FAQ's
Note: As new FAQ's are posted I will list them at the TOP of each section and date the question.
General
Can you recommend outside reading? I would if I could but much of it is very confusing. I would recommend you review DiPiro. Some areas get deeper involved that I think is necessary. I don't hold you responsibile for anything not discussed in class.
Renal
1) ATN patients arent making any urine, you still try the fluid challenge? Yes, you sould at least try to give some fluid to see if they urinate.
2) What about strict glucose control- it is not done if overt proteinuria but otherwise it is done? There is no data. The stricter control the more likely pts get HYPOglycemic so the risks start to outweigh the benefits.
3) Anemia of CKD they're normochromic/cytic- will you tell us whether MCV and MCHC are normal? I will give you normal ranges for these labs.
4) To clarify, protein is restricted in stage 1-3 pts and nondiabetic nephropathy, not stage 5? and what about 4? Here is the deal on protein. Don't protein load anyone with stage I-IV CKD it may worsen kidney disease. Although there is some data in non-diabetics on efficacy in slowing progression, protein restriction is difficult so most people recommend the RDA of 0.8 g/kg/day (which is actually low compared to the american diet). With Stage V on dialysis, the protein requirements are higher (1.3 to 1.5 g/kg/day) given the risk of malnutrition.
5) ACE's are ok to give in stage 1-3, and 5, caution in 4? YEP
6) When is low PTH a problem (ie. dialysis patient) because I'm not sure when adynamic bone disease occurs? Adynamic bone disease and low PTH are essentially the same. It is a complex disorder which is very difficult to treat. Some patients get it b/c we are TOO agressive with VitaminD therapy when trying to prevent/treat hyperparathyroid (high bone turnover) disease.
7 ) What is the dose limiting side effect for cyclosporine and tacrolimus? I'm not sure there is ONE, they could be different for different patients.. Certainly, acute changes in renal function b/c of afferent vasocontriction is an issue. With tacrolimus, you will see some CNS stuff (like tremor).
8) Is azathioprine & mycophenolate's dose limiting side effect leukopenia? For azathioprine, yes. For mycophenolate, the GI effects become an issue at higher doses although you can still see the leukopenia.
9) Do we need to know the different types of bone disease and how to differentiate b/w them? Basically, yes.
10) With Vit D supplements (calcitriol), it absorbs Ca and P from the gut? (according to the notes) Isn't that bad considering P is the thing we want to work on? Absolutely! It really becomes a balancing act. In fact, if a patient is hyperphosphatemic,
11)Are we responsible for specifics with Vit D supplements, or just that they help with Ca and P?
12) Is epogen specifically for dialysis and procrit specifically for cancer and dialysis or doesn't it really matter? They are marketed for those specific indications but are used interchangabley since they are the same drug, so it really doesn't matter.
13)Should iron and/or procrit/epogen be given prophylatically in dialysis or only if the Hct/HB drops? Start EPO when Hb <10 and titrate to goal Hb 11-12. Over 90% of dialysis patients need epo. Some stage IV need it as well. Start iron if iron studies low, can use "maintenance" iron to keep iron levels good.
14)If at Stage 4, ACEI are not recommended for HTN, but what is? You can use everything else, need to look at patient and see other compelling indications. NDCCB's are probably second line for diabetic nephropathy.
15) Is dialysis necessary in ALL Stage 5 patients? No Stage V is defined as a GFR of < 15 ml/min. MOST patients will need dialysis at this point but not all.
Sodium/Water balance
Can you use lactated ringer's solution in hyponatremia? (11/22/04) That would likely NOT be a good idea. In addition to sodium, Lactated ringers contains lots of electolytes (K, Mg, etc). Therefore, you may induce other electrolyte abnormalities if you infuse this solution versus other Normal Saline. Surgeons tend to use this infusion in trauma patients. It is really not that widely used.
I am very confused with the sodium thing, what should I do? I would suggeest that you make up a grid/picure which outlines the different sodium imbalances and start to think them through. Pure memorizations doesn't work!
What are the signs and symptoms of hypovolemic hypotonic hyponatremia? Signs/symptoms of hypovolemia include things like postural hypotension, poor skin turgor, dry mucous membranes, low urine sodium. This is VERY different from signs/symptoms of hypotonicity (also called hypoosmolality) - symptoms of hypotonicity are CNS-related and are due to fluid shift into brain cells.
Why do I have know about IV's, pharmacists aren't that involved with IV therapy? That is true. However, pharmacists are getting more involved in IV therapy at home and in the hospital. In addition, sometimes we need to know things to be able to converse intelligently with doctors.
What is the difference between dehydration and volume depletion? What a great question! Dehydration is when water shift out of cells. The primary sign of dehydration is a high serum sodium - the primary symptom is THIRST. Volume depletion is a bit different, this is when the intravascular amount of sodium and water is reduced. The S/S's of volume depletion are tachycardia, hypotension, decreased urine output, poor skin turgor, dry mucous membranes. So people can have volume depletion and dehydration, but that would mean the serum sodium would need to be high and the total body sodium/water would be reduced.
Electrolytes
What is GIK? "GIK" stands for glucose, insulin and potassium (K). when you give Glucose and insulin, it forces potassium into cells. Don't confuse this...it does not mean that you give potassium !
Why don't we list sodium bicarb as a treatment for hyperkalemia more often? It is unclear that it works well and certainly doesn't work as well as insulin. There is some data that sodium bicarb may worsen intracellular acidosis. Finally, sodium bicarbonate does contain lots of sodium so it could cause problems in patients with CHF. If patients have SEVERE acidosis (pH<7.1) then it is indicated.
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