CHF & CKD

Staging

100

Common laboratory makers of CKD

1. BUN

2. SCr

3. eGFR

4. Albumin in urine/proteinuria

200

Definition of Heart failure

heart is not able to supply sufficent oxygen rich blood to the body due to impaired ability of the left ventricle to either fill with or eject blood

300

EF Staging

Ejection Fraction

55-70% Normal

> 50% Preserved (HFpEF)

41-49% mildy reduced (HFmrEF)

< 40% reduced (HErEF)

400

Signs and Symptoms of HF

Labs

- increased BNP, increased NT-proBNP

Left sided signs and symptoms

- orthopnea, paroxysmal noctornal dyspnea, bibasilar rales, S3 gallop, Hypoperfusion

Right sided s/s

- peripheral edema, ascites, JVD, hepatomegaly

General

- Dyspnea, cough, fatigue, weakness, reduced exersice capability

500

Patient JB is a 32M with PMH of drug abuse that caused CKD. He comes to the ED complaining of trouble breathing and is diagnosed with CAP. What stage CKD would he be classified as?
eGFR = 36

Albuminuria = 222 mg/g

G3B A2

CHF General

100

Cardiac Output (CO) equation

CO = HR x Stroke Volume (SV)

200

Natural products for HF and how would you know what product to recommend

1. Omega-3 fatty acids

2. Coenzyme Q10

3. Hawthorn (avoid with digoxin)

ONLY PRODUCTS WITH SOME EVIDENCE!

Natural products data based, research based evidence, USP certification

300

Two MAIN types of Heart Failure causes

1. Ischemic - decreased blood supply to the heart (Ex: MI)

2. Non-ischemic - long standing uncontrolled HTN (most common)

Others:

Valvular disases, excessive alcohol, illicit drug use, congenital heart defects, viral infctions, diabetes, cardiotoxic drugs, chest radiation

400

Lifestyle managment for HF patients

1. avoid excessive sodium intake <1,500mg/day

2. restrict fluids 

3. stop smoking/drinking/drug use

4. Vaccines

5. Reduce weight

6. Exercise

500

What is the body's four compensatory mechanisims of HF

1. Increased SNS activity

2. Increased RAAS 

3. Increased ADH

4. Increased naturietic peptides

CKD General

100

What should be the pharmacists first action for any patient with renal disease?

Assess for nephrotoxicity risks

200

Cockcroft Gault equation

CrCl = [ ( 140-age) x weight ] / ( 72 x SCr) x 0.85 if female

300

Final Modality of therapy for CKD

Dialysis

400

KDIGO recommendation of SBP in patient with HTN and CKD?

SPB < 120

Less than ACC/AHA for general population

500

Common complications of CKD

1. Mineral and Bone Disorder

2. Hyperphosphatemia

3. Anemia

4. Vitamin D Deficiency

5. Secondary Hyperparathyroidism

6. Hyperkalemia/Metabolic Acidosis

CHF medications

100

Four Pillars of GDMT and which have mortality benefit

1. ARNI/ ACE/ ARB

2. BB

3. Aldosterone receptor antagonist

4. SGLT2i

All have benefit in mortality

200

What beta-blockers are used for heart failure and what is an important counseling notes for patients?

Metoprolol succinate ER, Bioprolol, Carvedilol 

Take with meals (helps prevent orthostatic hypotension and absorption)

Do not abruptly discontinue (to avoid tachy/hypotension or ischemia)

300

Sacubitril/Valsartan warnings

Angioedema

Hyperkalmia

Renal impairment

Pregnancy

400

Drugs that can cause or worsen HF

DI NATION

DDP-4i

Immunosuppressants

Non-DHP CCBs

Antiarrhythmics

Thiazolidineiones

Itraconazole

Oncology

NSAIDs

500

When would we add hydralazine and/or nitrate on a heart failure regimen?

For a self-identified african american patient with class III-IV HF that have optimized other treatments and still have symptoms

CKD medications

100

4 Pillars of CKD GDMT

• RAS Inhibitors (ACEi/ARB): Recommended as first-line therapy to lower blood pressure and reduce proteinuria, particularly for patients with albuminuria. Doses should be maximized to the highest tolerated levels. 
• SGLT2 Inhibitors: Proven to slow CKD progression, reduce cardiovascular risks, and lower heart failure hospitalizations. Current guidelines recommend starting these for appropriate patients regardless of diabetes status. 
• Non-steroidal MRAs (ns-MRA): Medications like finerenone provide potent kidney and heart protection by reducing inflammation and fibrosis, and they are especially beneficial in patients with diabetic kidney disease.
• GLP-1 Receptor Agonists: Highly recommended for patients with concurrent Type 2 Diabetes and CKD for metabolic control, weight loss, and cardiovascular risk reduction.

200

Contraindicated drugs in CKD

CrCl < 60: Nitrofurnatoin

CrCL < 50: TDF, Voriconazole IV

CrCL < 30: TAF, NSAIDs, Dabigatran (PE/DVT indication)eGFR < 30: Metformin

Others: Meperidine, Bisphosphonates, Duloextine, Fondaparinux, Tadalafil, Tramadol, SOtalol, ect.

Nephrotoxic: Aminoglycosides, Amphotericin B, Cisplatin, Loop diuretics, Vancomycin, Tacrolimus, Polymyxins, Pressors, etc. 

300

Steps for treating severe hyperkalemia

1. Stabilize Heart = Calcium gluconate

2. Shift K intracellulary 

    a. Regular insulin + dextrose

    b. sodium bica

    c. albuterol

3. Remove K

    a. loop diuretics

    b. sodium polysrene sulfonate (SPS)

    c. Patiromer (K-bind)

    d. Sodium zirconum cyclosilcate (SZC)

    e. Hemodialysis

400

What is expected in a patient after starting an ACEi or ARB that should be relayed to patient/MD?

SCr can increase up to 30% and treatment should not be stopped, 

However, if increase is greater than 30% stop treatment

500

Name some drugs in regards to renal disease that work at each part of the nephron

1. DCT

2. PCT

3. Loop of Henle (Ascending)

4. Collecting duct

1. DCT = Thiazide diuretics & Potassium-sparing diuretics

2. PCT = SGLT2i

3. Loop of Henle (Ascending) = Loop diuretics

4. Collecting duct =  Potassium-sparing diuretics