ Clearance

Anti-infectives

- _____, _____, _____, _____, _____, _____

Cardiovascular Drugs

- _____, _____

GI Drugs

- _____

Other

- _____, _____, _____

Anti-infectives

- aminoglycosides, beta-lactams (except nafci/oxacil and ceftriax), fluconazole, NRTI's, quinolones, vancomycin

Cardiovascular Drugs

- anticoagulants, anti-arrythmics (dofetalide, sotatol, digox)

GI Drugs

- H2RA's (famotidine), metaclopramide

Other

- bisphosphonates, lithium, PDE-5 inhibitors

Key Monitoring Parameters for CKD (4)

PTH, phosphorus, Ca and vitamin D levels

Hyperphosphatemia contributes to elevated ___ levels and must be treated by restricting ___ - containing foods

PTH levels

phosphorus

Phosphate Binders

MOA:

Drugs:

MOA: block absorption of dietary PO4 by binding it in intestine

Drugs: aluminum-based (e.g. aluminum hydroxide), calcium-based (e.g. calcium acetate) and aluminum/calcium-free products (e.g. sevelamer)

Phosphate Binders: Aluminum hydroxide

ADE:

ADE: aluminum intoxication

Phosphate Binders: Calcium Acetate / Calcium Carbonate

Brand Name:

ADE:

Notes:

Brand Name: Calphron / Tums

ADE: Hypercalcemia, constipation

Notes: hyperCa more likely with vitamin D usage

Which class of phosphorus binders is most expensive, but has least ADE/toxicity risk

Aluminum and calcium free products (e.g. Lanthanum and sevelamer)

Phosphate Binders: Ferric citrate

Brand:

Warnings:

Brand: Auryxia, velphoro

Warnings: iron absorption can occur with ferric citrate

Phosphate Binders: Lanthanum carbonate

Brand:

ADE:

Notes:

Brand: Fosrenal

ADE: N/V, diarrhea, constipation

Notes: must chew tablet thoroughly

Phosphate Binders: Sevelamer carbonate/HCl

Carboante Brane Name:

HCl Brand Name:

ADE:

Notes:

Carboante Brane Name: Renvela

HCl Brand Name: Renagel

ADE: N/V, diarrhea

Notes: can lower total cholesterol and LDL

Separate phosphate binders from what drugs?

Levothyroxine, quinolones and tetracyclines

Vitamin D deficiency in CKD occurs when the kidneys cannot hydroxylate via D to final active form ___

1,25-dihydroxy vitamin D

Vitamin D3 (cholecalciferol)

Produced in the skin by UV light

Vitamin D2 (ergocalciferol)

vitamin D derived from plants in the diet

vitamin D analogues should be reserved for stage

4 and 5 of CKD

vitamin D analogues effets on calcium reabsorption and PTH

↑ calcium reabsorption and ↓ in PTH

Cinacalcet can inhibit

PTH release

Vitamin D analog: Calcitriol

Warnings:

Notes:

Warnings: hyperCa

Notes: calcitriol is the active form of vitamin D3

Calcimimetics: Cinacalcet

Brand Name:

Warnings:

Brand Name: Sensipar

Warnings: hypoCa

Calcimimetics: Etelcalcetide

ADE:

ADE: muscle spasms, parasthesia

Primary Problem of Anemia in CKD

lack of EPO's

-epoetin or dabepoetin ; risks = HTN, DVT/PE, only initiate if _____ and d/c if _____ , only work if adequate IRON storage

Hgb < 10 g/dL ; Hgb>11

Drugs that raise K Levels (4)

Canagliflozin

Drospirenone-containing OC's

Calcineurin inhibitors

Bactrim

SE of high K

muscle weakness, bradycardia, fatal arrhythmias

K-Binders: SPS

Warnings:

Notes:

Warnings: GI necrosis

Notes: bind other oral meds

K-Binders: Patriomer

Warnings:

ADE:

Notes:

Warnings: hypoMg

ADE: constipation

Notes: binds oral drugs, separate by at least 3 hours

Separate Lokelma from other drugs by ___ hours

2 hours

Monitor what with Drugs that replace Bicarb in CKD

sodium levels

As CKD progresses, bicarbonate elimination is ____

ENHANCED leading to metabolic acidosis

Characteristics of Drugs that are More Likely to be Removed During Dialysis

- small molecules

- small Vd

- low protein-bound drugs

- higher dialysis blood flow rates

- high-flux and high-efficiency HD filters

Normal Phos levels

2.5-4.5 mg/dL