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CKD and ESRD
Shogbon 3 lectures
25
Pharmacology
Professional
04/30/2012

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Cards

Term
What are markers of kidney damage?
Definition
- Persistent proteinuria
- Abnormalities in blood or urine
- Decreased GFR/CrCl
Term
What are the stages of CKD?
Definition
Stage 1 - >/ 90
Stage 2 - 60-90
Stage 3 - 30 - 59
Stage 4 - 15 - 29
Stage 5 - Kidney failure, <15 or dialysis
Term
What are initiation factors of CKD?
Progression factors?
Definition
- DM2, HTN, autoimmune diseases
- above, and smoking, protein in urine, lipids, drug use
Ace-I and ARBs reduce proteinuria - presence of albumin or globulin
Term
What patients are at risk for CKD?
Definition
Diabetes, hypertension, family history of CKD, > 60 years, belong to U.S. racial or ethnic minority
Term
What are types of proteinuria?
Definition
- Normal - < 30
- Microalbuminuria - 30 to 300 mg/day
- Macroalbuminuria - >/300 mg/day
Term
What are symptoms of CKD, especially in later stages?
Definition
Edema/cold intolerance, SoB, cramping, depression, itching, weight gain
Uremia causes itching and loss of appetite, mental confusion
As condition worsens in Stage 3, iron deficiency and anemia, electrolyte disorders, Vit D can't activate
Term
What are goals in CKD?
Definition
- Slow progress by:
- Decreasing protein intake, insulin therapy and Ace-I reduce albuminuria
- HTN goal <130/80 - AceI + aldosterone inhibitor
Term
How is HTN treated in CKD?
Definition
1st line - AceI/ARB
- Then use non-DHP CCBs in patients w/o HF
- Give diuretic, thiazides don't workin in patients w/ GFR < 30
Term
What are other goals in CKD?
Definition
- LDL goal < 100 per K/DOQI guidelines, need statin
- QUIT SMOKING!
- Treat anemia
Term
What main electrolyte abnormalities are seen in CKD?
Definition
- Lose ability to excrete Na after CrCl < 20 (stage 4 and 5) - increased volume overload
- 90% potassium excreted by kidneys
Term
How is Hyperkalemia managed in CKD?
Definition
- Calcium gluconate when symptomatic, then excrete or push K back into cells w/ insulin, albuterol, an kayexelate
- Can use lasix, but not in stage 5
Term
What causes metabolic acidosis in CKD, and how is it treated?
Definition
Increased uremia, have to draw ABG often
Try to keep pH normal and bicarb between 22-26.
Correct w/ sodium bicarbonate, sometimes chronically
Term
How is secondary hyperparathyroidism recognized in CKD and what are it's implications?
Definition
A high phosphate level (over ) inhibits Vitamin D --> lowers calcium. When calcium is low, PTH tries to correct and increases abnormally --> low Ca, high PTH, high phos, Ca*Phos > 55
Term
What are treatments for high phosphate in sHPT?
Definition
- Restrict dietary phosphorus
- Calcium based phosphate binders if normal calcium level - Phoslo
- In STAGE 5 - non-calcium phosphate binder, use in presence of incr calcium - Sevelamer, Lathanum, aluminum last line
Term
How do you evaluate Vit D deficiency?
Definition
Use Vit D when PTH level high AND Ca/Phos normal.
Use Vit D if < 30 - Ergocalciferol
Give active vit D if PTH very high (300) - may cause incr Calcium
D/C all forms if Ca > 10.2, if Phos uncontrolled
Term
When should Sensipar be used?
Definition
Calcimimetic, only used in stage 5
Used in patients not eligible for Vit D due to a high calcium, last line
Take with food, GI effects, lowers calcium
Term
What is the cause of anemia in CKD?
Definition
RBC life span decreased, EPO excreted. Anemia panel assesses, Hgb < 12 in women, 13.5 in men
Goal TSAT > 20%, ferritin > 100
treat w/ iron supplements w/ Vit C
Use EPO after anemia causes treated, cannot give w/ uncontrolled BP, give when HGb < 10, target Hgb 11
Term
What are CV goals associated w/ CKD?
Definition
HTN - BP goal < 130/30
LDL < 100 per KDOQI
Term
What are other possible complications of CKD?
Definition
- Pruritus due to uremia and toxins
- Malnutrition, loss of water soluble vitamin, uremic bleeding
Term
What are normal electrolyte values associated with CKD?
Definition
K: 3.5 - 5.0
Na: 135 - 145
Mg: 1.5 - 2.5
Phos: 2.5 - 4.5
Ca: 8.5 - 10.5
Term
When is dialysis indicated?
Definition
Planning begins in stage 4
Assessed via clinical status
Usually RRT - Toxins move into dialysis fluid and are excreted via diffusion
Term
How is hemodialysis access managed?
Definition
- AV fistula - anastomosis between cephalic vein an radial artery - takes time to mature thus planning in stage 4. Lowest rate of infection
- AV graft - much higher infection, lower shelf life
- Venous catheter - highest risk
Term
What are complications that can result from dialysis?
Definition
- Intradialytic - hypotension, cramps, uremia, HA, pain, infection
- Thrombosis - common in venous catheter. Lock access port & flush with saline
- Infection - MRSA
Term
What is peritoneal dialysis better than HD?
How does it work?
Definition
Less infection, preserves renal function longer, less visits
Travels by diffusion across membrane, sits in the kidneys, then drains
- Catheter can kink, pain at site, infection
Term
How does HD effect drug dosing?
Definition
if the drug has a large size, is protein bound, or a high Vd --> decreased removal
Dose of meds depends on filter
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