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33 Cards in this Set

  • Front
  • Back
Drugs that causes Hyperkalemia
Aldosterone antagonist
spirolactone
ACEi
ARB
Renin antagonist: aliskiren
K sparing diuretics
Eplerenone
Which opiate is metabolized to a neurotoxic metabolite that may cause seizures if it accumulates ?
Mependine (demerol)
Which toxicities are associated with high levels of aminoglycosides?
neuromuscular blockade
ototoxicity
Which factors will increase the likelihood that a drug will be removed by hemodialysis?
Hydrophilicity
Low plasma protein binding
Ionized at physiologic pH
acute kidney injury (formerly acute renal failure):
rapid loss of kidney function
hours to weeks
Defined by 50% increase in SCr (> 0.5 g/dL)
chronic kidney disease:
also called chronic renal insufficiency, progressive kidney disease
progressive loss of function
months to years
gradual replacement of normal kidney architecture with interstitial fibrosis
Causes of AKI
Pseudofailure/pseudoinjury
Prerenal azotemia
Acute functional renal failure
Intrinsic acute renal failure
Postrenal
Pseudofailure/pseudoinjury
drugs cause interference with measurement of BUN and/or creatinine (Case I)
Prerenal azotemia
inability to perfuse kidney
OFTEN A PERIOPERATIVE PROBLEM
Acute functional renal failure
altered renal hemodynamics lead to decreased filtration (Case II and III)
Intrinsic acute renal failure
damage to glomerulus, tubules, interstitium
Postrenal
obstruction to outflow
What does Li cause?
DI at LDT, use thiazide for TX
Pseudofailure vs Acute Functional Failure
Pseudofailure – medications increase measurement of BUN or serum creatinine
no harm to kidney
-BUN
Steroids
Tetracyclines
-Creatinine
FYI Cimetidine
Trimethoprim
Cephalosporins in older creatinine assay methods

Acute Functional Failure – alteration of hemodynamics leads to reduction in filtration
ACEI/ARB
NSAIDs
Radiocontrast media
FYI Cyclosporine
FYI Tacrolimus
During Acute functional failure
glomerulus compensate by:
INcrease vasodilation of Aff, due to PG
and constriction of efferent by A2
During Acute functional failure
Adding ACEI or ARB will
Dilate effernt and decrease filtration P. by PGi
During Acute functional failure
adding NSAID/radiocontrast media will
Constrict affernt and dilate efferent
Worst case scenerio
Prevention of Hemodynamically-Mediated Kidney Failure
Recognize high-risk patients

Hydration!

Use analgesics with less PG inhibition (acetaminophen, aspirin, non-acetylated salicylates NOTE: low dose aspirin is unlikely to be problematic!!)

Initiate ACEIs and Ang II blockers at low doses in high-risk patients

Monitor renal function in high-risk patients requiring NSAIDs or ACEIs
ACEI (end in –pril) and ARB (end in –arten)
use
Make sure patient is hydrated at initiation
Consider withholding diuretic until Cr stable
Expect ↑Cr up to 25% initially
In CKD, if acute-on-chronic develops, hold and re-initiate when renal parameters stabilize
In high risk patients – go low go slow
Bilateral renal arterial stenosis, renal vessel dz, prerenal, concomitant NSAIDs
ADE: hyperkalemia; ACEI angioedema, cough
Prerenal = loss of flow
aggressive diuresis, antihypertensives, anesthesia, vasopressors, drugs that induce clots, radiocontrast
Intrinsic damage**
ATN: aminoglycosides, radiocontrast, platinum containing cytotoxics, amphotericin, PPI; ATN is most common, due in part to high O2 demand of tubules!!!
Glomerular damage: NSAIDs, Gold salts, lithium, phenytoin
Tubulointerstitial: phosphates
Allergic nephritis: NSAIDs, penicillins
Chronic interstitial nephritis: analgesics, cyclosporin
Postrenal
Tubule obstruction: methotrexate, statins, sulfonamides, ascorbic acid, indinavir, allopurinol
Aminoglycosides
cause
non-oliguric failure via ATN
Inhibit lysosomal hydrolases, causing phospholipidosis and rupture of lysosome
Aminoglycosides
use
MONITOR TROUGH AND RENAL PARAMETERS
Cr change will not occur for DAYS after damage
Slow recovery may occur
Use lowest dose for shortest possible duration
Pulse-dosing?
HYDRATION!!!!!
NSAIDs
Can cause
acute functional renal failure and/or structural damage
NSAIDs
Risk factors
Renal disease
High renin states
SLE
Concomitant nephrotoxins
ACEI/ARB
NSAIDS
Prevention
AVOID NSAIDs in high risk if possible!!!
Initiate ACEI/ARB with caution
Monitor renal indices in high risk or with other nephrotoxins
Radiographic contrast media
Acute functional renal failure, occasionally with acute tubular necrosis
Radiographic contrast media
Risks
Diabetes
Underlying renal insufficiency (GFR<60ml/min)
Radiographic contrast media
Features
Increase in Scr in 2-5 days, decreased FeNa and UNa, possibly casts in urine
Radiographic contrast media
PREVENTION
HYDRATION
N-acetylcysteine
Bicarbonate?
Use of non-ionic low osmolal agents?
What meds protects from radiographic contrast media
N-acetylcysteine
Nephrolith Etiologies
Calcium oxalate and phosphate
Treat with hydration, thiazide diuretics
Struvite (Mg NH4+ PO4)
Tend to recur; lithotripsy
Urate
Will increase risk: probenecid
Cysteine
Drugs:
Sulfonamides, acyclovir, indinavir, methotrexate, triamterene, vitamin C