initial doses are 50-100 units/kg IV or SC 3x/wk. allow 2-4 wks before making change in dose. if change in hgb is <1 g/dL in a 4-wk period and iron stores are adequate, increase ESA by 25%, if change in hgb is >1g/dL in 2-wk period or hgb is approaching 12, reduce ESA by 25%.
iron defieciency: cause of resistance to tx w/ ESA.
Iron supplementation in anemia (CKD)
ensure not def. b/c this can cause resistance to ESA tx.
recommended dose is 200 mg elemental iron.
Iron sucrose: 100 mg dose diluted in 100 mL of normal saline and given IV over 15 mins or adminsitered undiluted over 2-5 mins
Iron dextran: 100 mg dose may be administered over 2 mins IV push, must give 25 mg test dose b/c of anaphylactic rxns
sodium ferric gluconate: 125 mg dose diluted in1 00 mL NS and admin over 1 hour or admin undiluted at a rate upt o 12.5 mg/min.
Phos restriction in CKD
800-1000 mg /day
Phos binding agents tips (CKD)
- titrate doses on basis of phos and ca product (phos X ca)
- limit use of calcium containing phosphate binders if hypercalcemia occurs
-aluminum is not 1st line agent.. use ONLY for short term (<30 days) to min rsk of accum
Iron sucrose dose in nondialysis and peritoneal dialysis patients
nondialysis CKD pts: 200 mg over 2-5 mins on 5 diff occasions w/n 14 day period
peritoneal dialysis: 300 mg in NS IV over 1.5 hrs f/u 2nd infusion of 300 mg 14 days later ---> 400 mg over 2.5 hrs 14 days later
IV form of iron approved for tx of iron deficiency in adults w/ CKD. dose is 510 mg (17 mL) as single dose! f/u 2nd 510 mg dose 3-8 days after initial dose.
calcimimetic agent which controls iPTH in ESRD patients. dose is 30 md / daily titrated no mroe freq. than q 2-4 wks.
Ferrous sulfate PO
Ferrous fumarate PO
Ferrous gluconate PO
Heme iron polypeptide
Sodium ferric gluconate
Ferrlecit (IV) weekly, TIW, or qmo
Iron sucrose (IV)
Iron dextran (IV)
How do you treat iron overload?
Sevelamer HCl (Renagel) and Sev. Carbonate (Renvela) can result in decreased LDL and increased LDL :) but Renvela has less risk of lowering bicarb than REnagel. Renvela!!!!!! will eventually replace Renagel
used as phosphate binder (but only for short term <30 d)
milk of mag, various
can be used as phos binders
Name all the Vitamin D prodcuts
Vitamin D precursor
Ergocalciferol (Drisdol- po)
" (Calciferol, po or iv)
Active Vitamin D
Calcitriol (Calcijex- iv)
Calcitriol (Rocaltrol- po)
Vitamin D analogs
Paricalcitol (Zemplar- po/iv)
Doxercalciferol (Hectorol- po/iv)
Vitamin D drugs activation in body?
ergocalciferol requires hydroxylation w/n liver to form calcifediol and second hydroxylation w/n kidney to form active vit d
doxercalciferol requires conversion to active form 1a,25-dihydroxyvitamin D2 in liver.
tell me about calcimimetics?
for stage 5 CKD who are on dialysis.
used w/ phos binder and vit D. initial dose is 30 mg titrated q2-4 wks on iPTH levels. DON'T start tx if corrected serumc a is <8.4 mg/dL.
Sensipar binds w/ ca-sensing receptor of parathyroid gland and increases senstivity of receptor to extracellular ca, thereby decreasing pth secr.
TAKE WITH FOOD
water soluble enzymes impt in CKD pts.. but what are ADEs?
B6 (pyrodoxine): neuropathy/ increased AST
Vit C (ascorbic acid): hyperoxaluria, dizzziness, fatigue
Folic acid: rash, pruritis, ha
Vitamin B complex, vitamin C and folic acid
Nephrocaps, Nephrovite, Nephrovite Rx, Renavite, Biotin Forte
Vit B complex, Vit C, folic acid, AND iron
Nephrovite Rx + Iron, NephrPlex Rx
Vit B complex
Allbee with C
Prorein restriction in CKD?
0.6-0.8 g/kg/d but weigh risk/benefit
icnreased protein req. should be considered for pts on dialysis (1.2 g/kg/d) and even more for pts on peritoenal dialysis b/c of increased protein loss w/ procedure.
Pritonititis bugs and drugs
gram positive: staph epidermidis and staph aureus
gram neg: enterobacteriacae and P. aeruginosa
emepiric therapy: graph pos (1str gen cephalo or vanco if MRSA AND gram-neg (ceftaz/aminoglyc))
hyperglycemia and dialysis??? how
glucose content in dialysate soln may cause hyperglycemia
how to manage secndary hyperparathyroidism?
control serum calcium/phosphorus and adminsitration of Vitamin D tx including precursors in early CKD based on kidney fucntion (Drisdol/Calciferol) and active Vit D tx for more severe dz (Calcijex/Rocaltrol, Zemplar, Hectorol). Sensipar is indicatred in stage 5.
Secondary causes of hyperlipidemia
obstructive liver dz
drugs: (BB, thiazides, oral contraceptives, oral estrogens, glucocorticoids, and cyclosporine)
initial lesion of atherosclerosis?
foam cells which present as result of ingestin of oxidized LDL by macrophages in subintimal space of aftery
common cause of mild-mod elevated LDL (160-250 mg/dL)
how to assess agitation?
riker Sedation-Agitation Scale
how to assess delerium in ICU?
use confusion assessment method for ICU CAM-ICU
Sublimaze (used in morphin intol, hemodynamic instability or renal dysfunc.. like hydromorphone)
Toradol (max use 5 days)
benzos for sedation in the ICU
lorazepam (Ativan) used for long-term sedation (>24-72hrs)
midazolam (Versed) used for acute/short term (< "")
propofol (Diprivan) used when rapid awakening is needed
DOC for delerium
neuromuscular blocking agents
pancuronium (Pavulon) general NMB agent of choice (lost cost) causes tachy
vecuronium (Norcuron) used in hemodynamic instability/renal dysfunc/cardiac dz
cisatracurium (Nimbex) used in renal/hepatic dysfunction
onset is <5 mins for all. 60-90 min duration for pan. and 30-60 mins for others.
pan excreted reanlly, ver is 50/50 (ren/hep), and cis is NOT organ dependent
monitoring w/ propofol
BP/HR/RR/intracranial pressure, serum triglycerides (made w/ fat) at baseline and 1-2 x a wk during long-term use
general note: if continuously sedated- daily wakening and assessment results in decr sedative use and shorter lenth of stay in ICU
provides 1 kcal/mL (lipid vehicle) CAUTION in egg allergy.. potentail medium for bacteria- max hang time is 12 hrs
structural analogues ofnatural metabolites--> insert themsleves inp lace of pyrimidne or purine ring, causing interference in nucelic acid synth. most active ins phase in tumors w/ high growth fraction (subdivided: folate, purine, pyrmidine antags)
counseling point w/ 5-fu
chew ice to reduce damage to mucosal lining
trouble urinating w/ what chemo drug?
recievie folic acid and b12 injections w/ what chemo drug?
flic acid antagonists
Antimetabolites: s phase specifics
1. pemetrexed (Alimta)
2. methotrexate (Rhumatrex
antimetabolites: s specific
1. azacitidine (Vidaza)- MDS
2. 5fu (adrucil)- colorectal, breast, head, neck
3. cytarabine (Cytosar-U-drip, Depocyt-intrathecal) --> ALL, AML, CML