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107 Cards in this Set

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What drugs can cause Prerenal Azotemia?
Vasopressors:
->Phenylephrine, NE
What clinical disorders can cause decreases circ volume and lead to prerenal azotemia?
Cirrhosis w/ ascites
CHF
What drugs can cause Functional ARF?
Aff. artery constrictrs:
---> NSAIDs & Cyclosporine
Eff. Artery Dilatrs:
---> ACEIs & ARBs
Calcium if leads to Hypercalcemia
What is fxnl ARF?
Decr perfusion of glomerulus due to aff artery constrictn or eff artery dilation
What drugs can cause Acute Tubular Necrosis (a type of Intrinsic ARF)?
Contrast media
Aminoglycosides
Ampho. B
What drugs can cause Acute interstitial nephritis (a type of Intrinsic ARF)?
PCN
Cipro
Sulfonamides
Is blockage of 1 kidney postrenally constitute Postrenal ARF?
NO
Must block BOTH by definition
What med cndtns can cx Postrenal ARF?
Bladder obstruction (ie BPH)
Ureter Obstruction
What meds can cx crystal deposits that can lead to Ureter Obstruction?
Oxalate
Indinavir
Sulonamides
Acyclovir
Signs of ARF?
Edema
Foamy/colored urine
Orthostatic HypoTN if volume depleted
Type of ARF assoc w/:
Increase in urination?
Intrinsic ARF
(Tubular can't concentrate urine)
Type of ARF assoc w/:
Decrease in force of urinary stream?
Postreal ARF
(obstruction, BPH)
Type of ARF assoc w/:
Cola-colored urine?
Intrinsic ARF
(glomulonephritis - blood in urine)
Type of ARF assoc w/:
Exc urine foaming?
Intrinsic ARF
(Glomuler - hi protein in urine)
Type of ARF assoc w/:
Bilateral flank pain?
Intrinsic ARF
(Glom or interstitium - swollen kidneys)
Type of ARF assoc w/:
Onset of weight gain?
All of the ARFs
Hearing rales indicates what?
Pulmonary congestion or Lft Ventr dsfx->
prerenal ARF w/ NO azotemia
What meds will cause seizures if not appropriately adjusted to ARF cndtns?
B-Lactam ABX
Imipenem
H2 Blockers
What is the rate of NS infusion to rehydrate an ARF pt?
1-2ml/kg/hr
What class of drug is most commonly admin to pts b4 a kidney transplant to prevent nephrotox?
CCB
Inhibits aff artery vasoconstriction
What is most commonly given to pts, prior to Amph B or Contrast dye, to prevent Neprhotox?
NS
(Sodium loading activates regulatory mxm to Decr RBF)
Do these have evidence of nephrotoxicity PREVENTION?
Mannitol
Loops
Dopamine
NO!
Should you give fluids in Oliguric ATN?
NO!
Should you give fluids in Oliguric Prerenal Azotemia?
YES!
If pt has ARF & severe GI loss, plasma loss or mild hemorrhage, what type of fluid s/b given?
NS or LR
If pt has ARF & increased urination or GI losses what fluid s/b given?
1/2 NS
(Hypovolemic solutions)
What are the 2 first line diuretics used in the tx of fluid overload?
Mannitol
Loops
What have I learned the most from Pharmacy school?
How to type quickly
How is DA used in ARF?
In ICU only, contriversially.
Low doses (0.5-2mcg/ml/min) increase urine but don't improve pt outcome
Tx for Acute interstitial nephritis die to meds?
Stops offending meds, steroids
Tx for Acute tubular necrosis due to meds?
Stop meds, give NS
What are the pt specific monitoring parameters for ARF?
Weight
Vital signs
Fluid intake & output
Review meds & adjust doses accord. to CrCl
Chem-7
CBC
What triggers Renin?
Low blood volume
Low sodium
What effects does Renin have?
Increases BP by vasoconstriction
Causes release of ADH & Aldosterone which Incr thirst & blood volume
How does Bradykinin affect Sodium reabsorption?
It inhibits it at the CD
The presence of XXX in a urinalysis is considered a principal marker for kidney damage
protein or albumin
Abnormal pH, nitrites, or luekocytes esterase in a UA is indicative of what?
Bacterial infx
High BUN implies what?
Kidneys not filtering Urea as they should
Rise in SCr implies what?
a decline in GFR
Also reliant on pts muscle mass (so don't use as only marker)
What 3 meds can alter CrCl?
Trimethoprim
Cimetidine
Probenecid
Disadvantages of mannitol for ARF?
Parenteral only
No renal clearance->may cx edema in oliguric pt
Disadvantages of loop in ARF?
Myalgia
Hearing loss
Ortho HypoTN
Hypo electrolytes
Metab. Alkalosis
What is better admin of loops for ARF: continuous or intermittent?
Continuous
b/c more natriuresis & lower [ ]s
What is most common loop used?
Dosage forms avail?
Furosemide
Oral & parenteral
Symptoms of late stage CKD?
Hand tremor/jerks
Pruritis
Taste Impairment
N/V
Anorexia
Encephalopathy
Bleeding
Symptoms of early stage CKD?
None- early stage CKD is asymptomatic!
How many stages of kidney disease?
5, 1 best 5 worst
What electrolytes are important to monitor for renal fx?
Na
K
HCO3
Cl
What 2 urinary enzymes are early predictors of rejection in kidney transplant pts?
NAG
AAP
Does evidence back the use of the MDRD to estimate GFR?
Yes, but only the version w/ 4 variables & ONLY in CKD pts
Does evidence back the use of Cockroft-Gault eq to estimate GFR?
YES
This measures inulin clearance
Do we NTK the Cockroft-Gault eq for the exam?
Not sure....
Define ARF in terms of SCr
Incr of 0.5 mg/dL from normal
Incr >1mg/dL in pts w/ CKD
What is urine output in:
Anuria?
Oliguria?
Nonoliguria?
Anuria: <50ml/day
Oliguria: 50-450ml/day
Nonoliguria: >450ml/day
List 4 chronic med cndtns assoc w/ development of kidney disease
Poorly controlled HTN
Diabetes
CHF
Liver failure
The presence of RBCs & RBC casts in UA indicate what?
Glomerular injury
How is kidney disease reflected in FE of Na %
FE-Na% increases as Kidney disease worsens
FE of Na% >2 indicated which type of ARF?
Intrinsic ARF
What agents have evidence of preventing hephrotoxicity when administered b4 contrast dye?
NS
Theophylline
Acetylcysteine
What agent has evidence of preventing nephrotoxicity in critically ill patients?
Insulin
- enough to maintain serum glucose of 80-110 mg/dL
What are the clinical indication for RRT (renal replacement therapy)?
A Acid base abnormality
E Electrolyte Imbalance
I Intoxications; ie salicylates, theophylline, phenobarb
O fluid Overload
U Uremia (waste products in blood)
What is RRT?
Renal replacement therapy refers to life-supporting treatments for renal failure, including:

hemodialysis
peritoneal dialysis
hemofiltration
renal transplantation
Which drugs show evidence of improved clinical outcome & Decr mortality in ARF?
NONE!
What is the tx in fluid overloaded non-oliguric pt w/ ARF?
What is the goal of this tx?
Loop diuretic
Prevention of pulmonary edema is an important goal
Which loop diuretic is used for ARF pts w/ a sulfa allergy?
Ethacrynic acid
If aggressive tx w/ one loop doesn't help pt w/ ARF, should you try another?
NO all are equipotent
If cirrhosis is causing diuretic resistance, how tx?
High-volume paracentesis
If pt has ATN in ICU & has developed diuretic resistance, how do you tx?
Higher dose of diuretic
Diuretic combo therapy
Add low-dose Dopamine
What is the most common physiological finding in ARF?
Which Pharmacokinteic aspect can it influence?
How would it affect drug dosing?
Edema
Influences Vd
Would need a higher dose but pts recieving CRRT will have excess fluid removed!
Normal range for: Calcium
8.5-10.5 mg/dL
Normal range for: Potassium
3.5-5 mEq/L
Normal range for: Chloride
92-109 mEq/L
Normal range for: Bicarb
24-31 mEq/L
Normal range for: Phosphorus
2.5-4.5 mg/dL
If pt w/ Renal Failure has UA, what type of RF does the presence of casts point to? If there are no casts?
Casts-->kidney injury/ATN
No casts-->prerenal azotemia ARF or functional ARF
What are the OBJECTIVE differences b/w prerenal azotemia & ATN?
Presence of casts
FE-Na% is different
Is Heart failure a risk factor for ARF?
No, it could potentiate it, but is not a risk factor! *
What is the most common type of community-acquired renal failure?
Prerenal azotemia
Is there any way I am going to pass this exam?
Only if miracles happen!
What type of ARF is most commony caused by medications?
Acute interstitial nephritis
Examples of aminoglycosides (which can cause ATN) are:
Gentamycin
Tobramycin
Amikacin
How do diltiazem & verapamil affect renal blood flow?
What class are they?
They decrease it by dilating the efferent arteriole
CCB
When should Mannitol NOT be used for ARF?
When pt does not have good urine output
Whys loop used in ARF pts?
for symptomatic control only, no improvement in recovery.
Examples of aminoglycosides (which can cause ATN) are:
Gentamycin
Tobramycin
Amikacin
How do diltiazem & verapamil affect renal blood flow?
What class are they?
They decrease it by dilating the efferent arteriole
CCB
When should Mannitol NOT be used for ARF?
When pt does not have good urine output
Whys loop used in ARF pts?
for symptomatic control only, no improvement in recovery.
What is the target BP for people w/ Stage 1-4 chronic renal dysfunction?*
130/80
What is the target BP for pts w/ ESRD?*
150/90
What is a treatment option for anemic pts with CKF?*
Epoetin Alpha (Epogen or preferrably Procrit)
80-120U/kg/wk SC (preferred)in divided doses
or
Darbopoetin alpha (Aranesp)
AND
Iron supplementation, even if pt doesn't have low iron
What is a possible ADR with erythropeitic agents?
HTN
What oral iron supplements are avail & what are dosages/freq?* (Note want 200mg elemental iron daily)
Ferrous sulfate: 50-75mg B-QID
Ferrous fumarate: 20-115mg 2-10x/d
Ferrous gluconate: 27-36mg Q4H
Polysaccharide ion: 50-150 QD-QID
Heme Iron polypeptide: 12mg 17x/d
What causes Renal Osteodystrophy if untreated?*
CKD
What is the Primary CAUSE of CKD?
Diabetes
What is the primary cause of DEATH in pts w/ CKD?
Heart Attack
What is the eq for Corrected Calcium?
Ca(corr)=Measured total Ca + [(4.0-pt albumin)x0.8)
Which 3 types of drugs interfere w/ absorption of iron?
PPIs
H2As
Antacids
Fluoroquinolone absorption is interfered with by what?
Iron
Calcium-containing Phosphate Binders decrease absorpt of which agents?
Iron
Fluoroquinolone Abx
Zinc
If pt has hyperPTH & hypercalcemia, how do you treat it?
cincalcet (Sensipar)
This is a calcimimetic that decr circ calcium
What is an ADR of a calcimimetic?
N/V
T or F: Food increases the absorption of cincalcet
TRUE
What are tx options for uremic bleeding?
What are each meds MofA?
Cryoprecipitate-> includes clotting factor
Desmopressin->mimics ADH (incr water resorpt) & incr Factor VIII release (Improves clotting)
Estrogen- Decr NO & eventually increases clotting
sevelamer (Renagel): What is:
Indication, MofA?
Administration/Dosing/Freq?
ADRs?
Indication/MoA: Hyperphosphatemia/Binds phosphate to decr absorptn
Admin/Dos/Freq: 400/800mg tabs, take w/ meals
level of 5.5-7.5=800mg TID w/ meals
7.5+ = 1600mgTID
ADRs=N/V/D & assoc sxs
Is it physically impossible to learn all this?
ABSOLUTELY!
What causes the damage in a hyperacute infxn after a transplant?
Complement being activated
Hyperacute is Cytotoxic Tcell mediated