Drug-Induced Kidney Disease- Hemodynamically Mediated and Pre-Renal Injury

Question 1

Drugs that can induce hemodynamically-mediated and pre-renal kidney injury

Answer 1

ACEIs/ARBs
NSAIDs
Diuretics (loops > thiazides)
Calcineurin inhibitors

Question 2

Mechanism of ACEis/ARBs

Answer 2

Efferent arteriole dilation

Question 3

Mechanism of NSAIDs

Answer 3

Afferent arteriole constriction

Question 4

Mechanism of diuretics

Answer 4

Reduced effective circulatory volume

Question 5

Mechanism of calcineurin inhibitors

Answer 5

Afferent arteriole constriction

Question 6

SGLT2is/NSAID + ACEi/ARB: what do SGLT2is and NSAIDs do?

(think of that one picture you thought you’d never see again from patho)

Answer 6

SGLT2is and NSAIDs can constrict the afferent arteriole (NSAIDs via a decrease in PGE2 production and SGLT2is stimulate afferent constriction via tubuloglomerular feedback)

Question 7

SGLT2is/NSAID + ACEi/ARB: what do ACEis/ARBs do?

Answer 7

ACEis and ARBs block efferent constriction via a decrease in angiotensin II which dilates the efferent arteriole

Question 8

SGLT2is/NSAID + ACEi/ARB: what is the net effect of this?

Answer 8

The net effect is a loss of autoregulation –> increase risk of decreased intraglomerular hydrostatic pressure –> decrease in GFR

Question 9

SGLT2is and tubuloglomerular feedback

Answer 9

SGLT2is deliver more salt to the macula densa cells and cells in the distal tubule tell the afferent arteriole to constrict

Basically: Increased sodium concentration → afferent arteriole constriction → decreased GFR

Question 10

SGLT2is might be protective in what way?

Answer 10

Reduction in albuminuria

Question 11

Prevention of pre-renal and hemodynamic-mediated injury

Answer 11

Maintain adequate fluid intake
Risk factor management (avoid concomitant nephrotoxins)
High-risk patients: start with the lowest dose of drugs that affect renal hemodynamics

Question 12

Monitoring in pre-renal and hemodynamic-mediated injury

Answer 12

SCr, BUN, K+, weight
Titrate meds up slowly
Hold diuretics while initiating/titrating these agents

Question 13

Which patient populations should you avoid the NSAID + ACEi/ARB combination in?

Answer 13

CKD, HF. cirrhosis/liver disease!!!

Question 14

Treatment of pre-renal and hemodynamic-mediated injury

Answer 14

D/C offending agent
Provide sufficient fluids to maintain effective circulatory volume
Monitor kidney function and electrolytes