Therapeutics: Complications of CKD 2
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About _______ units of Epoetin alpha is equal to 1 mcg of darbopeotin.
What route is most useful for ESA therapy in ND and PD-CKD patients?
What route is most useful for ESA therapy in HD-CKD patients?
- To avoid Pure red cell aplasia
What are the symptoms of pure red cell aplasia (PRCA)?
- Rapid decrease in Hgb ( 0.5-1g/dL/wk)
- Absolute reticulocyte count <10,000 units/L
- PLT & WBCs normal
When Hgb <10 and patient already on ESA, what should you do next?
Increase dose by 25%, no more than every 4 weeks
If a patient needs a downward adjustment of ESA needed per Hgb response, how would you perform this?
Decrease ESA dose rather than withholding dose
What are the SEs for ESA?
What patients require a REMS submission?
- On ESA and have cancer
- Optional for CKD
CHOIR, CREATE and TREAT studies found what?
Treating HGB above 11g/dL increases death, stroke, MI and CV event
What dose HGB need to be to start ESA therapy?
When should you adjust ESA dose as you see HGB rising?
- ND or PD: approaching or exceeding 10 g/dL
- HD: approaching or exceeding 11 g/dL
In ND-CKD Start ESA only when Hgb _____ g/dL
In ND-CKD adjust dose when Hgb ______ g/dL
> or = to 10
In HD-CKD Start ESA only when Hgb _____ g/dL
In HD-CKD adjust dose when Hgb ______ g/dL
> or = to 11
For ESA therapy, how often should you monitor for Hgb or HCT?
At least once weekly until stable, then at least monthly
What is an expected change in HGB/HCT for a patient placed on ESA?
- Expect increase in Hgb of 1 g/dL after 2-4 wks
- Increase in Hct 1-2 %/week, but no more than 4 % in 2 weeks
May need CBC with differential for a patient on ESA?
to watch for PRCA
What are some reasons that high dose of ESA would not be effective?
- Iron deficiency
- Catheter insertion
- Elevated CRP
- Chronic bleeding
- Chemotherapy & Cancer
On the exam, you should use corrected or non-corrected Calcium values?
What is the corrected Calcium equation?
Corrected calcium= [(4 - albumin) x 0.8 mg/dL) + Serum Ca]
What are the treatments for secondary hyperparathyroid in CKD?
- Dietary PO4 restriction (800-1000mg/d)
- Pharmacologic Therapy (Phosphate binders, Vitamin D, Calcimimetics)
What is the MOA of Phosphate binders in preventing renal osteodystrophy and MBD-CKD?
Binds dietary PO4 in the GI tractForms insoluble Ca, Mg or Al Phosphate that is excreted in the feces
What are the pharmacologic treatment options for secondary hyperparathyroid in CKD?
- Phosphate binders (Ca- or Non-Ca Containing)
- Vitamin D
What are the First line phosphate binders used in renal osteodystrophy and MBD-CKD?
- Calcium containing ones are used first
- Calcium carbonate (Tums®, Oscal®)
- Calcium acetate (PhosLo®)
What is the starting dose of Phosphate binder?
- Total elemental Ca starting dose = 1000-1500 mg/day
- Do not exceed elemental Ca 1500 mg/d, total daily intake no > 2000 mg/d (ie. oral supplement + food)
When is a phosphate binder not recommended for renal osteodystrophy and MBD-CKD?
2 consecutive serum Ca >10.2 or iPTH is <150
Chronic use of phosphate binders can have what negative impact?
May increase risk of vascular and tissue calcification
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