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What is goal HgB concentration in kidney pts?
When do you create a fistula for kidney pts?
Cr >4, GFR <20
When do you refer to a nephrologist? (labs)
Cr >3.0, GFR <30
When do you use the adjusted ideal body weight formula?
Pts >130% of IBW
Who has the most benefit from ACE-Is and ARBs in tx HTN?
Pts with proteinuria >3g/24
What do you monitor when using CCBs in tx HTN?
Bradycardia, edema (caution in HF pts)
When do you lower HTN goals?
When protein excretion >1g/24h
What do you restrict Na intake to?
Which two statins don't have to be adjusted for renal function?
Pravastatin and Atorvastatin
When you are tx anemia, how often do you check Hb?
q1-2 weeks after new dose, then q4w when stable
When do you increase ESA doses?
If Hb increases <1g in 4w
When do you decrease ESA dose?
If Hb increases >3g in 4 weeks or Hb >12 g/dl
How often do you monitor iron therapy?
qMo during intial ESA therapy, q3mo in stable therapy
What daily dose of iron is recommended?
What are FePO's DI?
- Levothyroxine, fluoros, antacids
- Take iron on empty stomach always
When do you initiate FeIV?
When TSAT and ferritin <goals
What is basic FeIV dosing?
100 mg of iron dextran/sucrose or 125 gluconate at each dialysis for 10 or 8 doses (respectively); if no increase, give a second course
What is basic FeIV dosing for TSAT and ferritin above goal, low Hb?
1 g Fe over 8-10 weeks
What is maintenance IV dosing?
25-125 mg weekly
When do you hold maintenance dosing?
TSAT>50%, ferritin 800 mg/mL
Which IV Fe product requires a test dose and why??
Iron dextran (25mgx1 dose) due to associaton with anaphylactic reaction
Why do you avoid rapid infusion with FeIV?
hypotension, GI effects, HA, flushing
Which drugs decrease serum phosphorus levels?
Which drugs supplement/replace active Vit D?
Vit D analogues
Which drugs directly antagonize PTH?
What are our phosphorous goals for CKD and ESRD?
- CKD: 2.7-4.6 mg/dL
- ESRD: 3.5-5.5 mg?dl
What are nl Ca ranges in CKD and ESRD?
- CKD: 8.5-10.5
- ESRD: 8.4-9.5
What is dietary phosphorous restriction?
800-1000mg/day when serum phosphorous or PTH are elevated
How do you counsel a pt on phosphate binders?
They must be taken with food, and take 1 tablet with large snacks
Why are aluminum containing phosphate binders used and what must you be cautious about?
They are more portent than calcium containing binders, but aluminum can accumulate in renal dysfunction
What are aluminum ADRs?
- Musculoskeletal pain
- Neurological effects
When do you consider aluminum binders? How do you dose?
When serum phos >7 mg/dL; use for < 4 weeks and one course only
When do you avoid calcium binders?
When Caxphos product >55
What is dietary calcium restriction while on calicum binders?
Calcium carbonate contains what % of elemental Ca?
What is PhosLo?
- Calcium acetate with 25% Ca
- Less pH dependent with less constipation but more GI complaints
What is Sevelamer?
Either a hydrochloride salt ( Renagel) or carbonate salt (Renvela)
What are Sevelamer's effects?
- Not absorbed into circulation
- Binds fat-soluble vitamins and folic acid
- Lowers serum cholesterol by 15%
- Lowers LDL by 40%
- Increases HDL by 20%
What is Sevelamer's dosing?
- 800 mg PO with meals for phosphorous <7.5 mg
- 1200-1600 mg for >7.5
What are Sevelarmer's CI?
- Bowel obstruction
- chewing or crushing (it expands)
What are Sevelamer's DI?
- Administer 1 h before or 3h after
What is Lanthanum?
a chewable tablet that binds phos at all pH levels
What do you need to know about prescribing Lanthanum?
- It may interfere with AXR
- Can accumulate in liver, lung, kidney
- GI side effects are common and can cause orthostatic HOTN
What are Lanthanum's CI?
- Ulcerative colitis
- Bowel obstruction
What are Lanthanum's drug interactions?
When do you initiate Vit D therapy?
When PTH is not controlled by management of hyperphosphatemia
When do you initiate ergocalciferol supplementation?
What are ADRs of ergocalciferol?
HYPERCALCEMIA: HA, N/V, confusion, bone pain, arrhythmias
When do you initiate Vit D tx?
When serum (OH)D >30 and PTH is above target
What is the best way to administer Vit D tx?
Intermittent IV is better than PO
What do you need to caution with in doxercalciferol?
When do you consider paricalcitol or doxercalciferol?
pts with increased Ca or phos
What is cinacalcet's MOA?
enhances sensitivity of ca-sensing receptors on parathyroid gland to extracellular Ca, supporessing PTH release
What is Cinacalcet's place in therapy?
ESRD pts with increased PTH limited by hypercalcemia
What are the warnings and ADRs with cinacalcet?
- Warnings: adynamic bone dz if PTH <100 pg/ml, avoid in severe hepatic or CV dz
- ADRs: hypocalcemia, NVD, dizziness, hypotension
How do you tx chronic metabolic acidosis?
- citric acid/sodium citrate (alkalinizing agent)
- sodium bicarb (neutralizes H ions)
What drugs are used in dialysis?
- Anticoag (Heparin, citrate)
- Abx (administered post-dialysis)
- Epoetin, Fe, VitD
What are urine level classifications?
- Anuria: <50
- Oligura 50-450
- Nonoliguric >450
How do you tx ATN?
- Remove agent
- Avoid fluid overload: consider diuretic
- Monitor electrolyte
What drugs cause AIN?