Therapeutics: Complications of CKD 1

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kyleannkelsey
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272474
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Therapeutics: Complications of CKD 1
Updated:
2014-04-29 23:13:09
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Therapeutics Complications CKD
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Therapeutics: Complications of CKD 1
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Therapeutics: Complications of CKD 1
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  1. What are the main functions of the kidney?
    • Filtration and excretion
    • Regulation of arterial blood pressure
    • Regulation of red blood cell production
    • Regulation of Vitamin D production
    • Gluconeogenesis
  2. What are the increasing prevalence of signs/symptoms associated with these in Stage 3-5 CKD
    • Anemia
    • Mineral bone disorder (CKD-MBD)
    • Renal osteodystrophy
    • Fluid & electrolyte disorders
    • Metabolic acidosis
    • Cardiovascular disease
    • Malnutrition
  3. How much iron is lost per day with Dialysis?
    3-9 mg/day
  4. What are the goals of treating anemia in CKD?
    • Increase O2-carrying capacity to:
    • Decrease dyspnea, orthopnea, fatigue and LVH
    • And associated mortality
  5. To rule out causes other than CKD for anemia, what tests would you recommend?
    Draw folate and B12 levels
  6. What is the target Ferritin level in Dialysis?
    • > 200 ng/mL
    • (<500 ng/mL)
  7. What is the target Ferritin level NOT ON Dialysis?
    • > 100 ng/mL
    • (<500 ng/mL)
  8. What is the target hemoglobin for patients with anemia and CKD?
    2006 = 11-12 g/dL2011 update: NMT 11 mg/dL
  9. What is the target TSAT for patient with CKD (on or off dialysis)?
    >20%
  10. What is the upper limit for Ferritin in a CKD patient?
    • NMT 500 ng/mL
    • Risk iron overload and would require chelator therapy
  11. How often should a CKD patient without anemia be tested for HGB?
    • Stage 3: at least annually
    • Stage 4/5 ND: at least 2x/year
    • Stage 5 HD or PD: at least every 3 months
  12. How often should a CKD patient with anemia and no treatment with ESAs for be tested for HGB?
    • Stage 3: at least every 3 months
    • Stage 5 HD or PD: At least monthly
  13. How often should a CKD patient with anemia and ESA treatment be tested for HGB?
    • Initiation phase of ESA: at least monthly
    • Maintenance phase of ESA ND: at least every 3 months
    • Maintenance phase of ESA HD: at least monthly
  14. How often should you draw TSAT and Ferritin levels?
    • At least every 3 months w/ ESA (including when deciding to start or continue iron therapy)
    • Draw more frequently when initiating or increasing ESA dose, blood loss, monitoring after IV iron therapy
  15. What are the non-pharmacologic interventions for anemia in CKD?
    Dietary intake of iron
  16. What are the Pharmacologic interventions for anemia in CKD?
    • Iron supplementation
    • EPO or ESA
  17. When should you initiate EPO therapy?
    After the patient is iron replete
  18. Should you simultaneously adjust EPO and IV iron?
    No
  19. After a repletion dose of iron, what should you do next?
    Assess EPO dosing
  20. Can you give EPO therapy alone?
    No need iron on board first (immature RBCs require iron and then EPO to activate)
  21. If a patient has anemia and is not currently on iron or ESA therapy, what treatment might you first recommend?
    • ND: 1-3 month trial of oral iron
    • HD: trail of IV iron
  22. If a patient has anemia and is on ESA therapy, what treatment might you recommend?
    • ND: 1-3 month trial of oral iron
    • HD: trail of IV iron
    • (same as if they were not on ESA)
  23. What is the goal for addition of iron therapy to an anemic patient not on ESA?
    • Increase Hgb without starting ESA
    • TSAT ≤ 30%, Ferritin ≤ 500 ng/mL
  24. What is the goal for addition of iron therapy to an anemic patient not on ESA?
    • Increase Hgb
    • Or decreases ESA
    • TSAT ≤ 30%, Ferritin ≤ 500 ng/mL
  25. Why do they break up doses of iron over multiple sessions?
    To reduce the chance of infusion reactions
  26. What is the recommendation for IV iron repletion dosing for a patient with the following levels: TSAT <20%, Ferritin in HD-CKD <200, Ferritin in ND-CKD or PD-CKD <100?
    1 gram elemental iron over 8-10 sessions
  27. What is the recommendation for PO iron repletion dosing for a patient with the following levels: TSAT <20%, Ferritin in HD-CKD <200, Ferritin in ND-CKD or PD-CKD <100?
    200 mg elemental iron
  28. What is a normal maintenance dose of iron for HD-CKD?
    • 50-100 mg IV Fe sucrose or 62.5-125 mgNa ferric gluconate
    • Titrate as necessary
  29. What is a normal iron maintenance dose for ND or PD CKD?
    • Try PO 200 mg elemental iron/day
    • Change to IV if necessary
    • (Consider ESA)\
  30. What is a normal treatment for a patiet with Ferritin >500 ?
    • Evaluate causes
    • Weight risk/benefit of their current IV iron therapy
    • Consider Chelation therapy
  31. What are the requirements of iron dextran?
    25 mg test dose before commencing therapy
  32. What are the SE of IV iron therapy?
    Allergic reaction, hypotension, dizziness, dyspnea, HA, arthralgia, syncope
  33. Which iron supplement can be given IV push?
    • Ferumoxytol
    • 510 mg/17mL
  34. What is the most common IV Iron supplement and what is its concentration and dose?
    • Iron sucrose (Venofer)
    • 100 mg/5mL
    • 25-1000 mg/dose
  35. When initiating a PO or IV iron therapy, at what interval should you perform monitoring?
    • Iron indices at least 1x per month for the first 3 months or until stable
    • IV: monitor for infusion reactions
  36. ______________ are required to stimulate division & differentiation of erythroid progenitor cells that will form reticulocytes.
    Erythropoietic growth factors
  37. Epoetin alfa (Epogen or Procrit) is dosed how often?
    3x week
  38. Darbepoetin alfa (Aranesp) is dosed how often?
    1x week
  39. What is the starting dose of Epoetin alfa (Epogen or Procrit)
    • Starting dose 50 U/kg/week
    • 3x week IV or SQ
  40. What would be a comparable SQ dose of Epoetin alfa to a 10,000 U/week IV dose?
    • 6,777 U/week
    • (SQ = 2/3 IV dose)
  41. What is the starting dose in an EPO naïve patient of Darbapeotin alfa (Aranesp)?
    • 0.45 mcg/kg IV or SQ
    • 1x week
    • Note it is in *MCG*

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