Drugs and the Kidney

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

Insulin

Dialysis

Synthetic erythropoeitin

Serum albumin

Serum creatinine

BUN

WBC

Because fat soluble vitamins can accumulate and cause toxicity.

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

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

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

"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."

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

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

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

Withhold diuretics and other antihypertensives until post-dialysis.

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

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

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

Diuretics should be used cautiously to avoid volume depletion.

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

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

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

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

Internal bleeding due to concurrent peptic ulcer disease

Bone marrow dysfunction

Hemolysis

Anemia

Peptic ulcer disease

Hypertension

Hyperlipidemia

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

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

Decreases hemolysis

Repairs bone marrow that can no longer release adequate reticulocytes

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

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

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

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

Nausea/vomiting, heartburn, bloating, and constipation

Nausea/vomiting, heartburn, bleeding, and constipation

Pruritus, abdominal distension, and difficulty concentrating

Bad breath, anorexia, constipation, and GI bleeding

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

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.

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

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.

Dialysis to remove excess P from the blood

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

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

Subtotal or total parathyroidectomy

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

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

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

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

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

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

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

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

Drug dosing adjustments are based on CrCl

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

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

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

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

It is an enzyme that activates various forms of prostaglandins

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

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

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).

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

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

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.

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

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

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

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

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

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

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

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

Sodium bicarbonate

IV fluids

Hemodialysis

IV insulin and glucose

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.

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.