Chronic Kidney Disease

1. Medication review Warren Prokopiw Pharmacy Resident 2011-12 Chronic Kidney Disease

2. Outline • Case intro • Renal failure issues • Hypertension, lipids, glucose, anemia • Renal bone disease, potassium, acid-base • GI Disorders, nutrition, puritis, gout • Nervous system disorders • Application to case • Questions

3. Meet Mr Smith • 80 year old gentleman with chronic renal failure eGFR = 20 • Managed at renal clinic • Previous medical history • DM 2 x 15 years • hypertension • osteoarthritis • glaucoma • psoriasis • gout

4. Current medication list

5. Hypertension • Common association – 75% of patients • Cause and consequence of CKD • Target is 130/80 – slow decline to target • Medications • ACEI/ARB and CCB • Diuretics - loop, thiazide, combination • Beta blockers (pts < 60) • Second or third line agents • Nitroglycerin, hydralazine, clonidine,

6. Hyperlipidemia • High prevalence in CKD patients • Major risk factor for progression of disease • Targets • LDL < 2.0; TC/HDL ratio < 4.0 TG < 10 • Medications • Statins for high LDL/low HDL • Gemfibrozil or nicacin for elevated TG

7. Diabetes • Risk factor for CKD and cardiovascular events • Tight control reduces diabetic nephropathy • HbA1C < 7.0% Fasting glucose 4-7 mmol/L • Medications • Gliclazide over glyburide • Avoid metformin when GFR < 30 ml/min • Part of multifactorial strategy promoting BP control and CV risk

8. Anemia • Due to erythropoetin deficiency • Target 110 g/L – start if Hg < 100 g/L • Medications • Erythropoetin and darbepoetin • Takes 64 days to reach new steady state • Reassess dose in 4 weeks • Require adequate iron, folic acid and B12 stores for synthesis

9. Iron Supplements • Targets - Tsat > 20% Ferretin > 100 ng/ml. • Oral - preferred • ferrous fumarate • ferrous gluconae • ferrous sulfate • IV – when patients fail/not tolerate oral • iron gluconate • iron sucrose • iron dextran

10. Renal Bone Disease • Reduced renal function → PO4 retention • Elevated PO4 → lowered Ca++ → less activation of Vit D → less Ca++ absorption → direct binding PO4 to Ca++ in blood • Parathyroid gland stimulated • ↑ renal Ca++ and PO4 reabsorption • ↑ Ca++ mobilization from bone

11. RBD Prevention • Goal – keep in normal range • PO4 0.75-1.4 mmol/L, Ca++ 2.2-2.5 mmol/L • Dietary PO4 restriction • PO4 Binder if no hypercalcemia • Calcium carbonate, calcium acetate, aluminum hydroxide, sevelamer, lanthanum, cinacalet • Ca++ supplement if hypocalcemic

12. RBD Prevention • Vitamin D supplement if PTH > 53 pmol/L • Alfacalcidol, calcitriol • Used TIW pluse therapy • Reduce Ca++ and Vit D if hypercalcemia

13. Hyperlakemia • Potassium usually 90% renally eliminated • In CRF, the DCT compensates with increased secretion • Aldosterone plays and important role • Further decrease in renal function • Increased secretion by the colon • Management • Dietary potassium restriction – avoid constipation • Monitor if on ACEI, avoid K+ sparing diuretics • Sodium polystyrene sulfonate • dialysis

14. Acid Base • Renal PO4 excretion provides buffer for elimination of H+ ions • ↓ PO4 excretion → metabolic acidoisis • Medication • Sodium bicarbonate • Sodium citrate • Monitor water balance due to sodium content

15. GI Disorders • Most CDK patients are diabetic • Diabetic gastopariesis • Taking high calcium loads • Constipation • Medications • Prokinetics • Domperidone and metoclopramide • Laxatives • Docusate sodium, Senna, Lactulose • AVOID Fleet enemas and Fruitlax

16. Nutritional Deficiencies • Dialysis removes water soluble vitamins and zinc • Deficient in vitamin B1, B2, B6, B12, niacin, pantothenic acid, niacinamide, folic acid and vitamin C • Medication • Replavite • Zinc Supplement

17. Puritis • Occurs in up to 86% of dialysis patients • Cause unknown • Dry skin, hyper PTH, increased Vit A and histamine • Medications • Hydroxyzine • Diphenhydramine • 10% uremol in glaxal base

18. Gout • Renal failure leads to hyperuricemia • Diuretics used for volume overload compound problem • Medications • Allopurinol – prevention • Colchicine – short term treatment • prednisone

19. Nervous System Disorders • Affect 50% of patients with EDRD • uremic polyneuropathy is axonal in nature • Restless legs syndrome • Occurs in 50% of ESRD patients due to uremia • Medictions • sinemet, clonidine, clonazepam

20. Nervous System Disorders • Leg cramps • May occur during dialysis • Associated with large volume draws • Medication • Quinine • Neuropathic pain • Typical pain agents • Desipramine, nortryptyline, carbamazepine, gabapentin

21. Current medication list

23. Questions