Drug - Induced KD Flashcards
What drugs cause Hemodynamic Renal Injury
NSAIDs
SGLT2 inhibitors
ACE inhibitors/ARBs
Calcineurin inhibitors
What drugs cause Pre-Renal injury?
Diuretics
What injuries happen to the kidney intrinsically?
Glomerulonephritis
Acute Tubular Necrosis
Acute Interstitial Nephritis
Vasculitis
What drugs can cause Glomerulonephritis?
Gold
Allopurinol
What drugs can cause Acute Tubular Necrosis?
IV Contrast Media
Amphotericin B
Aminiglycosides
What drugs can cause Acute Interstitial Nephritis?
Peniciilin
NSAIDs
PPIs
Sulfa drugs
What drugs can cause Vasculitis?
PTU
Allopurinol
Levamisole(coke)
Phenytoin
What is a Post-Renal injury?
Nephrolithiasis
Rhabdomyolysis
Lithium-Induced CKD
What drugs can cause Post-Renal Nephrolithiasis?
*Topiramate
*Sulfonamides
*Furosemide
Allopurinol
Acyclovir
What are risks factors for Drug - induced Kidney Disease?
Age > 65
CKD
Concomitant nephrotoxins
Known allergy
Duration of Therapy
Diabetes
HTN
Renin dependent state (eg HF, cirrhosis)
How do you prevent DIKD?
Direct prevention to undelying mechanism
Avoid neohrotoxic meds and combos
Maintain adequate kidney perfusion with hydration
Therapeutic Drug Monitoring
What traditional markers are used to monitor kidney function?
BUN
SCr
eGFR
UO
What novel biomarkers are used to monitor kidney function?
KIM1 - ATN
NGAL - Ischemic injury
IGFBP7 & TIMP2 - cellular arrest
What type of fluids do you give to someone with kidney injury?
Balanced crystalloids
Why are balanced crystalloids preferred over normal saline?
Mimic normal plasma Electrolyte concentration
Closer to neutral pH
Decreased risk of death
Decreased risk of RRT
Decreased risk of renal dysfunction
What are the types of balanced crystalloids?
Lactated Ringers
Plasma - Lyte A
Constituents of Lactated Ringers?
Na
Cl
Lactate
K
Ca
Constituents of Plasma - Lyte A?
Na
Cl
K
Mg
Acetate
Gluconate
How do NSAIDs cause Pre- Renal Injury?
block afferent arteriole dilation by reducing PGE2 production
How do SGLT2 inhibitors cause Pre - Renal Injury?
stimulate afferent arteriole constriction via tubuloglomerular feedback
How do ACEi/ARBs cause Pre- Renal Injury?
block efferent arteriole constriction via decrease in Angiotensin II
How does a decrease in angiotensin II cause Pre- Renal Injury?
There will be loss of autoregulation followed by increase risk of intraglomerular hydrostatic pressure which leads to decrease in GFR
How does Tubuloglomerular Feedback work?
Macula densa cells sense high Na concentration in distal tubule
Relays info to afferent arteriole to constrict
Decrease intraglomerular hydrostatic pressure
True or False. Tubuloglomerular Feedback is never protective.
False. It is protective with a decrease in albuminuria
True or False. Contrast Media injures the kidney only via direct toxicty.
False. Via Multiple mechanisms
What are the risk factors for Contrast Media induced Kidney Disease?
Diabetes
Large or High volume
High osmolal contrast
Ionic contrast
Short interval between doses
How to prevent Contrast Media Renal Injury?
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
How should you monitor Contrast Media?
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
How does AIN occur?
Immune activation/hypersensitivity > Leukocyte infiltration > Inflammation
What is the treatment for AIN?
Stop offending agent
Avoid cross reactors
Supportive Care
Steroids - large bolus
*Earlier you stop offender ans start steroids - the better
What other drug can cause AIN aside from Beta Lactams, PPIs, Sulfas and NSAIDs?
Vancomycin
What paramters show Vancomyin induced AIN?
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
How to prevent Drug Induced AIN?
Antibiotic Stewardship
Avoid Concomitant Drugs
Monitoring
How does Nephrolithiasis cause renal injury?
Backup of fluid into kidneys
True OR False. Most stones are made of Calcium so Ca supplementation may increase risk of Nephrolithiaisis.
True
How to prevent Nephrolithiasis?
Hydration (2 -3 L of water/day; UO > 2.5L/DAY)
Ca in urine? > thiazide
Treatment of Nephrolithiasis
Pain management
Lithotripsy - passage/stone removal
What is Rhabdomyolysis and how can it cause kidney injury?
It is muscle breakdown and can cause intratubular obstruction
What drugs can cause rhabdomyolysis?
Stains and statin-fibrate combos
How to prevent rhabdomyolysis?
Avoid statin DDI
Counsel pt on symptoms
Check urine color
How to manage rhabdomyolysis?
D/C drug
Treat with aggressive fluids
Urinary alkalization (solubilize myoglobin)
Target a UO of 3 ml/kg/h
How does Lithium cause kidney injury?
Chronic interstritial nephritis
It is related to duration of use
CUMULATIVE DRUG EXPOSURE
How to prevent Lithium-Induced CKD?
Routine TDM
Avoid Dehydration
Monitor renal function
Avoid DDIs (HCTZ)
How to treat Lithium-Induced CKD?
D/C Lithium
Hydration
Amiloride
Avoid other nephrotoxins
