ESRD, Dialysis and Drug Induced Kidney Injury (TEST 4)

< 15 ml/min/1.73 m^2

What is the GFR for ESRD?

diabetes and HTN

What are the main causes of ESRD?

dialysis

Most people (71%) with ESRD are on ______________.

S/S of ESRD

- Oliguria

- N/V→ uremic toxins

- Loss of appetite

- Sleep disturbance

- Fatigue and weakness→ anemia

- Confusion→

uremia, blood flow changes

- Muscle twitches & cramps→ hypocalcemia

- Frailty/bone break→ hypocalcemia, vitamin D deficiency

- Peripheral edema→ impaired sodium & water retention

- SOB→ sodium and water retention

- HTN→ increased blood volume, sodium concentrations, vasoconstriction, and endothelin-1

- Persistent itching→ high phosphate levels and uremic toxin accumulation

- Uremic pericarditis→ uremia

- Uremic frost→ uremia

- Oligomenorrhea

Creatine Clearance (CrCl)

used as a screening approximation for dose adjustments in patients with renal impairment, using Cockcroft-Gault equation

< 60 mL/min

If a patient is taking gabapentin or pregabalin at what CrCl should we reduce them?

< 50 mL/min

If a patient is taking one of these drugs: edoxaban, rivaroxaban, famotidine, nizatidine, ranitidine, and cimetidine then at what CrCl should they be reduced?

< 30 mL/min

If a patients CrCl is ________ then their dose should be reduced for Ciprofloxacin, TMS, Colchicine, enoxaparin, tramadol IR.

Amiloride, Dabigatran, Spironolactone Triameterene, and Tramadol ER

If a patient's CrCl is < 30 mL/min then what drugs should be avoided?

Apixaban

What drug should be avoided if your CrCL is < 25 mL/min?

TMS, edoxaban, and rivaroxaban

What drugs should be avoided if your CrCL is < 15 mL/min?

Dialysis

a procedure to remove waste products, excess fluid, and electrolytes from the blood/body when the kidneys stop working properly

Hemodialysis

-Form of renal replacement

therapy where blood is filtered

across a semipermeable

membrane to remove waste,

balance fluids, and

electrolytes

-Water, urea, creatinine,

potassium, uremic toxins, and

drugs, move from the blood

into the dialysate by passive

diffusion or convection.

-Use: ESRD, AKI, life-

threatening hyperkalemia,

acidosis, or hypervolemia

Peritoneal Dialysis

- Form of renal replacement

therapy where blood and a

dialysate solution are filtered

across the semipermeable

peritoneal cavity to remove

waste, balance fluids &

electrolytes

- Diffusion and convection

CANNOT be tightly controlled.

- Can alter

dialysate

volume, dwell time,

and number of

exchanges per day for

control

- Relies on peritoneal

membrane for diffusion

ESRD

What is peritoneal dialysis used for?

Continuous renal replacement

- Continuous, slower

venovenous

hemodialysis and/or

hemofiltration

- Use: AKI,

hemodynamically

unstable patients, ICU

Advantages of Hemodialysis

- High solute clearance

- Early detection of under dialysis

- Low technique failure rate

- Hemostasis parameters are better

corrected with HD

- Closer monitoring of patient

- IV route for administration of drugs, such as iron infusions

Disadvantages of Hemodialysis

- Multiple visits each week

- Complications: disequilibrium, dialysis-

induced hypotension, muscle cramps

- Increased risk of infection, thrombosis,

and blood loss

- Decline of residual kidney function is

more rapid

Advantages of Peritoneal Dialysis

- Slow ultrafiltration rate = high hemodynamic

stability = less AE

- Higher clearance of larger solutes

- Better preservation of residual kidney

function

- Convenient intraperitoneal route for

administration of drugs, such as abx and

insulin

- Freedom from machine

- Less blood loss and iron deficiency

Disadvantages of Peritoneal Dialysis

- Patient burnout and technique failure

- High risk of malnutrition

- Risk of peritonitis and tunnel infection

- Inadequate ultrafiltration and solute

clearance in pts w/ large body size

- Mechanical problems—hernias, dialysate

leaks, hemorrhoids, back pain

renal transplanataion

What is the best tx option of ESRD due to its survival benefit compared to long-term dialysis therapy?

Deceases Donor donation

-transplant list

-CKD eligibility for deceased donor is eGFR < 20 mL.min/1.73 m^2

Living Donor donation

-healthy donor with 2 kidneys

-can be done prior to needing dialysis (preemptive transplant)

lower abdomen near bladder in groin

Where is the donated kidney placed?

NSAIDs

reduce blood flow to kidney, increase risk of ATN and glomerularnephritis

Diuretics

increase urine output and lower blood volume, increase risk of AIN

ACEi

dilates efferent arteriole, leading to drop in perfusion pressure

Aminoglycosides

increased risk of ATN

Anti-virals

risk of ATN, crystal formation

Bisphosphonates

Electrolyte imbalances with CKD, crystal formation, and ATN

Calcineurin inhibitors

risk of ATN and AIN

PPIs

significantly increased risk of CKD, ATN, and AIN

Sodium Phosphate Laxatives

electrolyte imbalances with CKD, crystal fomation

Contrast Agents

renal medullary hypoxia, inflammation, and ROS

NSAIDs

Ibuprofen, naproxen, and diclofenac

Diuretics

HCTZ, Furosemide, Spironalactone

ACEi

Benazepril, Lisinopril, and Enalapril

Aminoglycosdies

Gentamicin, Streptomycin, Tobramycin

Anti-virals

Acyclovir, Ganciclovir, Tenofovir, and Foscarnet

Bisphosphonates

Zoledronic acid, alendronate, risedronate

Calcineurin inhibitor

Tacrolimus, cyclosporine

PPIs

Omeprazole, Lansoprazole, Pantoprazole

Prerenal and intrinsic AKI

What type of AKI do NSAIDs and Diuretics affect?

Prerenal AKI

What type of AKI does ACEi affect?

Intrinsic

What type of AKI does Aminoglycosides, Bisphosphonates, Calcineurin inhibitor, PPIs, and Contrast agents affect?

Intrinsic and post-renal

What type of AKI does Anti-virals affect?

Post renal

What type of AKi do Sodium Phosphate Laxatives affect?