Drug-induced AKI

Question 1

Which drugs cause pre-renal DIKD?

Answer 1

-Diuretics (volume depletion, Loops more than Thiazides)
-COX-inhibitors; NSAIDs (afferent vasodilation)
-RAAS inhibitors (ACEi, ARBs): efferent vasoconstriction

Question 2

How to treat pre-renal DIKD?

Answer 2

-too much fluid loss
-discontinue or lower the dose -> risk/benefit in case of compelling indication (if they need ACE/ARB) discontinuing or lowering an ACEi or ARB
-give IV fluid

Question 3

Which drugs cause Acute tubular Necrosis?

Answer 3

-Aminoglycosides
-Amphotericin (antifungal)
-Radiocontrast
-Platinum chemotherapy agents (Cisplatin, Carboplatin)
-Ifosfamide (cancer)

Question 4

How are ATNs treated if they occur?

Answer 4

Pull of the drug that causes it

Question 5

How to prevent Aminoglycoside-induced ATN

Answer 5

Extended-interval dosing, maintaining appropriate trough levels (<2mcg/ml)

Question 6

Prevent Amphotericin-induced ATN

Answer 6

-use the lipid formulation (less nephrotoxic than the deoxycholate formulation)

-sodium-loading: IV 250-500 ml saline pre and post amphotericin bolus

Question 7

Prevent Radiocontrast-induced ATN

Answer 7

-hydration before administration
-hold metformin 48 hours prior to administration
-statins might reduce contrast-induced ATN (research data)

Question 8

Prevent Platin chemotherapy agents- induced ATN

Answer 8

-symptoms: Mg and Ph goes down
-Cisplatin > Carboplatin
-aggressive pre and post-hydration

Question 9

Prevent Ifosfamide-induced ATN

Answer 9

-symptoms: Hemorrhagic cystitis (urinary bladder lining becomes inflamed and bleeds

-give Mesna (cytoprotectant: protects the bladder by binding to Ifosfamide metabolites -> prevents hemorrhagic cystitis)
-pre and post-hydration

Question 10

Types of Intrinsic DIKD

Answer 10

-ATN
-Acute Interstitial Nephritis (AIN)
-Glomerulonephritis

Question 11

Which drugs cause Acute Interstitial Nephritis (AIN)?

Answer 11

-drug hypersensitivity reaction (could be any drug)

-most often:
Antibiotics (ß-lactam, nafcillin)
Sulfonamides (TMP-SMX)
Fluoroquinolones
NSAIDs
PPI

Question 12

How to treat AIN?

Answer 12

-stop the drug, do not rechallenge to give it again (even with same class drugs)

-some patients benefit from steroids

Question 13

Symptoms of AIN

Answer 13

-low-grade fever
-eosinophilia
-hematuria (blood in the urine)

Question 14

How to treat/prevent Glomerulonephritis?

Answer 14

-diuretics
-corticosteroids
-immunosuppressants

Question 15

Signs of Glomerulonephritis

Answer 15

-proteinuria! the kidney cant filter protein
-low-grade fever
-eosinophilia
-hematuria (blood in the urine)

Question 16

What causes post-renal/obstructive DIKD?

Answer 16

precipitation of drugs -> crystals in the ureter causing renal obstruction

Question 17

Which drugs cause post-renal/obstructive DIKD?

Answer 17

-acyclovir
-TMP/SMX

Question 18

How to treat post-renal/obstructive DIKD?

Answer 18

-hydration
-Tamsulosin (stone passage)

Question 19

Which drugs cause Pseudonehprotoxicity?

Answer 19

a drug that inhibits the secretion of creatinine -> higher SCr -> looks like the kidney suffers from damage

-Trimethoprim (TMX part of Bactrim)
-Cimetidine (OTC H2-blocker)
-Steroids -> elevated BUN in the blood (can be a marker for impaired kidneys)

Question 20

What type of kidney injury is caused by Amphotericin?

Answer 20

ATN
-use the lipid formulation
-give sodium bolus

Question 21

Negative Effect of NSAIDs on the kidney

Answer 21

Pre-renal
causes vasoconstriction to the afferent arterioles -> less perfusion

Question 22

Negative Effect of Bactrim on the kidney

Answer 22

-post-renal -> crystallization
-could also be pseudo-nephrotoxic (TMX part of bactrim)

-give fluids or Tamsulosin
-Q: how to know the difference between tmx pseudonephrotoxicity and post-renal damage?

Question 23

Type of kidney injury caused by diuretics

Answer 23

volume depletion - pre-renal
-give IV fluids
-consider dose-lowering or discontinuing the diuretics if possible

Question 24

Negative Effect of ifosfamide on the kidney

Answer 24

ATN
Prevention:
-give Mesna (prevents hemorrhagic cystitis)
-pre and post-hydration

Question 25

Negative Effect of steroids on the kidney

Answer 25

Pseudonephrotoxicity
-can elevate BUN