Drug-Induced Kidney Disease

Question 1

Causes for prerenal AKI

Answer 1

Volume Depletion

1. Hemorrhagic
2. GI losses
3. Renal losses: Drug-induced, osmotic diuresis, diabetes insipidus
4. Skin losses: Burns
5. Third spacing (hypoalbuminemia)

Functional

1. ACE-1, ARB
2. NSAIDs

Question 2

List causes for Acute tubular necrosis

Answer 2

Exogenous toxins:

1. Nephrotoxic drugs
2. Contrast

Question 3

List causes for post renal AKI

Answer 3

Obstruction:

1. BPH
2. Tumor (malignancy)
3. Anticholinergic drugs
4. Displaced bladder catheter

Question 4

What is the MC presentation of DIKD in hospitalized patients?

Answer 4

Acute Tubular Necrosis (ATN)

Question 5

List the nephrotoxic agents that cause AKI

Answer 5

1. Aminoglycosides
2. Contrast
3. Amphotericin B
4. Osmotically active agents

Question 6

Pathogenesis in hemodynamically mediated kidney injury

Answer 6

Decrease in glomerular capillary hydrostatic pressure

Question 7

List the agents that cause hemodynamically mediated kidney injury

Answer 7

1. ACE-1

2. NSAIDs

Question 8

How many days after you initiated therapy would you see clinical manifestations of acute allergic interstitial nephritis (AIN)? Sx’s?

Answer 8

14 days

1. Fever
2. Maculopapular rash
3. Eosinophilia
4. Arthralgia
5. Hematuria, proteniuria, oliguria

Question 9

What is the most common electrolyte disorder?

Answer 9

Hyperkalemia

Question 10

What other electrolyte disorders do we see in kidney disease?

Answer 10

1. Hyperglycemia and insulin resistance

2. Hypertriglyceridemia

Question 11

What is the pathogenesis of ATN with Aminoglycosides abx

Answer 11

Accumulation of high drug concentration in tubular epithelial cells leads:

1. Tubular damage
2. Kidney necrosis

Question 12

How many days after initiation of Aminoglycosides do we see evidence of injury?

Answer 12

5-10 days

Question 13

What is one of the main risk factors in ATN with the use of Aminoglycosides?

Answer 13

Pre-existing clinical condition

1. Dehydration*
2. CKD
3. DM

Question 14

What is the main preventative strategy in ATN with the use of Aminoglycosides?

Answer 14

Avoid volume depletion

Question 15

Pathogenesis of Contrast-Induced Nephrotoxicity (CIN)

Answer 15

Renal ischemia from systemic hypotension and acute vasoconstriction (contrast is a vasoconstrictor) d/t disruption of normal RBF

Question 16

Clinical presentation of Contrast-Induced Nephrotoxicity (CIN)

Answer 16

1. Injury present w/in 24-48 hrs of administration
2. Serum Cr peaks w/in 3-5 days
3. Recovery in 7-10 days

Question 17

Risk factors in Contrast-Induced Nephrotoxicity (CIN)

Answer 17

1. Pre-existing kidney dz, GFR <60 mL/min
2. Decreased RBF: CHF, dehydration
3. Concurrent use of nephrotoxins: NSAIS, ACE-1

Question 18

Prevention of Contrast-Induced Nephrotoxicity (CIN)

Answer 18

Use alternative imaging procedures

Question 19

Pathogenesis of ATN with the use of Amphotericin B

Answer 19

1. Increased permeability and necrosis

2. Decreased RBF exacerbates necrosis

Question 20

What electrolytes will you see wasting with Amphotericin B?

Answer 20

1. Potassium
2. Sodium
3. Magnesium

Question 21

When does the dysfunction become apparent with the use of Amphotericin B? Lab findings?

Answer 21

1-2 weeks
Decrease in GFR
Increase in Serum Cr and BUN

Question 22

What should you switch to for high risk patients in place of with the use of Amphotericin B?

Answer 22

Liposomal form

Question 23

Amphotericin B prevention

Answer 23

1. Increase infusion time

2. Alternative antifungals: Azoles, Caspofungin

Question 24

What do patients take Cyclosporine for?

Answer 24

Prevent kidney graft rejection

Question 25

What is unique about Cyclosporine toxicity?

Answer 25

Dose-Dependent

Question 26

Presentation of nephrotoxicity with use of ACE-1 and ARBs

Answer 26

1. Decrease in UO 2. Acutely reduces GFR 3. Rise in Serum Cr up to 30% in 3-5 days

Question 27

How long after discontinuing the ACE-1 or ARB do you stabilize?

Answer 27

1-2 weeks

Question 28

Risk factors for nephrotoxicity with the use of an ACE-1 or ARB

Answer 28

1. Renal artery stenosis | 2. Decrease arterial blood flow: CHF, volume depletion

Question 29

When should you discontinue an ACE-1 or ARB?

Answer 29

SCr increases >30% in 1-2 weeks

Question 30

Pathogenesis of NSAIDs and COX-2 in pre-renal AKI

Answer 30

Inhibits synthesis of vasodilatory prostoglandins=unopposed vasoconstriction of afferent arteriole

Question 31

Presentation of NSAIDs and COX-2 in pre-renal AKI

Answer 31

1. Decreased UO 2. Weiht gain/edema 3. HTN 4. Elevated SCr, BUN, K+

Question 32

What is a a potent compound you should avoid in high risk patients with NSAIDs/COX-2 pre-renal AKI

Answer 32

Indomethacin

Question 33

What NSAID can you consider that has a shorter half life for prevention management in pre-renal AKI?

Answer 33

Sulindac

Question 34

What is Methicillin-induced AIN associated with? When do you see injury after initiation of these drugs?

Answer 34

Beta-lactacm abx | 14 days after initiation

Question 35

Clinical presentation of Methicillin-induced AIN

Answer 35

``` 1. Fever 2, Maculopapular rash 3 Eosinophila 4. Arthralgia 5. Oliguria ```

Question 36

How do you treat/manage Methicillin-induced AIN

Answer 36

Immediate corticosteroids

Question 37

List the cause for chronic interstitial nephritis

Answer 37

1. Cyclosporine

Question 38

List the cause for papillary necrosis

Answer 38

NSAIDs

Question 39

What drugs can cause intratubular obstruction (obstructive nephropathy)?

Answer 39

1. Acyclovir | 2. Sulfonamides

Question 40

what conditions can cause intratubular obstruction (obstructive nephropathy)?

Answer 40

1. Hyperuricemia | 2. Rhabdomyolysis

Question 41

What drugs increases your risk for Rhabdomyolysis?

Answer 41

1. HMG-CoA reductase inhibitors (statins) | 2. Concurrent CYP3A4 drugs

Question 42

What drugs cause renal vasculitis and thrombosis

Answer 42

1. Hydralazine | 2. Methamphetamine

Question 43

What drugs cause a cholesterol emboli

Answer 43

1. Warfarin | 2. Thrombolytic agents

Question 44

What drugs cause glomerular disease?

Answer 44

1. NSAIDs | 2. COX-2 inhibitors