Drug - Induced KD

Question 1

What drugs cause Hemodynamic Renal Injury

Answer 1

NSAIDs
SGLT2 inhibitors
ACE inhibitors/ARBs
Calcineurin inhibitors

Question 1

What drugs cause Pre-Renal injury?

Answer 1

Diuretics

Question 2

What injuries happen to the kidney intrinsically?

Answer 2

Glomerulonephritis
Acute Tubular Necrosis
Acute Interstitial Nephritis
Vasculitis

Question 3

What drugs can cause Glomerulonephritis?

Answer 3

Gold
Allopurinol

Question 4

What drugs can cause Acute Tubular Necrosis?

Answer 4

IV Contrast Media
Amphotericin B
Aminiglycosides

Question 5

What drugs can cause Acute Interstitial Nephritis?

Answer 5

Peniciilin
NSAIDs
PPIs
Sulfa drugs

Question 6

What drugs can cause Vasculitis?

Answer 6

PTU
Allopurinol
Levamisole(coke)
Phenytoin

Question 7

What is a Post-Renal injury?

Answer 7

Nephrolithiasis
Rhabdomyolysis
Lithium-Induced CKD

Question 8

What drugs can cause Post-Renal Nephrolithiasis?

Answer 8

*Topiramate
*Sulfonamides
*Furosemide
Allopurinol
Acyclovir

Question 9

What are risks factors for Drug - induced Kidney Disease?

Answer 9

Age > 65
CKD
Concomitant nephrotoxins
Known allergy
Duration of Therapy
Diabetes
HTN
Renin dependent state (eg HF, cirrhosis)

Question 10

How do you prevent DIKD?

Answer 10

Direct prevention to undelying mechanism
Avoid neohrotoxic meds and combos
Maintain adequate kidney perfusion with hydration
Therapeutic Drug Monitoring

Question 11

What traditional markers are used to monitor kidney function?

Answer 11

BUN
SCr
eGFR
UO

Question 12

What novel biomarkers are used to monitor kidney function?

Answer 12

KIM1 - ATN
NGAL - Ischemic injury
IGFBP7 & TIMP2 - cellular arrest

Question 13

What type of fluids do you give to someone with kidney injury?

Answer 13

Balanced crystalloids

Question 14

Why are balanced crystalloids preferred over normal saline?

Answer 14

Mimic normal plasma Electrolyte concentration
Closer to neutral pH
Decreased risk of death
Decreased risk of RRT
Decreased risk of renal dysfunction

Question 15

What are the types of balanced crystalloids?

Answer 15

Lactated Ringers
Plasma - Lyte A

Question 16

Constituents of Lactated Ringers?

Answer 16

Na
Cl
Lactate
K
Ca

Question 17

Constituents of Plasma - Lyte A?

Answer 17

Na
Cl
K
Mg
Acetate
Gluconate

Question 18

How do NSAIDs cause Pre- Renal Injury?

Answer 18

block afferent arteriole dilation by reducing PGE2 production

Question 19

How do SGLT2 inhibitors cause Pre - Renal Injury?

Answer 19

stimulate afferent arteriole constriction via tubuloglomerular feedback

Question 20

How do ACEi/ARBs cause Pre- Renal Injury?

Answer 20

block efferent arteriole constriction via decrease in Angiotensin II

Question 21

How does a decrease in angiotensin II cause Pre- Renal Injury?

Answer 21

There will be loss of autoregulation followed by increase risk of intraglomerular hydrostatic pressure which leads to decrease in GFR

Question 22

How does Tubuloglomerular Feedback work?

Answer 22

Macula densa cells sense high Na concentration in distal tubule
Relays info to afferent arteriole to constrict
Decrease intraglomerular hydrostatic pressure

Question 23

True or False. Tubuloglomerular Feedback is never protective.

Answer 23

False. It is protective with a decrease in albuminuria

Question 24

True or False. Contrast Media injures the kidney only via direct toxicty.

Answer 24

False. Via Multiple mechanisms

Question 25

What are the risk factors for Contrast Media induced Kidney Disease?

Answer 25

Diabetes Large or High volume High osmolal contrast Ionic contrast Short interval between doses

Question 26

How to prevent Contrast Media Renal Injury?

Answer 26

Give Saline Hydration - 0.9% NaCl 1 - 1.5 mL/kg/hr 12 hours before and after Give NAC (add if higher risk) Low/Iso-osmol Contrast - Not Diatrizoate or Metrizoate Sodium bicarb has potential harm

Question 27

How should you monitor Contrast Media?

Answer 27

SCr and BUN Q12H for 2 days then Q24H for 5 - 7 days UO with strict ins and outs for 4 days Medication regimen review Check Elytes if pt develops kidney injury

Question 28

How does AIN occur?

Answer 28

Immune activation/hypersensitivity > Leukocyte infiltration > Inflammation

Question 29

What is the treatment for AIN?

Answer 29

Stop offending agent Avoid cross reactors Supportive Care Steroids - large bolus *Earlier you stop offender ans start steroids - the better

Question 30

What other drug can cause AIN aside from Beta Lactams, PPIs, Sulfas and NSAIDs?

Answer 30

Vancomycin

Question 31

What paramters show Vancomyin induced AIN?

Answer 31

Elevated trough concentration 24 HR AUC > 600 Daily dose > 4g >7 days duration of therapy High severity of illness High weight (>101.4 kg) Concomitant nephrotoxins

Question 32

How to prevent Drug Induced AIN?

Answer 32

Antibiotic Stewardship Avoid Concomitant Drugs Monitoring

Question 33

How does Nephrolithiasis cause renal injury?

Answer 33

Backup of fluid into kidneys

Question 34

True OR False. Most stones are made of Calcium so Ca supplementation may increase risk of Nephrolithiaisis.

Answer 34

True

Question 35

How to prevent Nephrolithiasis?

Answer 35

Hydration (2 -3 L of water/day; UO > 2.5L/DAY) Ca in urine? > thiazide

Question 36

Treatment of Nephrolithiasis

Answer 36

Pain management Lithotripsy - passage/stone removal

Question 37

What is Rhabdomyolysis and how can it cause kidney injury?

Answer 37

It is muscle breakdown and can cause intratubular obstruction

Question 38

What drugs can cause rhabdomyolysis?

Answer 38

Stains and statin-fibrate combos

Question 39

How to prevent rhabdomyolysis?

Answer 39

Avoid statin DDI Counsel pt on symptoms Check urine color

Question 40

How to manage rhabdomyolysis?

Answer 40

D/C drug Treat with aggressive fluids Urinary alkalization (solubilize myoglobin) Target a UO of 3 ml/kg/h

Question 41

How does Lithium cause kidney injury?

Answer 41

Chronic interstritial nephritis It is related to duration of use CUMULATIVE DRUG EXPOSURE

Question 42

How to prevent Lithium-Induced CKD?

Answer 42

Routine TDM Avoid Dehydration Monitor renal function Avoid DDIs (HCTZ)

Question 43

How to treat Lithium-Induced CKD?

Answer 43

D/C Lithium Hydration Amiloride Avoid other nephrotoxins