Chronic Kidney Disease Medication
- Author: Pradeep Arora, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Medication Summary
In chronic kidney disease, doses and intervals of drugs that are excreted or metabolized renally should be adjusted accordingly for the residual glomerular filtration rate (GFR). Some drugs are contraindicated in moderate-to-severe renal impairment because of potentially serious effects from drug or metabolite accumulation. Routine consultation of the appropriate references should be undertaken when prescribing any new drug to a patient with chronic kidney disease.
Hart et al found that among patients with stage 3 chronic kidney disease and atrial fibrillation who took part in the Stroke Prevention in Atrial Fibrillation III trials, rates of ischemic stroke/systemic embolism were higher. Adjusted-dose warfarin reduced ischemic stroke/systemic embolism by a great degree among these patients.[32]
Hyperphosphatemia is treated with dietary phosphate binders and dietary phosphate restriction. Hypocalcemia is treated with calcium supplements and possibly calcitriol. Hyperparathyroidism is treated with calcitriol or vitamin D analogs.
Phosphate-Lowering Agents
Class Summary
Dietary phosphate binders promote the binding of phosphate, typically with calcium, to reduce hyperphosphatemia.
Calcium acetate (PhosLo, Eliphos)
This agent is used for treatment of hyperphosphatemia in chronic kidney disease. It combines with dietary phosphorus to form insoluble calcium phosphate, which is excreted in feces.
Calcium carbonate (Caltrate, Oystercal, Oysco, Alcalak)
This agent is used for treatment of hyperphosphatemia or as a calcium supplement in chronic kidney disease. It successfully normalizes phosphate concentrations in patients with chronic kidney disease.
Calcium carbonate combines with dietary phosphate to form insoluble calcium phosphate, which is excreted in feces. It is marketed in a variety of dosage forms and is relatively inexpensive.
Calcitriol (Rocaltrol, Calcijex, Vectical)
Calcitriol (1,25-dihydroxycholecalciferol or 1,25-dihydroxyvitamin D3), the hormonally active form of vitamin D, is used to suppress parathyroid production and secretion in secondary hyperparathyroidism and for treatment of hypocalcemia in chronic kidney disease by increasing intestinal calcium absorption.
Doxercalciferol (Hectorol)
Doxercalciferol is a vitamin D analog (1-alpha-hydroxyergocalciferol) that does not require activation by the kidneys. It is indicated for the treatment of secondary hyperparathyroidism in end-stage renal disease (ESRD).
Lanthanum carbonate (Fosrenol)
Lanthanum carbonate is a noncalcium, nonaluminum phosphate binder indicated for reduction of high phosphorus levels in patients with end-stage renal disease. It directly binds dietary phosphorus in the upper GI tract, thereby inhibiting phosphorus absorption.
Sevelamer (Renagel, Renvela)
Sevelamer is indicated for the reduction of serum phosphorus levels in patients with end-stage renal disease (ESRD). This agent binds dietary phosphate in the intestine, thus inhibiting its absorption. In patients on hemodialysis, sevelamer treatment results in fewer hypercalcemic episodes than calcium acetate treatment.
Paricalcitol (Zemplar)
Paricalcitol is a synthetic analog of calcitriol that is used for treatment of secondary hyperparathyroidism in ESRD. It reduces parathyroid hormone levels, stimulates calcium and phosphorus absorption, and stimulates bone mineralization.
Hematopoietic Growth Factors
Class Summary
Growth factors are used to treat anemia of chronic kidney disease by stimulating red blood cell (RBC) production.
Epoetin alfa (Epogen, Procrit)
This agent stimulates division and differentiation of committed erythroid progenitor cells. It induces release of reticulocytes from the bone marrow into the blood stream.
Darbepoetin (Aranesp)
Darbepoetin is an erythropoiesis-stimulating protein closely related to erythropoietin, a primary growth factor produced in kidney that stimulates development of erythroid progenitor cells. Its mechanism of action is similar to that of endogenous erythropoietin, which interacts with stem cells to increase red cell production.
Darbepoetin contains 5 N-linked oligosaccharide chains, whereas epoetin alfa contains 3 such chains. Darbepoetin has longer a half-life than epoetin alfa, and may be administered weekly or biweekly.
Peginesatide (Omontys)
Pegylated erythropoiesis-stimulating agent indicated for anemia associated with chronic kidney disease in adults. Administered SC or IV as a once-monthly injection.
Iron Salts
Class Summary
Iron salts are nutritionally essential inorganic substances used to treat anemia.
Ferrous sulfate (Feosol, Fer-In-Sol, Slow FE, Fer-iron, MyKidz Iron 10)
Ferrous sulfate is used as a building block for hemoglobin synthesis in patients with anemia of chronic kidney disease who are being treated with erythropoietin.
Iron dextran (DexFerrum, InFed)
Iron dextran is used to treat microcytic, hypochromic anemia resulting from iron deficiency, and to replenish iron stores in individuals on erythropoietin therapy, when oral administration is infeasible or ineffective. A 0.5-mL (0.25 mL in children) test dose should be administered prior to starting therapy. This agent is available as 50 mg iron/mL (as dextran).
Iron sucrose (Venofer)
Iron sucrose is used to treat iron deficiency (in conjunction with erythropoietin) in patients receiving long-term hemodialysis. Iron deficiency in these patients is caused by blood loss during the dialysis procedure, increased erythropoiesis, and insufficient absorption of iron from the GI tract. There is a lower incidence of anaphylaxis with iron sucrose than with other parenteral iron products.
Ferric gluconate (Ferrlecit, Nulecit)
Ferric gluconate replaces the iron found in hemoglobin, myoglobin, and specific enzyme systems, allowing transportation of oxygen via hemoglobin.
Ferumoxytol (Feraheme)
This agent is indicated for iron replacement in adults with chronic kidney disease who have iron deficiency anemia.
Calcimimetic Agents
Class Summary
These agents reduce parathyroid hormone levels.
Cinacalcet (Sensipar)
Cinalcet directly lowers intact parathyroid hormone (iPTH) levels by increasing the sensitivity to extracellular calcium of calcium-sensing receptors on chief cells of the parathyroid gland. It also results in a concomitant decrease in serum calcium. It is indicated for secondary hyperparathyroidism in patients with chronic kidney disease on dialysis.
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