Transcript T2 - 11-30

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Therapeutics 2 Tutoring
Sarah Darby
[email protected]
November 30, 2016
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Lectures Covered
 CKD
Progression and Complications
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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
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CKD
 HH
has a GFR of 49ml/min and an AER of
45g/24h. Stage his CKD based on KDIGO.
A.
G3a A2
B.
G3b A2
C.
G3a A1
D.
G3b A1
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CKD
 PK
has a GFR of 32ml/min and an AER of
45g/24h. Stage his CKD based on KDOQI.
A.
Stage 3
B.
Stage 4
C.
G3b A2
D.
G3b A1
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CKD
 FM
has a GFR of 12ml/min and an AER of
450mg/24h. Stage his CKD based on KDIGO.
A.
G3 A4
B.
G4 A3
C.
G5 A3
D.
Stage 5
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CKD
 Complications
 Fluid/electrolyte
 Metabolic
abnormalities
Acidosis
 Hypertension
 CVD
 Anemia
 Mineral
and bone disorder
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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?
A.
Furosemide
B.
Furosemide + HCTZ
C.
HCTZ
D.
Metolazone
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CKD
 Which
of the following will not contribute to
hyperkalemia?
A.
Captopril
B.
pH = 7.8
C.
Spironolactone
D.
Nu-Salt (salt substitute)
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CKD
 Which
of the following is not a possible
treatment for hyperkalemia?
A.
Calcium
B.
Albuterol
C.
Polystyrene sulfonate
D.
Dextrose
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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?
A.
PO bicarbonate
B.
IV bicarbonate
C.
PO potassium citrate
D.
IV potassium citrate
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CKD
 JH
is a 48 yo WM with CKD stage 4.
 CrCl=
25 ml/min
 pH=7.33,
 What
pCO2=36, HCO3=16
is the goal bicarbonate level for JH?
A.
18-22 mEq/L
B.
22-26 mEq/L
C.
26-30 mEq/L
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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?
A.
<120/80
B.
<130/80
C.
<130/90
D.
<140/90
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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?
A.
Ramipril
B.
Ramipril + Candesartan
C.
Ramipril + Aliskiren
D.
Aliskiren
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CKD
AER
Diabetes
No Diabetes
Goal BP
Preferred Drug
<30mg/24h
≤140/90
--
30-300mg/24h
≤130/80
ACEI or ARB
>300mg/24h
≤130/80
ACEI or ARB
<30mg/24h
≤140/90
--
30-300mg/24h
≤130/80
--
>300mg/24h
≤130/80
ACEI or ARB
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CKD

TJ has been advised to restrict the amount
of protein in his diet. His GFR is now 20ml/min.
Which is false?
A.
Dietary protein restriction is controversial for CKD
progression prevention.
B.
The MDRD trial showed reduced protein intake
was beneficial in late stages of CKD.
C.
TJ may lower his protein intake to 0.58g/kg/day
D.
TJ should avoid high protein intake.
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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
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
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.
A.
Do not recommend treatment.
B.
Atorvastatin
C.
Atorvastatin + Ezetimibe
D.
Colesevelam
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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.
A.
Do not recommend treatment.
B.
Atorvastatin
C.
Atorvastatin + Ezetimibe
D.
Colesevelam
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CKD

KM is a 48 yo female with CKD and starting
dialysis. The physician asks if cholesterollowering therapy is appropriate to continue.
She has been taking Rosuvastatin x 3 years.
A.
Discontinue treatment.
B.
Continue Rosuvastatin.
C.
Add Ezetimibe.
D.
Change to Colesevelam.
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CKD

KM is a 58 yo female with CKD stage 2. The
physician asks for your recommendation
regarding cholesterol-lowering therapy.
A.
Do not recommend treatment.
B.
Atorvastatin
C.
Atorvastatin + Ezetimibe
D.
Colesevelam
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CKD

KM is a 58 yo female with CKD stage 4. The
physician asks for your recommendation
regarding cholesterol-lowering therapy.
A.
Do not recommend treatment.
B.
Atorvastatin
C.
Atorvastatin + Ezetimibe
D.
Colesevelam
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CKD

KM is a 45 yo male with CKD. PMH: MI, DM.
The physician asks for your recommendation
regarding cholesterol-lowering therapy.
A.
Do not recommend treatment.
B.
Atorvastatin
C.
Atorvastatin + Ezetimibe
D.
Colesevelam
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CKD - Anemia

What decreases the RBC’s ability to carry
oxygen in renal disease?
A.
Increased tissue demand for oxygen
B.
Decreased release of erythropoietin
C.
Decreased availability of oxygen in the
blood
D.
Structural change in hemoglobin
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CKD – Iron therapy

Provide 200mg elemental
iron daily.

Problems with oral iron
therapy include reduced
absorption, GI side effects,
frequent dosing, and drug
interactions.


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.
IV therapy is generally
preferred for patients on
dialysis.
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CKD
When to initiate iron therapy
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CKD
 According
to KDOQI, which of the
following scenarios warrants a trial of iron
therapy?
A.
TSAT=34% in HD-CKD pt
B.
TSAT=23% in PD-CKD pt
C.
Ferritin=150ng/ml in PD-CKD pt
D.
Ferritin=175ng/ml in HD-CKD pt
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CKD
 What
are we most concerned about with
the use of IV iron?
A.
Anaphylaxis
B.
Extravasation
C.
Hypertension
D.
Iron toxicity
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CKD
 Which
of the following does not cause
decreased absorption of iron?
A.
Ranitidine
B.
Doxycycline
C.
Omeprazole
D.
Azithromycin
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CKD
 According
to KDIGO, which iron therapy is
preferred in a patient with PD-CKD?
A.
Sodium ferric gluconate
B.
Ferrous sulfate
C.
Ferrous gluconate
D.
Iron polysaccharide
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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?
A.
500mg once
B.
500mg in divided doses
C.
1000mg once
D.
1000mg in divided doses
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CKD
 Which
agent may be given during a
hemodialysis session through the dialysate?
A.
Iron sucrose
B.
Ferric pyrophosphate citrate
C.
Ferumoxytol
D.
Iron dextran
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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.
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CKD – ESA therapy
Agent
Patient
Dose
Epoetin alfa
All Pts
50-100 units/kg TIW
Dialysis
0.45mcg/kg/week
OR
0.75 mcg/kg q 2
weeks
Non-dialysis
0.45mcg/kg q 4
weeks
All Pts
0.6mcg/kg q 2
weeks
Darbepoetin
alfa
Mircera
Admin.
IV or SQ
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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?
A.
39 mcg q 2 weeks
B.
39 mcg q week
C.
39 units q 2 weeks
D.
390 mcg q 2 weeks
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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?
A.
Increase the dose by 25%
B.
Decrease the dose by 25%
C.
Maintain current dose
D.
Discontinue treatment
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CKD – Mineral/Bone Disorder

Maintain normal phosphorus
levels (2.5-4.5mg/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 35. Doses may need to be reduced or
discontinued if hypercalcemia,
hyperphosphatemia, or too low levels
of PTH occurs.
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CKD
 Which
of the following is false?
A.
Phosphorus accumulation in CKD reduces
activation of vitamin D.
B.
Vitamin D3 directly suppresses the synthesis
of PTH.
C.
PTH leads to a decrease in calcium levels.
D.
PTH increases osteoclast activity.
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CKD
 What
does KDIGO recommend as the
goal calcium phosphate product?
A.
>100
B.
<100
C.
>55
D.
<55
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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?
A.
Sevelamer carbonate
B.
Lanthanum carbonate
C.
Calcium carbonate
D.
Ferric citrate
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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?
A.
Take it once daily.
B.
Take with every meal.
C.
Take on an empty stomach.
D.
Take with a full glass of water.
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CKD
 Which
agent requires conversion to its
active form once in the body?
A.
Calcitriol
B.
Paricalcitol
C.
Doxercalciferol
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CKD
 All
of the following are true about
Cinacalcet except:
A.
It is used in combination with vitamin D
for ESRD patients.
B.
Therapy should not be initiated if the
corrected calcium >10mg/dL.
C.
Patients may experience nausea,
vomiting, and abdominal pain.
D.
It may inhibit the metabolism of TCAs
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Therapeutics 2 Tutoring
Questions?
Sarah Darby
[email protected]
November 30, 2016