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bigfootedbertha
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What is goal HgB concentration in kidney pts?
10-12
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When do you create a fistula for kidney pts?
Cr >4, GFR <20
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When do you refer to a nephrologist? (labs)
Cr >3.0, GFR <30
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When do you use the adjusted ideal body weight formula?
Pts >130% of IBW
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Who has the most benefit from ACE-Is and ARBs in tx HTN?
Pts with proteinuria >3g/24
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What do you monitor when using CCBs in tx HTN?
Bradycardia, edema (caution in HF pts)
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When do you lower HTN goals?
When protein excretion >1g/24h
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What do you restrict Na intake to?
<2.4g/d
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Which two statins don't have to be adjusted for renal function?
Pravastatin and Atorvastatin
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When you are tx anemia, how often do you check Hb?
q1-2 weeks after new dose, then q4w when stable
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When do you increase ESA doses?
If Hb increases <1g in 4w
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When do you decrease ESA dose?
If Hb increases >3g in 4 weeks or Hb >12 g/dl
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How often do you monitor iron therapy?
qMo during intial ESA therapy, q3mo in stable therapy
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What daily dose of iron is recommended?
200mg
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What are FePO's DI?
- Levothyroxine, fluoros, antacids
- Take iron on empty stomach always
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When do you initiate FeIV?
When TSAT and ferritin <goals
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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
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What is basic FeIV dosing for TSAT and ferritin above goal, low Hb?
1 g Fe over 8-10 weeks
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What is maintenance IV dosing?
25-125 mg weekly
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When do you hold maintenance dosing?
TSAT>50%, ferritin 800 mg/mL
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Which IV Fe product requires a test dose and why??
Iron dextran (25mgx1 dose) due to associaton with anaphylactic reaction
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Why do you avoid rapid infusion with FeIV?
hypotension, GI effects, HA, flushing
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Which drugs decrease serum phosphorus levels?
Phosphate binders
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Which drugs supplement/replace active Vit D?
Vit D analogues
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Which drugs directly antagonize PTH?
Cinacalcet
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What are our phosphorous goals for CKD and ESRD?
- CKD: 2.7-4.6 mg/dL
- ESRD: 3.5-5.5 mg?dl
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What are nl Ca ranges in CKD and ESRD?
- CKD: 8.5-10.5
- ESRD: 8.4-9.5
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What is dietary phosphorous restriction?
800-1000mg/day when serum phosphorous or PTH are elevated
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How do you counsel a pt on phosphate binders?
They must be taken with food, and take 1 tablet with large snacks
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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
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What are aluminum ADRs?
- Osteomalacia
- Musculoskeletal pain
- Anemia
- Neurological effects
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When do you consider aluminum binders? How do you dose?
When serum phos >7 mg/dL; use for < 4 weeks and one course only
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When do you avoid calcium binders?
When Caxphos product >55
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What is dietary calcium restriction while on calicum binders?
<200 mg/day
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Calcium carbonate contains what % of elemental Ca?
45%
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What is PhosLo?
- Calcium acetate with 25% Ca
- Less pH dependent with less constipation but more GI complaints
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What is Sevelamer?
Either a hydrochloride salt ( Renagel) or carbonate salt (Renvela)
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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%
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What is Sevelamer's dosing?
- 800 mg PO with meals for phosphorous <7.5 mg
- 1200-1600 mg for >7.5
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What are Sevelarmer's CI?
- Bowel obstruction
- chewing or crushing (it expands)
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What are Sevelamer's DI?
- Antiarrhythmics
- Antiepileptics
- Fluoros
- Administer 1 h before or 3h after
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What is Lanthanum?
a chewable tablet that binds phos at all pH levels
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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
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What are Lanthanum's CI?
- PUD
- Ulcerative colitis
- Crohns
- Bowel obstruction
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What are Lanthanum's drug interactions?
- Antiepilpetics
- Antiarrhythmatics
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When do you initiate Vit D therapy?
When PTH is not controlled by management of hyperphosphatemia
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When do you initiate ergocalciferol supplementation?
When 25(OH)D<30
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What are ADRs of ergocalciferol?
HYPERCALCEMIA: HA, N/V, confusion, bone pain, arrhythmias
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When do you initiate Vit D tx?
When serum (OH)D >30 and PTH is above target
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What is the best way to administer Vit D tx?
Intermittent IV is better than PO
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What do you need to caution with in doxercalciferol?
Hepatic impairment
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When do you consider paricalcitol or doxercalciferol?
pts with increased Ca or phos
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What is cinacalcet's MOA?
enhances sensitivity of ca-sensing receptors on parathyroid gland to extracellular Ca, supporessing PTH release
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What is Cinacalcet's place in therapy?
ESRD pts with increased PTH limited by hypercalcemia
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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
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How do you tx chronic metabolic acidosis?
- citric acid/sodium citrate (alkalinizing agent)
- sodium bicarb (neutralizes H ions)
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What drugs are used in dialysis?
- Anticoag (Heparin, citrate)
- Abx (administered post-dialysis)
- Epoetin, Fe, VitD
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What are urine level classifications?
- Anuria: <50
- Oligura 50-450
- Nonoliguric >450
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How do you tx ATN?
- Remove agent
- Avoid fluid overload: consider diuretic
- Monitor electrolyte
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What drugs cause AIN?
- PCNs
- Sulfonamides
- Furosemide
- NSAIDs
- Rifampin
- Allopurinol
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