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Informatics in Pharmacy

Chronic Kidney Disease

August 13, 2018 By Dr. G, PharmD

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KDOQI Staging

StageGFR
Stage 0>=90 with risks (diabetes, HTN, history)
Stage 1>=90 w/damage
Stage 260-89 w/damage
Stage 3 30-59 w/damage
Stage 4 15-29 w/damage
Stage 5 <15

KDIGO Staging:

All in damaged kidneys.

StageGFR
G1>=91
G2>=60-89
G3a45-59
G3b30-44
G415-29
G5<15

Albuminuria:

 ACR
A1<30
A230-300
A3>300
  • Goal BP in CKD = 130/80 in some guidelines, especially with marked albuminuria.
  • ACEI or ARB should be used in any degree of proteinuria, even if not hypertensive.
  • Calcium channel blockers are second line after ACEI/ARB.
  • DASH Diet: limit salt to 1500-2300 mg daily
  • Assess hyperlipidemia and treat, unless on dialysis.

Stage 3 CKD: monitor every 12 months.
Stage 4-5 CKD: monitor every 6 months.
Stage 5 + dialysis CKD: monitor every 3 months.

Renal Replacement Therapy

Remember AEIOU:
A: Acidosis (not responding to bicarb)

E: Electrolyte abnormality (hyperkalemia, hyperphosphatemia)

I: Intoxication (theophylline, boric acid, ethylene glycol, lithium, methanol, phenobarbital, salicylate)

O: Overload of fluid (symptomatic, pulmonary HTN)

U: Uremia (pericarditis and weight loss)

Complications of CKD

  • Anemia: Treating with erythropoiesis-stimulating agents (ESA) increases cardiovascular events.
    • Only initiate if hemoglobin less than 10.
    • Use in caution with patients with a history of cancer or stroke.
    • Hold or reduce dose if hemoglobin is greater than 10 or greater than 11 in dialysis.
    • Do not exceed hemoglobin greater than 13.
    • Most patients receiving ESAs also need iron. Dialysis pts usually need 1000 mg per dialysis, usually IV.
  • Calcium and Phosphorus homeostasis: Can cause hyperphosphatemia, reduced absorption of calcium in the gut, decreased free calcium.
    • Calcium and phosphorus go together: calcium binds phosphorus
    • Treatment: Restrict phosphorus to 800-1000 mg/day or remove with dialysis.  Can take phosphate binders with meals (calcium carbonate, calcium acetate, sevelamer, lanthanum, sucroferric, aluminum hydroxide, ferric citrate)
    • Supplement with vitamin B if needed.
    • Calcitriol: Manage hypocalcemia, but can cause hyperalcemia.
    • Paricalcitol: Vitamin D analog
    • Doxercalciferel: Vitamin D analog, lower incidence of hypercalcemia than calcitriol
    • Cinacelet: 30 mg daily. Calcium mimic, especially useful in patients with high calcium and phosphate concentrations and high PTH.

Drugs in hemodialysis:

  • Large molecules like vancomycin will be removed.
  • Water-soluble drugs are more likely to be removed.
  • Protein-bound drugs can’t pass through the membrane
  • Drugs with a small volume of distrubution cannot be removed, even if they are not protein bound

Filed Under: Nephrology

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020