1. Therapeutics 2 Tutoring
Sarah Darby
November 30, 2016

2. Lectures Covered
CKD Progression and Complications

3. CKD Definition and Classification
KDOQI
Definition
Kidney damage
GFR < 60ml/min
3 months or more
5 stages based on GFR
KDIGO
Classified by:
Cause
GFR
Six categories
3a & 3b
Albuminuria
A1, A2, A3

4. CKD
HH has a GFR of 49ml/min and an AER of 45g/24h. Stage his CKD based on KDIGO.
G3a A2
G3b A2
G3a A1
G3b A1

5. CKD
PK has a GFR of 32ml/min and an AER of 45g/24h. Stage his CKD based on KDOQI.
Stage 3
Stage 4
G3b A2
G3b A1

6. CKD
FM has a GFR of 12ml/min and an AER of 450mg/24h. Stage his CKD based on KDIGO.
G3 A4
G4 A3
G5 A3
Stage 5

7. CKD Complications Fluid/electrolyte abnormalities Metabolic Acidosis
Hypertension
CVD
Anemia
Mineral and bone disorder

8. CKD
FR is a 58 yo WF with CKD stage 4. She is complaining of “puffy” lower legs. Which of the following is not appropriate to treat her edema?
Furosemide
Furosemide + HCTZ
HCTZ
Metolazone

9. CKD Which of the following will not contribute to hyperkalemia?
Captopril
pH = 7.8
Spironolactone
Nu-Salt (salt substitute)

10. CKD
Which of the following is not a possible treatment for hyperkalemia?
Calcium
Albuterol
Polystyrene sulfonate
Dextrose

11. CKD JH is a 48 yo WM with CKD stage 4. CrCl= 25 ml/min
pH=7.33, pCO2=36, HCO3=16
What therapy do you recommend for acute treatment?
PO bicarbonate
IV bicarbonate
PO potassium citrate
IV potassium citrate

12. CKD JH is a 48 yo WM with CKD stage 4. CrCl= 25 ml/min
pH=7.33, pCO2=36, HCO3=16
What is the goal bicarbonate level for JH?
18-22 mEq/L
22-26 mEq/L
26-30 mEq/L

13. CKD
KM is a 65 yo AAM with CKD stage 3a, AER=320mg/day, hx of HTN, BPH, CABG, and hyperlipidemia. What is his goal BP?
<120/80
<130/80
<130/90
<140/90

14. CKD
KM is a 65 yo AAM with CKD stage 3a, AER=320mg/day, hx of HTN, BPH, CABG, and hyperlipidemia. His current meds include Metoprolol 100mg BID, Atorvastatin 40mg daily, and Tamsulosin 0.4mg daily.
What additional therapy do you recommend?
Ramipril
Ramipril + Candesartan
Ramipril + Aliskiren
Aliskiren

15. CKD AER Goal BP Preferred Drug Diabetes <30mg/24h ≤140/90 --
≤130/80
ACEI or ARB
>300mg/24h
No Diabetes

16. CKD
TJ has been advised to restrict the amount of protein in his diet. His GFR is now 20ml/min. Which is false?
Dietary protein restriction is controversial for CKD progression prevention.
The MDRD trial showed reduced protein intake was beneficial in late stages of CKD.
TJ may lower his protein intake to 0.58g/kg/day
TJ should avoid high protein intake.

17. CKD - Lipids Dialysis patients Do not initiate statin.
If already on statin, continue.
Fire and Forget
Non-Dialysis patients
Adults 50 and older
GFR <60: statin or statin/ezetimibe
GFR≥60: statin
Adults 18-49
Only if compelling indication

18. CKD
KM is a 39 yo female with CKD stage 3b due to long standing HTN. PMH: asthma. The physician asks for your recommendation regarding cholesterol-lowering therapy.
Do not recommend treatment.
Atorvastatin
Atorvastatin + Ezetimibe
Colesevelam

19. CKD
KM is a 48 yo female with CKD and starting dialysis. The physician asks for your recommendation because she currently is not taking cholesterol-lowering therapy.
Do not recommend treatment.
Atorvastatin
Atorvastatin + Ezetimibe
Colesevelam

20. CKD
KM is a 48 yo female with CKD and starting dialysis. The physician asks if cholesterol- lowering therapy is appropriate to continue. She has been taking Rosuvastatin x 3 years.
Discontinue treatment.
Continue Rosuvastatin.
Add Ezetimibe.
Change to Colesevelam.

21. CKD
KM is a 58 yo female with CKD stage 2. The physician asks for your recommendation regarding cholesterol-lowering therapy.
Do not recommend treatment.
Atorvastatin
Atorvastatin + Ezetimibe
Colesevelam

22. CKD
KM is a 58 yo female with CKD stage 4. The physician asks for your recommendation regarding cholesterol-lowering therapy.
Do not recommend treatment.
Atorvastatin
Atorvastatin + Ezetimibe
Colesevelam

23. CKD
KM is a 45 yo male with CKD. PMH: MI, DM. The physician asks for your recommendation regarding cholesterol-lowering therapy.
Do not recommend treatment.
Atorvastatin
Atorvastatin + Ezetimibe
Colesevelam

24. CKD - Anemia
What decreases the RBC’s ability to carry oxygen in renal disease?
Increased tissue demand for oxygen
Decreased release of erythropoietin
Decreased availability of oxygen in the blood
Structural change in hemoglobin

25. CKD – Iron therapy Provide 200mg elemental iron daily.
Problems with oral iron therapy include reduced absorption, GI side effects, frequent dosing, and drug interactions.
IV therapy is generally preferred for patients on dialysis.
Iron dextran and Ferumoxytol both have a BBW for hypersensitivity reactions.
Iron dextran requires a test dose before administration.
Problems with IV iron therapy include dyspnea, wheezing, itching, and hypotension.
Ferumoxytol and Ferric carboxymaltose are unique by allowing greater doses to be given over a shorter period of time.

26. CKD
When to initiate iron therapy

27. CKD
According to KDOQI, which of the following scenarios warrants a trial of iron therapy?
TSAT=34% in HD-CKD pt
TSAT=23% in PD-CKD pt
Ferritin=150ng/ml in PD-CKD pt
Ferritin=175ng/ml in HD-CKD pt

28. CKD What are we most concerned about with the use of IV iron?
Anaphylaxis
Extravasation
Hypertension
Iron toxicity

29. CKD
Which of the following does not cause decreased absorption of iron?
Ranitidine
Doxycycline
Omeprazole
Azithromycin

30. CKD
According to KDIGO, which iron therapy is preferred in a patient with PD-CKD?
Sodium ferric gluconate
Ferrous sulfate
Ferrous gluconate
Iron polysaccharide

31. CKD
TJ is a 59 yo M. Hb=11.2, Hct=34, TSAT=15%, Ferritin=300ng/ml. Which dose is appropriate for repletion of iron?
500mg once
500mg in divided doses
1000mg once
1000mg in divided doses

32. CKD
Which agent may be given during a hemodialysis session through the dialysate?
Iron sucrose
Ferric pyrophosphate citrate
Ferumoxytol
Iron dextran

33. CKD – ESA therapy
Half-life: Epoetin alfa < Darbepoetin alfa < Methoxy PEG epoetin beta
SQ or IV administration is available. SQ is a good option for patients who are not seen frequently.
An increase in ESA dose should be considered when the Hb increases by less than 1g/dL in 4 weeks.
A decrease in ESA dose should be considered when the Hb increases by more than 1g/dL in 2 weeks.
Side effects may include hypertension, seizures, and thrombotic events.
Resistance may occur if low iron stores, bleeding, inflammation, malignancy, hyperparathyroidism, or aluminum toxicity.
Avoid correcting the hemoglobin level. KDIGO suggests not going >11.5g/dL. For dialysis patients with Hb<10g/dL, start ESA to prevent Hb<9g/dL. For non-dialysis patients with Hb<10g/dL, consider starting ESA.

34. CKD – ESA therapy Agent Patient Dose Admin. Epoetin alfa All Pts
units/kg TIW
IV or SQ
Darbepoetin alfa
Dialysis
0.45mcg/kg/week OR
0.75 mcg/kg q 2 weeks
Non-dialysis
0.45mcg/kg q 4 weeks
Mircera
0.6mcg/kg q 2 weeks

35. CKD
LK is a 49 yo female who has ND-CKD stage 4. Hb=9.2, Hct=28, 65kg. The physician wants to start Mircera. Which of the following doses is appropriate?
39 mcg q 2 weeks
39 mcg q week
39 units q 2 weeks
390 mcg q 2 weeks

36. CKD
LK is a 49 yo female who has ND-CKD stage 4. Hb=9.2, Hct=28, 65kg. The physician wants to start Mircera. At a check-up two weeks later, her labs are Hb=10.8, Hct=32. What do you recommend?
Increase the dose by 25%
Decrease the dose by 25%
Maintain current dose
Discontinue treatment

37. CKD – Mineral/Bone Disorder
Maintain normal phosphorus levels ( mg/dL) through dietary restriction and phosphate binders.
Maintain normal calcium levels (8.5-10mg/dL).
Control PTH through use of vitamin D and cinacalcet.
Phosphate binders have numerous drug interactions. Avoid taking with other medications.
Vitamin D agents should be used to correct deficiencies in CKD stages Doses may need to be reduced or discontinued if hypercalcemia, hyperphosphatemia, or too low levels of PTH occurs.

38. CKD Which of the following is false?
Phosphorus accumulation in CKD reduces activation of vitamin D.
Vitamin D3 directly suppresses the synthesis of PTH.
PTH leads to a decrease in calcium levels.
PTH increases osteoclast activity.

39. CKD What does KDIGO recommend as the goal calcium phosphate product?
>100
<100
>55
<55

40. CKD
KM’s lab values today in clinic are P=5 and Ca=10.2. She recently started restricting high phosphorous foods but still needs to lower her phosphorus level. Which phosphate binder do you want to avoid?
Sevelamer carbonate
Lanthanum carbonate
Calcium carbonate
Ferric citrate

41. CKD
KM’s lab values today in clinic are P=5 and Ca=10.2. She recently started restricting high phosphorous foods but still needs to lower her phosphorus level. How will you counsel her on the phosphate binder?
Take it once daily.
Take with every meal.
Take on an empty stomach.
Take with a full glass of water.

42. CKD
Which agent requires conversion to its active form once in the body?
Calcitriol
Paricalcitol
Doxercalciferol

43. CKD All of the following are true about Cinacalcet except:
It is used in combination with vitamin D for ESRD patients.
Therapy should not be initiated if the corrected calcium >10mg/dL.
Patients may experience nausea, vomiting, and abdominal pain.
It may inhibit the metabolism of TCAs

44. Therapeutics 2 Tutoring Questions?
Sarah Darby
November 30, 2016