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Elderly: CG IBW
Obese: CG IBW (ABW if BMI > 40) or CKD-EPI individualized for BSA
PK Changes
A: ↓ = ↓ peristalsis, gut edema, chelation interactions; ↑ = uremic CYP inhibition and ↓ 1st pass
D: ↓ protein binding due to hypoalbuminemia and displacement by uremic toxins; ↑ Vd due to tissue
protein binding
- 3a: 45-59
- 3b: 30-44
- 4: 16-29
- 5: <15
- Blood pressure < 140/90 (130/80 if diabetic CKD with ACR > 3)
- AIC < 7% (if type 2 DM), FBG between 4-7 mmol/L (if type 1 DM)
- ACR ≤ 3
- LDL < 2 or >50% reduction
ACEI/ARB monitoring
- SCr and serum K+ : At baseline and in 1-2 weeks (after initiation and dose change); up to 30%
increase in SCr expected (reduce dose if 30-50% increase, if>50% increase, d/c)
- Avoid K+-sparing diuretics and restrict dietary K+; may stop ACEI if K+ > 5.5
- ADRs: hyperkalemia, orthostatic hypotension (dizziness, fainting, falls), dry cough (ACEI > ARB),
angioedema (ACEI > ARB)
- Benefits: ACEIs/ARBs ↓ BP and albuminuria, ↓ CV mortality and slowing progression of CKD
- Albuminuria and CKD ↑ CV events
- Indications: CVD, >55yo with CV risk factors, diabetic microvascular complications
- Agents/protective doses: perindopril 8 mg daily, ramipril 10 mg daily, telmisartan 80 mg daily
(8,10,80)
Bolded can cause drug-induced pre-renal acute renal failure in hypovolemic patients.
Dializability of CV meds
Diuretics :
- Furosemide (Loop diuretics): require no dosage adjustment with declining renal function.
- HCTZ (Thiazide diuretic): Does not work well <30 ml/min.
- Spironolactone, Eplerenone( K+-sparing diuretic): Avoid due to hyperkalemia risk.
LDL-lowering in CKD
- No statins in dialysis.
- Use low doses of statins pre-dialysis if primary prevention; use high dose if secondary
prevention
- Atorvastatin: 1° (20 mg daily), 2° (80 mg daily)
- Rosuvastatin: 1° (10 mg daily), 2° (40 mg daily)
- Simvastatin: 1° = 40 mg daily (20 mg with 10 mg ezetimibe)
Lifestyle modification
- Smoking cessation
- Diet (low fat, low sodium, be mindful of carbs if diabetic)
- Exercise
- Weight loss
Metabolic acidosis
- Kayexalate (sodium polystyrene sulfonate): non-urgent K+ lowering; mix 30g with 125 ml of
water (not juice!); Avoid oral suspension due to colonic necrosis; Space 3h from all PO meds
- Insulin+dextrose( emergency): shifts K+ into ICF
- IV calcium (emergency) reverses cardiotoxicity
- Dialysis
- Tolvaptan (vasopressin receptor antagonist) prevents cyst growth and slows decline of renal
function in ADPKD patients.
- Requires liver enzyme monitoring as potential for liver damage.
- Given as 2 doses per day (1 large dose in am and 1 small dose in pm since want to avoid
urination at night; reverse order if shift work at night); titrate dose q3 months prn
- Interactions: substrate of 3A4/pgp so avoid 3A4 and pgp inhibitors/inducers
In CKD:
- ↑ PO4 due to ↓ excretion (PO4 can complex with Ca2+ and ↓ free Ca2+); complex causes
vascular calcification; also ↑ PTH
- ↓ Ca2+ due to above and because kidney cannot activate vitamin D = ↓ GI Ca2+absorption and
Ca2+ mobilization
- ↑ PTH due to hypocalcaemia = ↑ PO4 and ↑ Ca2+ reabsorption except kidneys suck so must
increase Ca2+ by promoting bone resorption = bone problems (osteomalacia, fractures, osteitis
fibrosa cystica)
- ↑ acid due to ↓ renal excretion = metabolic acidosis; associated with Ca2+ loss and ↑K+
Hyperphosphatemia and 2° Hyperparathyroidism
- Targets (stage 5 CKD): PO4 < 1.8 mmol/L, PTH < 55 pmol/L, corrected Ca 2.2-2.5 mmol/L
Hyperphosphatemia treatment
Phosphate binders (up to TID since taken with meals; space 2h from oral iron, levothyroxine,
fluoroquinolones, and tetracyclines)
- Calcium carbonate/acetate: max out calcium first (max 2g elemental/day); can make case for
coverage of other binders if insufficient response or hypercalcaemia; constipation
- Sevelamer: do not chew/crush, covered in NS; N/V, diarrhea/constipation
- Lanthanum: chew, covered in NS with conditions; N/V, diarrhea/constipation
- Magnesium hydroxide: avoid since diarrhea
Cinacalcet Only if: PTH > 88 on 2 occasions that are 6 weeks apart (hyperparathyroidism) – the
normal pth levels are between 0.6-55 pmol/L
Anemia in CKD
Targets: TSAT > 20%, Hgb 95-115 g/L, ferritin > 200,
- If :TSAT <20% and Hgb < 100 g/L: Give PO or IV iron (PO first; if not successful -> IV)
- If TSAT < 20%, switch to IV Iron
- Gluconate:30mg,Sulphate:60mg,Fumarate:100mg
IV: iron sucrose (Venofer): Watch pt for 30 minutes post-IV for allergic reaction
- Initiate ESA (TSAT target has been reached; now want to↑ Hgb to 95-115g/L; but the
patient should continue their maintenance dose of iron to maintain TSAT>20%)
- SC epoetin- Dose: 50-100 U/kg . Frequency: once/week. (T1/2=30 hours)
- IV epoetin: Dose: 50-100 U/kg. Frequency: 3 times/week (T1/2=5-11 hours)
- IV/SC darbepoetin: Dose: 0.45-0.9 mcg/kg Frequency: once/wk(dialysis), once/2weeks if
pre-dialysis
- *Titrate : ↑ Any or ↓ must be 25% of the dose; do not exceed >10 g/L increase in Hgb
during any 2-week period
- Start ESA when HgB=90-100 g/L, but never when HgB<90 g/L. Target: 95-115 g/L
- Assuming iron stores (TSAT>20%): Continue iron maintenance dose if on iron
- If Hgb level < target (90-95g/L): ↑ ESA dose
- If Hgb level > target (>115g/L ) ↓ ESA dose or hold to prevent ↑ BP (stroke/MI risk)
Pruritus
Anticoagulants
- NOACs: avoid if CrCl < 30 EXCEPT apixaban < 15); dabigatran dialyzable (80%)
- Warfarin: adjust dose based on INR (no adjustment baed on CrCl)
- LMWH (Dalteparin, Tinzaparin, Enoxaparin): adjust dose if CrCl < 30
Antibiotics
Analgesics
Gout drugs (A and C come first; higher adjustment, F comes later, lower adjustment)
Other
OTC meds
- Hypertension (Ma-Huang, white willow bark, ginseng): The asian sound shit=DOJO=tension
- Diuretic effects (Parsley, juniper, uva ursi): “I would DIE(uretic) if I went to Junipers ,Marsley,
or Uranus (Uva Ursi)
- Hyperkalemia (alfalfa, dandelion, noni juice, nettle): “K+, Alfalfa got Hyper after drinking his
noni’s juice, so he relieved his steam (nettle) running in dandelion fields.
- Hypokalemia (licorice): “Eating black LiK+Orice is nasty, it makes me hypoactive”
- Labs: Acute ↑in SCr and Acute↓in GFR+urine output; fractional excretion of sodium < 1% in
pre-renal and BUN ↑
- Anuric AKF: <50 ml urine/day
- Oliguric: 50-400 ml urine/day
- Goal: >400 ml/day
Types
Pre-renal
Intrinsic
- Acute tubular necrosis: drugs kill tubular epithelium directly (aminoglycosides, cyclosporine,
contrast dyes, lithium, acyclovir, amphotericin B, cisplatin); discontinue offending agent
- Mnemonic: “Amin, NO! .. Cycling is a good sport, in fact, it’s LIT. In contrast, Acyclists, are
inactive and only eat plats of pho”. Amin,NO=Aminoglycosides, Cycling is a good
sport=Cyclosporine, LIT=Lithium, Contrast=Contrast dyes, Acycysys=Acyclovir, Plats=Cisplatin,
Pho=Amphotericin B
- Mnemonic: “Allo, 911? My fam got pinpoint pupils from the beta-carrots that he ate when he
went tidine after his sulphone died. We forgot that he’s allergic to carrots and hypersensitive”.
- “Allo=Allopurinol”, “Fam has pin” =Rifampin that he, beta-carrots=beta-lactams,
tidine=rantidine, sulphone=sulfonamides
-
- Glomerulonephritis: infections (e.g. Staph infections of kidney), immune-related (e.g. lupus)
Post-renal
Hemodialysis
Pros:
- Better clearance
- Low technique failure rate
- Allows for close monitoring of patient
Cons:
- Loss of autonomy
- Complications (hypotension, fatigue, blood loss/anemia, leg cramps, etc.)
- Vascular access (via cardiac catheter or arm fistula) increases risk of infection and thrombosis
- Residual renal function disappears
Peritoneal dialysis
Pros:
Cons:
Dialyzability of drugs
Drug factors
Dialysis factors
- Dialysis membrane pore size (bigger pore size allows higher MW drugs to be removed)
- Blood/dialysate flow rates (flow in opposite directions to generate concentration gradient,
increasing blood flow rate during HD permits greater clearance)
Other
- Non-renal clearance (if drug is mostly cleared through the biliary route, not likely to be dialyzed;
if eliminated by the kidney, then will be dialyzed)