DIKD Flashcards
What does DIKD stand for?
Drug-induced kidney disease
What are the changes in lab values in DIKD?
Lower GFR
Decreased UO
Increased SCr
Increased BUN
What is normal BUN?
5-20
What is normal SCr?
0.8-1.2
What is normal BUN:SCr ratio?
10-15:1
What is normal UO?
> 500 mL/day
What medications can cause DIKD?
Abx: AG, sulfonamides, PCN, cipro, Levo
Antifungal: Ampho B
Antivirals: Acyclovir, foscarnet, indinivir
OTC: NSAIDs, PPIs, Calcium
Other: ACE/ARB, diuretics, TAC, CsA, Allopurinol, MTX, Celecoxib
What are the risk factors for DIKD?
- Medications that can cause DIKD
- Age > 60
- Critically ill (ICU)
- Dehydration
- High dose of medications
- Multiple medications
- Increase in SCr >/= 0.3 w/in 48 hours; SCr increase >/= 1.5 x baseline w/in 7 days
- UO < 0.5 mL/kg/h for 6 hours - Patient produces < 400-500 mL of urine in a day; check Is & Os in the chart or ask a nurse to begin checking
What should always be monitored in DIKD?
SCr
What drugs are the cause of pre-renal DIKD?
ACE/ARBs
NSAIDs
TAC
CsA
What drugs are the cause of intrinsic ATN DIKD?
AGs
Ampho B
Radiocontrast dye
What drugs are the cause of intrinsic AIN DIKD?
PCN
Cipro/Levo
What drugs are the cause of intrinsic CIN DIKD?
TAC
CsA
What drugs are the cause of postrenal DIKD?
Acyclovir
MTX
Calcium
What happens to GFR when the AA is constricted?
Decreased
What happens to GFR when the AA is dilated?
Increased
What happens to GFR when the EA is constricted?
Increased
What happens to GFR when the EA is dilated?
Decreased
How do ACE/ARB affect the kidney?
Dilate the EA and inhibit constriction of the EA
Decreases perfusion pressure
How do we manage the affects of ACE/ARB on the kidney?
Remove/decrease offending agent
Start or reinitiate at a low dose and titrate up
Supportive care for AKI
A rise greater than ___% in SCr may indicate AKI
30%
How do NSAIDs affect kidney function?
Constrict AA and inhibit prostaglandin-mediated dilation of AA
Decreased perfusion pressure
What is the management of the affect of NSAIDs on the kidney?
Remove offending agent or decrease dose
Patients with a high dose of IBU and AKI should be switched to APAP
Supportive care for AKI
What is NSAIDs cause if not managed properly?
ATN
How do TAC/CsA affect kidney function?
Increase potent vasoconstrictors (TXA2, endothelin, renin) Decrease vasodilators (NO, prostacyclin, prostaglandin E2) Presents w/in days w/HTN and oliguria **Net imbalance of afferent and efferent tone, but more vasoconstriction of AA
What is the management of the affect of TAC/CsA on the kidney?
Dose reduction and/or D/c interacting drugs
Monitor trough levels if SCr and/or BUN increase
Supportive care for AKI
What is supportive care for AKI?
Maintain adequate hemodynamic status
Maintain glucose control
Manage complications
What drugs should not be combined?
TAC/CsA/NSIADs with ACE/ARBs
What does ATN stand for?
Acute tubular necrosis
What is the most common cause of acute injury and failure?
ATN
What are the lab values in ATN?
BUN:SCr = 20:1 Brown urine Granular casts (b/c of dead cells)
How do AGs cause ATN?
Absorbed in proximal tubule, stored in lysosomes
Lysosomes burst and release large amount into rest of nephron -> saturation -> epithelial damage
Presents gradually 5-10 days after initiation
How do we manage the affects of AG in ATN?
D/c or adjust dose/frequency:
- if SCr increases > 0.5 mg/dL
- maintain adequate hydration
How do we prevent the affects of AG in ATN?
Monitor levels
Once daily dosing: except in seriously ill, immunocompromised, and elderly
How does ampho B affect kidney function?
Direct tubular toxicity from interaction with cholesterol
-Ion channels form -> increase permeability -> lipid peroxidation -> necrosis
Renal ischemia - Decreased perfusion intrarenally
Presents with K, Na, and Mg wasting; also non-oliguria -> usually in 1-2 weeks
What is the management of ampho B in ATN?
Consider using other formulations: liposomal, lipid complex, colloidal, dispersion
D/c therapy and use another antifungal
What are preventative measures for ATN when taking ampho B?
Monitor electrolytes daily (order chem 7 and Mg)
Administer 1 L IV NaCl daily during treatment
AND
10-15 mL/kg before each dose
What is the mechanism for ATN when using radiocontrast dye?
Renal ischemia - hypotension and/or vasoconstriction decreases intrarenal perfusion
Direct proximal tubule toxicity
What is the prevention for ATN when using radiocontrast dye?
Use lowest dose possible
Sodium bicarbonate or fluid hydration pre- and post-administration - controversial
What is the management of ATN when using radiocontrast dye?
Supportive care
What is the cause of AIN?
Interstitial tissue and tubules inflame d/t hypersensitivity
What are the drugs that cause AIN?
PCN
Levo/Cipro
What will present in the labs in patients with AIN?
Blood smear will show eosinophils
UA will have eosinophils, WBCs and casts
What is the management of AIN?
Methylprednisolone or prednisone
What drugs cause CIN?
Calcineurin Inhibitors and Lithium
What is the pathophysiology of CIN?
May affect all 3 tubule compartments Results from chronic ischemia from: -Increased endothelin-1 -Decreased Nitric acid -Upregulation of TGF-beta
What intrinsic DIKD is dose dependent?
AIN
What are the etiologies of post-renal AKI?
BPH Nephrolithiasis Pelvic or cervical cancer Bladder cancer Urethral obstruction Neurogenic bladder Precipitation of drugs in a low urine volume with relative insolubility in either alkaline or acidic urine
What drug causes precipitation at phsyiologic urine pH in dehydrated oliguric patients?
Acyclovir
What drugs can cause nephrolithiasis?
Acyclovir
MTX
Calcium
What will we see in a lab analysis of patients with post-renal AKI?
Little proteinuria
Resembles pre-renal but progresses to intrinsic
BUN:SCr >/= 20:1
What is the management of patients with post-renal AKI?
Hydrate patient before administration
Increase fluids if nephrolithiasis
Catheterization or stenting to relieve pain
Pain management
