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43 Cards in this Set
- Front
- Back
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Factors contributing to 2PTH |
1. High Phos 2. Decreased 1,25 dihydroxy Vit D production 3. Reduced Ca from gut 4. Decreased ionized Ca 5. Diret PTH stimulation 6. Elevated PTH: high Phos, increased Ca reabsorp |
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At GFR below 30: calcium is not absorbed well from where? |
Gut Now is coming from bone d/t high PTH Renal osteodystrophy |
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Five lab abnormalities of CKDMBD |
1. Phosphorous 2. CORRECTED Calcium 3. Intact PTH 4. Alk Phos 5. 25-OH Vit D |
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Goals for Ca, Phos, iPTH in varying stages of CKD |
Stage 3: all normal Stage 4: all normal Stage 5: all normal Stage 5 + dialysis (all normal with iPTH 2-9times upper normal) |
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Non drug therapy |
1. Phos restriction to 800-1000mg/day once S3 CKD 2. Parathyroidectomy (if unreponsive hyperpara) |
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Drug therapy |
Phosphate binders Take with meals to bind Phos in gut May be used in combos for additive effects |
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Calcium carbonate |
40% elemental Ca 500, 1000, 1250mg 1250mg TID with meals Initial choice S3/S4 Treat hypocalcemia + dec met acidosis |
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Calcium acetate (PhosLo) |
25% elemental Ca 667 cap, tab and 667mg/5mL solution 2001mg TID with meals Initial choice S3/S4 better Ca binder and less Ca absorption |
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Sevelamer hydrochloride (Renagel) |
400, 800 tab P: 5.5-7.5: 800mg TID with meals P: 7.5-9: 1200-1600 TID with meals P >9: 1600mg TID with meals
Non-absorbable binder (binds Phos in exchange for Cl) NO FEEDING TUBES Primary therapy in S5 Consider if hypercalcemia or Ca intake >recommended dose with binders |
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Sevelamer carbonate (Renvela) |
800mg tab Same doses Avoids metabolic acidosis Primary therapy in S5 Consider if hypercalcemia or Ca intake >recommended dose with binders Titrate Q2 weeks by 400-800 a meal |
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Lanthanum carbonate Fosrenol |
500, 750, 1000
250-500mg TID with meals
Flavorless chew tab disscoaites into lanthanum ions which bind dietary Phos
Consider if patient has hypercalcemia |
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Sucroferric oxyhydroxide (Velphoro) |
500mg chew tab 500 TID with meals |
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Aluminum carbonate |
400, 500mg 400-500 TID with meals |
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Alum Hydroxide |
300, 600 300-600 TID with meals Avoid in general limit to 4 week course |
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Al toxicity |
Adynamic bone diease Encephalopthy EPO resistance Watch citrate: inc toxicity |
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Total elemental Ca/day |
200mg 1500: binder 500: diet |
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What effect does sevelamer have on TC? |
Increases HDL Decrease LDL |
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Which phos binder is most effective? |
No data to support any greater!
Sevelamer/lanthanum cause less hyperCa and reduce Ca burden |
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Use of ergo/cholcalcerifol |
Stage 3-5 CKD for patients with low 25-OH Vit D levels Repeat Vit D levels in 6 months |
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Dose Vit D if <5 |
Severe deficiency Weekly PO X 12 weeks then monthly or single IM dose |
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25-OH level 5-15 dose |
Mild def Weekly PO dose X 4 weeks then monthyl |
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16-30 dose Vit D |
Insuffiency Monthly PO doses |
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Use of Vit analogs in CKD |
Suppress PTH synthesis and reduce concentrations
Limited by resultant hypercalcemia |
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Calcitriol low dose oral |
Reduces hypocalcemia Does not sig reduce PTH |
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How often to dose-adjust calcitriol |
Q4 weeks |
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Lower incidence of hypercalcemia with which formulations? |
Paricaltriol and doxercalciferol -Dec. mobilization of Ca from bone -Dec. absorb of Ca from gut |
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Which formulation requires hepatic orenal activation? |
Doxer: needs hepatic activation (prodrug) |
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Cinacalcet |
Calcimimetic attaches to Ca receptor on PTH gland and increases sensitivity to serum Ca conc: reduces PTH
-Very useful in patients with high Ca X P and high PTH when Vit D analaogs cant be used |
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Initial dose Cinacalcet |
30mg (always no matter PTH conc) |
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Monitor cinalalcet |
q1-2 weeks monitor Ca
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Do not start cinacalcet if Ca is what |
<8.4 |
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Caution with cinacalcet in what disorde |
seizures (hypocal can worsen) |
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AE cinacalcet |
N and D |
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CYP cinacalcet |
Inhibits 2D6 (watch with flecainide, TCAs) Met by CYP3A4: potent inhibitors like ketoconazole can increase conc. 2 fold |
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Aluminum therapy pearls |
-Reserved for Ca X Phos >55 Works within one week Max 30 days Citrate will inc absorption Avoid use of OTC Al products Baseline Al <20mcg/L |
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Acetate to Sevelamer conversion |
667: 800mg 1334: 1600mg |
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Monitor Ca, Phos, Alk Phos, iPTH at what stage |
CKD S3 |
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Make all therapeutic descisions based on trends, not single data points |
!! |
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Dialysate Ca concentration in CKD5D |
2.5-3mEq/L |
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When to reduce levels of CC-PB |
1. Adynamic bone disease 2. Low PTH levels 3. Hypercalcemia |
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continuous high rate of production of PTH by the parathyroid glands promotes parathyroid hyperplasia |
Nodular tissue demonstrates more rapid growth potential and appears to be associated with fewer vitamin D and calcium-sensing receptors, resulting in resistance to the effects of calcium and vitamin D therapy |
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3 types of bone abnormalities |
osteitis fibrosa cystica (high bone turnover disease), osteomalacia (low bone turnover disease), and adynamic bone disease |
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Intake of calcium from calcium-based binders may also contribute to coronary artery calcification (CAC) |
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