Peritoneal Dialysis-Related Peritonitis Treatment

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Questions and Answers

What is a risk factor for the development of diabetic nephropathy?

Hypertension (correct)

Retinopathy

Hyperlipidemia

Proteinuria

When should annual monitoring for albuminuria begin for patients with Type 1 diabetes mellitus?

Immediately after diagnosis

5 years after diagnosis (correct)

10 years after diagnosis

At the time of retinopathy diagnosis

What is a key component of managing diabetic nephropathy?

Protein restriction

Aggressive blood glucose control (correct)

Stopping smoking

All of the above

According to the American Diabetes Association, what is the target blood pressure for patients with diabetic nephropathy?

140/80 mm Hg Signup and view all the answers

What is the first-line treatment for patients with diabetic nephropathy and proteinuria?

ACE inhibitors Signup and view all the answers

When should ACE inhibitors or ARBs be held in patients with diabetic nephropathy?

If serum potassium is greater than 5.6 mEq/L Signup and view all the answers

What type of diuretic is recommended for patients with diabetic nephropathy in stages 4 and 5?

Loop diuretics Signup and view all the answers

What is a potential risk of combining ACE inhibitors or ARBs with direct renin inhibitors?

Hyperkalemia Signup and view all the answers

What is the primary factor responsible for anemia in patients with chronic kidney disease?

Decreased erythropoietin production Signup and view all the answers

A patient with CKD on peritoneal dialysis presents with fever and abdominal pain. What is the best empiric therapy for this patient?

Cefazolin plus ceftazidime instilled intraperitoneally Signup and view all the answers

What is the recommended frequency for hemoglobin/hematocrit monitoring in patients with stage 3 CKD?

At least annually Signup and view all the answers

What is the consequence of using ESAs to achieve high hemoglobin concentrations (greater than 13 g/dL)?

Increased cardiovascular events Signup and view all the answers

What is the normal value for mean corpuscular volume?

80-100 fL Signup and view all the answers

When should anemia evaluation be initiated in patients with CKD?

When CrCl is less than 60 mL/minute Signup and view all the answers

What is the benefit of treating anemia in patients with CKD?

Decreased left ventricular hypertrophy Signup and view all the answers

What is the recommended frequency for hemoglobin/hematocrit monitoring in patients with stage 5 (dialysis) CKD?

At least every 3 months Signup and view all the answers

What is the upper limit of hemoglobin suggested by KDIGO?

11.5 g/dL Signup and view all the answers

What is the target for ferritin in non-HD CKD and PD patients?

100 ng/mL Signup and view all the answers

How often should ESA dose adjustments be made?

Every 4 weeks Signup and view all the answers

What is the maximal increase in hemoglobin every 2-4 weeks?

1 g/dL Signup and view all the answers

How often should hemoglobin be monitored in the initiation phase of ESA therapy?

Every 2-4 weeks Signup and view all the answers

What is the most common cause of inadequate response to ESA therapy?

Iron deficiency Signup and view all the answers

Why do most patients with CKD require parenteral iron therapy?

Due to increased requirements and decreased oral absorption Signup and view all the answers

What is the usual amount of iron given to adult patients who undergo dialysis?

1000 mg Signup and view all the answers

Why is cinacalcet especially useful in patients?

With high calcium/phosphate concentrations and high PTH concentrations Signup and view all the answers

What should be done before initiating cinacalcet therapy?

Monitor serum calcium Signup and view all the answers

In which patients should cinacalcet be used with caution?

Patients with seizure disorders Signup and view all the answers

What is a common adverse effect of cinacalcet?

Nausea and diarrhea Signup and view all the answers

What is the recommended route for iron administration in patients with CKD on hemodialysis?

Intravenous Signup and view all the answers

Which medication interaction is a concern with cinacalcet?

Ketoconazole increases the plasma level of cinacalcet Signup and view all the answers

What is the patient's calcium level?

9.5 mg/dL Signup and view all the answers

What is the primary objective of replacement therapy in iron deficiency anemia?

To achieve TSAT levels above 30% Signup and view all the answers

Which of the following agents is NOT recommended for non-HD patients?

Ferumoxytol Signup and view all the answers

What is the likely cause of relative epoetin resistance in this patient?

Hyperparathyroidism Signup and view all the answers

What is the best approach to managing this patient's hyperparathyroidism and renal osteodystrophy?

Change calcium acetate to sevelamer and add cinacalcet Signup and view all the answers

What is a common adverse effect of iron dextran administration?

Hypersensitivity Signup and view all the answers

What is the primary contributor to renal osteodystrophy?

Elevated PTH concentrations Signup and view all the answers

At what GFR level may the process of renal osteodystrophy begin?

60 mL/minute Signup and view all the answers

What is the result of unabated calcium loss from the bone in renal osteodystrophy?

Renal osteodystrophy Signup and view all the answers

What is the primary mechanism by which elevated PTH concentrations contribute to renal osteodystrophy?

Decreased reabsorption of phosphorus in the proximal tubule Signup and view all the answers

Study Notes

Empiric therapy for peritonitis in a patient on peritoneal dialysis: intraperitoneal cefazolin plus ceftazidime
Gram stain and culture of dialysate fluid are ordered to guide antibiotic therapy

Anemia in Chronic Kidney Disease (CKD)

Factors responsible for anemia in CKD:
- Decreased erythropoietin production
- Shorter life span of RBCs
- Blood loss during dialysis
- Iron deficiency
- Anemia of chronic disease
- Renal osteodystrophy
Treatment of anemia in CKD:
- Erythropoiesis-stimulating agents (ESAs)
- Iron therapy
Monitoring anemia in CKD:
- Initiate evaluation when CrCl is less than 60 mL/minute or hemoglobin is less than 10 g/dL
- Monitor hemoglobin/hematocrit regularly (at least annually for stage 3 CKD, at least twice per year for stage 4 and 5, and at least every 3 months for stage 5 on dialysis)

Diabetic Nephropathy

Pathogenesis:
- Hypertension (systemic and intraglomerular)
- Glycosylation of glomerular proteins
- Genetic links
Diagnosis:
- Long history of diabetes
- Proteinuria
- Retinopathy (suggests microvascular disease)
Monitoring:
- Begin annual monitoring for albuminuria 5 years after diagnosis for type 1 diabetes mellitus
- Begin annual monitoring for albuminuria immediately for type 2 diabetes mellitus
Management:
- Aggressive BP management
- Blood glucose control
- Protein restriction
- Manage hyperlipidemia
- Stop Smoking

Erythropoiesis-Stimulating Agents (ESAs)

ESA dose adjustment is based on hemoglobin response
Maximal increase in hemoglobin is about 1 g/dL every 2-4 weeks
Dosage adjustments upward should not be made more often than every 4 weeks
Monitoring:
- In initiation phase, monitor hemoglobin every 2-4 weeks
- In maintenance phase, monitor hemoglobin at least monthly in dialysis patients and at least every 3 months in nondialysis patients with CKD

Iron Therapy

Most patients with CKD who are receiving ESAs require parenteral iron therapy
Goals for iron therapy:
- Ferritin > 200 ng/mL (HD) and > 100 ng/mL (non-HD-CKD and PD)
- TSAT > 30%
Agents used for iron therapy:
- Iron dextran
- Sodium ferric gluconate
- Iron sucrose
- Ferumoxytol
- Ferric carboxymaltose

Renal Osteodystrophy and Secondary Hyperparathyroidism

Pathophysiology:
- Hyperphosphatemia
- Decreased production of 1,25-dihydroxy vitamin D3
- Reduced absorption of calcium in the gut
- Decreased ionized (free) calcium concentrations
- Direct stimulation of PTH secretion
Signs and symptoms:
- Especially useful in patients with high calcium/phosphate concentrations and high PTH concentrations when vitamin D analogs cannot be used or cannot be increased

Cinacalcet

Used to treat secondary hyperparathyroidism
Caution in patients with seizure disorder (hypocalcemia may exacerbate)
Adverse effects: nausea and diarrhea
Drug interactions:
- Ketoconazole ↑ the plasma level of Cinacalcet
- Cinacalcet ↑ the plasma level of flecainide, tricyclic antidepressants, and thioridaine

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Description

A patient with CKD on peritoneal dialysis presents with fever and abdominal pain. What is the best empiric therapy for this patient? The 2010 recommendations for peritoneal dialysis-related peritonitis are considered.