Drugs and the Kidney

Question

Select all limitations for using CrCl to assess renal function.

Answer 1

Creatinine is a metabolic by-product of muscle so elderly or cachectic patients may have falsely low CrCl estimates, due to high SCr.

Answer 2

It's unreliable in rapidly changing patients.

Answer 3

10-15% of creatinine is eliminated by active tubular secretion so it overestimates GFR, especially in patients with reduced renal functioning.

Answer 4

Creatinine clearance is difficult to measure so instead we use serum phosphorous levels as the gold standard for estimating GFR.

Answer 5

Give PO or PR cationic exchange resins to increase GI excretion of K.

Answer 6

Give an insulin and glucose infusion, which is highly effective and rapid.

Answer 7

Give sodium bicarbonate if the patient is acidotic.

Answer 8

Give fluid boluses stat.

Answer 9

Give packed RBCs and plasma expanders.

Answer 10

ACE inhibitors (ACEI) and/or angiotensin receptor blockers (ARB)

Answer 11

Synthetic erythropoeitin

Answer 12

Serum albumin

Answer 13

Serum creatinine

Answer 14

Because fat soluble vitamins can accumulate and cause toxicity.

Answer 15

Because they can't digest or absorb supplemental vitamins via PO route due to GI problems associated with CKD (e.g. PUD, gastroparesis).

Answer 16

Because they will cause CKD patients to experience a metallic taste in their mouth.

Answer 17

Because patients with CKD don't need supplemental B complex, C, or folic acid, which are common ingredients in OTC multivitamins.

Answer 18

"I'm glad to hear that the antacids are working for you. If you would like to discuss taking a prescription for your ulcers, I can mention it to the physician."

Answer 19

"Make sure to stay hydrated and drink lots of water when you are taking chewable antacids."

Answer 20

"Due to your kidney disease, there is a risk that you might accumulate toxic levels of magnesium in your body due to the antacids."

Answer 21

"If you are taking antacids, you should also be taking supplemental vitamin D and calcium."

Answer 22

Withhold diuretics and other antihypertensives until post-dialysis.

Answer 23

Give the patient packed RBCs and plasma expanders prophylactically if they have experienced hypotension due to hemodialysis in the past.

Answer 24

There is nothing you can do to prevent hypotension. Monitor the patient closing during and after dialysis.

Answer 25

Hypotension is very normal after hemodialysis. No interventions are required.

Answer 26

Diuretics should be used cautiously to avoid volume depletion.

Answer 27

Diuretics should be used in all patients with CKD to prevent edema.

Answer 28

Loop diuretics (e.g. Lasix or furosemide) are no longer effective when CrCl is less than 25 ml/minute.

Answer 29

if a patient is on diuretics, the dose should be increased prior to hemodialysis.

Answer 30

Reduction in renal production of EPO in response to tissue hypoxia and/or iron deficiency

Answer 31

Internal bleeding due to concurrent peptic ulcer disease

Answer 32

Bone marrow dysfunction

Answer 33

Peptic ulcer disease

Answer 34

Hypertension

Answer 35

Hyperlipidemia

Answer 36

Increases release of reticulocytes from bone marrow, causing a rise in serum Hgb

Answer 37

Increases the iron stores in the body, thus reducing the need for patients to take supplemental iron

Answer 38

Decreases hemolysis

Answer 39

Repairs bone marrow that can no longer release adequate reticulocytes

Answer 40

The main side effect of erythropoiesis stimulating agents (ESAs) is hypertension. Patients may need a 30% increase in their dose of antihypertensive medication.

Answer 41

Oral iron supplementation is the safest, most effective, and most cost efficient form of supplementation.

Answer 42

Iron supplementation is most effective when delivered via IV and iron dextran is the preferred product.

Answer 43

Erythropoiesis stimulating agents (ESAs) can be given regardless of the patient's iron stores.

Answer 44

Nausea/vomiting, heartburn, bloating, and constipation

Answer 45

Nausea/vomiting, heartburn, bleeding, and constipation

Answer 46

Pruritus, abdominal distension, and difficulty concentrating

Answer 47

Bad breath, anorexia, constipation, and GI bleeding

Answer 48

Elevated P leads to a drop in Ca. Low Ca stimulates PTH secretion, which mobilizes Ca from bone, leading to bone disease.

Answer 49

Low P leads to a drop in Ca. Low Ca stimulates PTH secretion, which further damages kidneys, leading to even lower Ca because of decreased activation of vitamin D.

Answer 50

High PTH secretion leads to decreased activation of vitamin D, which leads to low levels of Ca. Low Ca leads to elevated P.

Answer 51

Peptic ulcer disease, common in CKD patients, leads to low absorption of Ca in gut. Low Ca stimulates PTH secretion, which mobilizes Ca from bone, leading to bone disease. High PTH also leads to elevated P.

Answer 52

Dialysis to remove excess P from the blood

Answer 53

Dietary restrictions of high P-containing foods, such as dairy, chocolate, beer, meat, and cola

Answer 54

Supplementation of vitamin B complexes and vitamin D, which decrease levels of P in blood

Answer 55

Subtotal or total parathyroidectomy

Answer 56

Calcium carbonate (e.g. Tums) should not be given to patients with CKD because there is a high risk of the patient developing hypercalcemia

Answer 57

Calcium carbonate (e.g. Tums) is a cheap and effective treatment that is only effective when given with meals

Answer 58

Sevelamer (Renagel) is used when patients cannot tolerate Ca because it increases fecal elimination of both calcium and phosphorus

Answer 59

Sevelamer (Renagel) is most effective when used in combination with calcium carbonate (Tums) to treat hyperphosphatemia

Answer 60

Ask Mr. Jones if he usually experiences stiffness in the morning and whether or not it lasts for less or more than 30 minutes.

Answer 61

Offer Mr. Jones an aspirin to relieve his joint pain. Reassess his pain in 20 minutes.

Answer 62

Offer Mr. Jones hot packs to place on his sore joints. Reassess his pain in 20 minutes.

Answer 63

Encourage Mr. Jones to take a short walk down the hallway and back to ease up his stiff joints.

Answer 64

Drug dosing adjustments are based on CrCl

Answer 65

All lab results are taken into consideration when determining drug dosing adjustments

Answer 66

Common drugs that do not need to be adjusted are antibiotics, antihypertensives, and hypoglycemic agents because they are not renally eliminated

Answer 67

Recent exposure to vancomycin or aminoglycoside decrease susceptibility for drug-induced nephrotoxicity

Answer 68

It is an enzyme that converts arachadonic acid into various forms of prostaglandin

Answer 69

It is an enzyme that activates various forms of prostaglandins

Answer 70

It is an enzyme that is vital for absorption of fat-soluble vitamins in the gut

Answer 71

It is a serum protein that plays a crucial role in the coagulation cascade

Answer 72

COX-1 is constitutive, meaning it's found in almost all tissues. COX-2 is inducible, meaning it is not there all the time (it's mostly found at sites of tissue injury).

Answer 73

COX-1 is the "bad" COX. COX-2 is the "good" COX.

Answer 74

COX-2 is "bad" because it promotes vasoconstriction, which can lead to further renal dysfunction.

Answer 75

COX-1 is inducible, meaning it is not there all the time (it's mostly found at sites of tissue injury). COX-2 is constitutive, meaning it's found in almost all tissues.

Answer 76

It is an enzyme that converts arachadonic acid into various forms of prostaglandin.

Answer 77

It is an enzyme that converts various forms of prostaglandin into arachadonic acid.

Answer 78

It is an enzyme that is inducible, meaning it is found mostly at sites of tissue injury.

Answer 79

It is an enzyme that is constitutive, meaning it is found in almost all tissues.

Answer 80

Promotes synthesis of TXA2, which stimulates platelet aggregation

Answer 81

Mediates fever and contributes to perception of pain

Answer 82

Bronchial smooth muscle is constricted by various prostaglandins, which are derived from COX

Answer 83

COX-derived prostaglandins relax the walls of the uterus to prevent contractions during pregnancy

Answer 84

COX catalyzes synthesis of prostaglandins that protect gastric mucosa by decreasing secretion of gastric acid and increasing secretion of bicarb and cytoprotective mucous.

Answer 85

COX catalyzes synthesis of prostaglandins that promote vasodilation and maintain renal blood flow

Answer 86

"You should not give your child Aspirin but you can give her Tylenol instead because it is safe for use in children."

Answer 87

"You should make sure to keep your daughter well hydrated and monitor the fever."

Answer 88

"You should make sure that you do not exceed the maximum daily dose."

Answer 89

"You should get your child to the hospital right away."

Answer 90

Sodium bicarbonate

Answer 91

Hemodialysis

Answer 92

IV insulin and glucose

Answer 93

Acetaminophen is metabolized via two pathways. The product from the major pathway is a nontoxic metabolite. The minor pathway requires glutathione to convert the toxic metabolite to a nontoxic metabolite. Alcohol depletes glutathione. Therefore, you should not take Tylenol in combination with alcohol.

Answer 94

Acetaminophen is metabolized via two pathways. The product from the minor pathway is a nontoxic metabolite. The major pathway requires glutathione to convert the toxic metabolite to a nontoxic metabolite. Alcohol depletes glutathione. Therefore, you should not take Tylenol in combination with alcohol.

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Drugs and the Kidney

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