r enal f ailure

1. Salman Bin AbdulAziz University College Of Pharmacy renal failure Therapeutics 1 PHCL 416

2. PRERENAL AND FUNCTIONAL ACUTE RENAL FAILURE Congestive Heart Failure and Nonsteroidal Anti-Inflammatory Drug Use

3. Case 1 • A.W. is a 71-year-old white man who had a ST-segment elevation myocardial infarction (STEMI) 2 months ago. His ejection fraction is currently 15% (normal, 50%–60%). • He presents today for his 2-month follow-up clinic appointment complaining of shortness of breath, dyspnea on exertion, and inability to produce much urine.

4. His medical history significant for longstanding hypertension, coronary artery disease, osteoarthritis, and recent-onset heart failure (HF) after his MI. • His home medications furosemide 40 mg every day, enalapril 5 mg daily, metoprolol XL 100 mg daily digoxin 0.125 mg daily, atorvastatin40 mg QD, naproxen sodium 550 mg twice daily (BID), Note :- all of which are taken orally (PO) With the exception of naproxen, A.W. often forgets to take his medications.

5. Physical examination • Reveals lower leg 3+pitting edema • Pulmonary crackles and wheezes, • Positive jugular venous distention • S3 heart sound. • Vital signs • Significant for a blood pressure (BP) of 198/97 mm Hg • Weight gain of 4 kg since his last visit 2 months ago. Last month • BUN and SrCr were 23 (normal, 5–20) and 1.2 mg/Dl (normal, 0.5–1.2),respectively. • [SI units: BUN, 8.2 mmol/L (normal, 1.8–7.1); SrCr, 106 mol/L (normal, 44.2 – 106)}

6. Case 1 • A.W.’s cardiologist obtains a stat digoxin level, electrolyt panel, urinalysis, and urine electrolyte panel. • The digoxin level is reported as “not detectable” (target, 0.5–0.8 ng/mL). • Other significant lab values [SI units: sodium, 140 mmol/L(normal, 135–145); BUN, 20 mmol/L (normal, 1.8–7.1); SrCr, 132.6 mol/L (normal, 44.2–106); urine Cr, 7691 mol/L]

7. .What are A.W.’s risk factors for ARF? • CHF with poor cardiac output (ejection fraction, 15%, meaning very low ) that resulted from his STEMI. • (NSAID), such as naproxen, are often overlooked as causes of ARF. • Indomethacin is associated with the highest risk of NSAIDs-induced renal ischemia, whereas aspirin appears to have the lowest risk. • Sulindac is the safest one used in acute renal failure CHF is a major cause of functional ARF. NSAID ↓ prostaglandin synthesis , compensatory vasodilation↓ renal perfusion .

8. How should A.W.’s prerenalazotemia be treated? Restoring and improving A.W.’s cardiac output and renal perfusion will rapidly correct the prerenalazotemia. This can be achieved by : • Assuring adherence to his heart failure medications (furosemide, enalapril, metoprolol XL, and digoxin) .2 Controlling BP to a goal of <135/85 mm Hg by decreasing both preload and afterload . 3. Modifying any drug therapy that has deleterious effects on the renal hemodynamics (e.g., NSAID). Naproxen should be discontinued and substituted with acetaminophen to treat his osteoarthritis.

9. Angiotensin-Converting Enzyme Inhibitor- and Angiotensin Receptor Blocker-Induced Acute Renal Failure

10. Case 2 • G.B. is a 53-year-old white woman with hypertension, coronary artery disease, peripheral vascular disease, and diabetes • Medication • hydrochlorothiazide 25 mg PO daily • atorvastatin 10 mg PO daily, • aspirin 81 mg PO daily, • NPH insulin 30 U subcutaneously Q morning and 15 U subcutaneously Q evening.

11. At last week’s clinic visit, she had two consecutive BP readings of 187/96 and 193/95 mm Hg, respectively, measured 20 minutes apart. • At that time, G.B.’s primary care physician discontinued her hydrochlorothiazide and started her on lisinopril 5 mg PO daily. • She returns to the clinic today for her 1-week follow-up appointment complaining of dizziness, very little urine production over the past week, and swelling in her ankles. • Her BP is 98/43 mm Hg. A stat serum electrolyte panel is significant for a BUN of 62 mg/dL (normal, 5–20) and an SrCr of 6.1 mg/dL (normal, 0.5–1.2).

12. Why is G.B. experiencing ARF? 2- what the risk factors for this patient?

13. Inhibition of the RAA system in patients with compromised renal blood flow is a common cause of functional ARF. • The administration of ACE inhibitors directly inhibits the formation of AT II, which is necessary for efferent arteriole vasoconstriction.

14. Are there other factors that predispose patients to ACE inhibitor-induced ARF? In addition to the above situation, First, conditions of sodium and water depletion (e.g., dehydration, overdiuresis, poor fluid intake, low-sodium diet) can increase the dependency of the efferent arteriole on AT II. ARF can be averted by withholding theACE inhibitor (or diuretic, or both) for a day and repleting the intravascular fluid volume with a saline-containing fluid (e.g., normal saline or 0.45% saline). Second, ACE inhibitors can decrease the mean arterial pressure to such a degree that renal perfusion cannot be sustained. Finally, ACE inhibitors may precipitate ARF in patients who are taking concomitant drugs with renal afferent arteriole vasoconstricting effects, most notably cyclosporine and NSAIDs.

15. How is ACE inhibitor-induced ARF managed? • Patients who are receiving ACE inhibitors should be monitored judiciously with regard to their serum creatinine and electrolyte concentrations. Once an ACE inhibitor is initiated, an increase in SrCr of 20% to 30% can be expected. • ARF related to ACE inhibitors is usually reversible.

16. Do angiotensin II–receptor blockers (ARB) cause less ARF compared with ACE inhibitors? • TheARBs competitively inhibit the angiotensin II receptor. • At least two subtypes of the angiotensin II receptors exist :AT I and AT II. • Few differences are seen in the incidence of ARF between ACE inhibitors and ARBs

17. INTRINSIC ACUTE RENAL FAILURE Acute Glomerulopathies PoststreptococcalGlomerulonephritis

18. Case 3 B.M. is an 18-year-old male college freshman in otherwise good health who recently developed strep throat. He received a 10-day course of amoxicillin, which cleared the infection. He returns to the student health center after completing his 10-day course complaining of “puffy eyes,” swelling in his legs, a cough productive of clear sputum, and decreased urine output that appears “tea-colored.” Other than the amoxicillin, he is not on any medication

19. .Baseline records from a routine physical examination 2 months ago revealed a serum BUN and creatinine of 10 mg/dL and 0.8 mg/dL (normal, 5–20 and 0.5–1.2), respectively, and a BP of 120/80 mm Hg.

20. Today, the physical examination is significant for a BP of 176/95 mm Hg, 2+ peripheral edema, and bilateral pulmonary rales. The urinalysis is significant for gross hematuria, nephritic-range proteinuria, RBC and WBC casts, and epithelial cells. B.M.’s SrCr has increased to 7.1 mg/dL. Based on the history, physical examination, and laboratory findings [SI units: BUN, 3.6 mmol/L (normal, 1.8–7.1); SrCr, 70.7 and 627.6 mol/L, respectively (normal, 44.2–106)]

21. what is the most likely cause of ARF in this patient?

22. Answer : B.M.’s recent history of a streptococcal infection with the development of ARF suggests poststreptococcalglomerulonephritis(PSGN) The pertinent positive physical findings include periorbital edema , and peripheral edema; tea-colored urine, hypertension, and decreased urine output Pertinent laboratory data in B.M. include elevated SrCr, and urinalysis positive for hematuria, proteinuria, WBC casts, and epithelial cells. Oliguria is common in PSGN but anuria is rare.

23. What are the therapeutic goals and treatment options for PSGN ? The therapeutic goals are to minimize further kidney damage and to provide symptomatic relief for B.M. : should be treated with appropriate antibiotics a. Family infected patient should receive antibiotic prophylaxis members and close contacts of the as well. b. Restriction of protein to 0.8 g/kg/day may be beneficial in patients with marked proteinuria . c. Sodium and water restriction is beneficial in reducing edema, and loop diuretics may be used as needed . d. Dialysis is rarely requied .

24. What drugs cause glomerulonephropathy? NSAID-induced inhibition of the cyclooxygenase pathway, which leads to arachidonate catabolism and proinflammatoryleukotriene production. The hallmark feature of NSAID-induced nephropathy is nephrotic-range proteinuria. The nephropathy resolves slowly over several months once the NSAID is discontinued.

26. (NSAID) • Indomethacin is associated with the highest risk of NSAIDs-induced renal ischemia, whereas aspirin appears to have the lowest risk. • Sulindac is the safest one used in acute renal failure NSAID ↓ prostaglandin synthesis , compensatory vasodilation↓ renal perfusion .

27. INTRINSIC ACUTE RENAL FAILURE Acute Tubular Necrosis Radiocontrast Media–Induced Acute Tubular Necrosis

28. Case 4 K.S., a 74-year-old man, presents to the emergency department complaining of chest pain. he has advanced coronary artery disease and he has been taken to laboratory for a percutaneous coronary intervention. Immediately before the procedure, K.S. is given io-hexol ( contrast) PO to enhance visualization of his cardiac arteries His medical history advanced type 2 diabetes mellitus,with retinopathy , peripheral vascular disease, and advanced coronary artery disease. LABS . His admission BUN is 37 mg/dL (normal, 5–20) and SrCr is 1.5 mg/dL (normal, 0.5–1.2). Two days later, pertinent laboratory findings include a BUN and SrCr of 60 and 2.0 mg/dL, respectively, and his urine output is 700 mL/day.

29. Why did K.S. develop ARF?

30. Answer Radiocontrast media administration is one of the most common causes of drug-induced ATN. It is generally considered when the SrCr increases by >0.5 g/dL over 2 to 5 days. Contrast-induced nephropathy (CIN) usually presents as a non oliguric ATN. The mechanisms by which radio contrast media induce ARF are complex.

31. Initially, the radio contrast medium produces renal vasodilation and an osmotic diuresis. This, however, is followed by intense vasoconstriction in the medullary portion of the kidney, which has been demonstrated by significant (decrease )in medullary Po2 after contrast administration. Consequently, disequilibrium exists between O2 supply and demand creating ischemic ATN.

32. What are the risk factors for CIN*? Others drugs ? Examples? * CIN : Contrast induced necrosis

33. What strategies can be performed to prevent the occurrence of CIN? • Hydration with normal saline, hypotonic saline (0.45% sodium chloride), and sodium bicarbonate in dextrose have all shown benefits in preventing CIN. (Begin 6–12 hours before procedure) • Maintain urine output greater than 150 mL/hour. • Discontinue nephrotoxic agents. Avoid diuretics. • Use low-osmolar or iso-osmolar contrast agents in patients at risk (more expensive).

34. Medications used to prevent contrast-induced nephropathy a) Acetylcysteine—antioxidant and vasodilatory mechanism. Accumulation of glutathione takes time and so may not be as effective in emergency cases. (b) Ascorbic acid—antioxidant. Give ascorbic acid 3 g before procedure and 2 g 2 times/day × two doses after procedure. May have role in emergency cases (c) Theophylline-aminophylline—Avoid. (d) Fenoldopam—Avoid, given the CONTRAST (Controlled Multicenter Trial Evaluating FenoldopamMesylate for the Prevention of Contrast-Induced Nephropathy) trial, which showed no benefit on contrast-induced nephropathy and an increased incidence of hypotension.

35. Aminoglycoside-Induced Acute Tubular Necrosis

36. Case 5 H.H. is a 43-year-old, 80-kg man being treated for gram-negative septic shock. He was admitted to the hospital 6 days ago, but he has spent the last 3 days intubated in the medical respiratory ICU because of hypotension, respiratory failure, and altered mental status. Since admission, H.H. has received ceftriaxone 2 g/day and gentamicin 140 mg IV Q 8 hr.

37. Admission laboratory results were significant for the following: BUN, 13 mg/dL (nor-mal, 5–20); SrCr, 0.9 mg/dL (normal, 0.5–1.2); and WBC count, 23,500 cells/mm3 (normal, 4,000–9,000) with a left shift (90% polymorphonuclear leukocytes [PMN] and 12% bands)

38. Serial blood, urine, and sputum cultures were positive for Acinetobacterbaumanii sensitive to ceftriaxone and gentamicin. In addition to the previously listed antibiotics, his current medication regimen norepinephrine IV 18 mcg/minute ,pancuronium 0.02 mg/kg IV Q 3 hr, famotidine 20 mg IV Q 12 hr, lorazepam IV 2mg/hour

39. Today (hospital day 7) H.H.’s vital signs • temperature, 101.5◦F (38.6◦C); BP, 90/40 mm Hg; pulse,135 beats/minute; and respirations, 20 breaths/minute. Significant laboratory values are as follows: BUN, 67 mg/dL; SrCr, 5.4 mg/dL; and WBC count, 16,700 cells/mm3with continued left shift.

40. Over the last 2 days, H.H.’s urine output has steadily declined, and today it is 700 mL/24 hours (normal, 1,500–2,500). Urine electrolytes were obtained and reveal Na+, 55 mEq/L (normal, 20–40) and creatinine, 26 mg/dL (normal, 50–100). A urinalysisrevealed many WBC (normal, 0–5), 3% RBC casts (normal, 0%–1%), brush-border cells (normal, negative), and granular casts (normal, negative) with an osmolality of 250 mOsm/kg(normal, 400–600). Serum gentamicinconcentrations obtained with the last dose reveal a peak of 15 mg/dL (target, 6–10) and atrough of 9.1 mg/dL (target,<2.0).

41. what is the likely source of H.H.’s ARF?

42. Answer : • The source of ARF multifactorial(Table 30-1). • First, H.H. is experiencing diminished renal perfusion from profound hypotension and septic shock. • As a result, he is receiving high-dose norepinephrine, a potent vasopressor. Consequently, the combination of these variables reduces renal perfusion further, resulting in prolonged renal ischemia.

43. received 1 week of gentamicin a well-known nephrotoxic antibiotic The risk factors for developing aminoglycoside nephrotoxicity are listed 9.1 mg/L is so high ( target the target value of <2 mg/L ) Second, .Table 30-5. The latest gentamicin trough concentration (traditional dosing 3 times daily) .Given the laboratory data (Table30-2) and the clinical course of prolonged hypotension, vasopressor, and aminoglycoside administration, nonoliguric ATN is the most likely diagnosis.

45. MCQ • Drugs that increases Aminoglycosides toxicity includes the following ? • Cyclosporine • amphotericin B • Diuretics • Vancomycin • All of the Above

46. The rational approach to aminoglycosidenephrotoxicity is : 1- use the less nephrotoxicaminoglycosideamikacin then tobramycin then gentamicin . 2- therapy is less than 3 days . 3- using once daily dose . 4- serum tough < 2 mg /L. 4- Between each aminoglycoside therapy and another therapy is at least 3 months.

47. How does aminoglycoside-induced ATN present, and what are the mechanisms of toxicity? H.H. illustrates the typical presentation of aminoglycoside-induced nephrotoxicity. Generally, the onset occurs after 5 to 7 days of treatment and presents as a hypo-osmolar, nonoliguric renal failure with a slow rise in SrCr. Because of the tubular necrosis that occurs, the urinalysis is often positive for low-molecular-weight proteins, tubular cellular casts, epithelial cells, WBC, and brush-border cells.

48. The mechanism of aminoglycoside-induced ATN is complex. Approximately 5% of filteredaminoglycoside is actively reabsorbed by the proximal tubule cells. These agents are poly cationic and bind to the negatively charged brush-border cells within the tubule lumen. Once attached, these agents undergo pinocytosisand enter the intracellular space, setting off complex biochemical events that result in the formation of myeloid bodies. With continued formation of myeloid bodies, the brush-border cells swell and burst, releasing large concentrations of aminoglycoside and lysosomal enzymes into the tubule lumen, which cause tubular destruction. The following rank order of nephrotoxicity has been collated from human and animal data: neomycin > gentamicin = tobramycin = amikacin = netilmicin > streptomycin.

50. Extended-Interval Dosing