Drug Induced Renal Disease

Question 1

4 types of drug induced kidney injury

Answer 1

Pre-renal and hemodynamic-mediated injury

Intrinsic Renal Injury

Post-Renal (Obstructive) Injury

Drug Induced CKD

Question 2

Balanced Crystalloids

Answer 2

Lactated Ringers
Plasma-Lyte A

Question 3

Pre-Renal and Hemodynamic-Mediated Injury

Answer 3

Drugs:
- ACE/ARBs
- NSAIDs
- diuretics (loop>thiazide)
- Calcineurin inhibitors (tacrolimus, cyclosporine)
- SGLT2i (-gliflozins)

Prevention:
- hydration
- Monitor SCr, BUN, K+, weight every 2 weeks until stable

Treatment:
- DC offending agent
- IV NS
- monitor kidney function and electrolytes

Question 4

Acute Tubular Necrosis (Agents)

Answer 4

• aminoglycosides
• amphotericin B
• IV contrast media
• anti-neoplastic agents (cisplatin, ifosfamide)

Question 5

Acute Tubular Necrosis (Presentation)

Answer 5

Increased: SCr, BUN
Decreased: GFR, urine output
Proteinuria
muddy brown casts
metabolic acidosis
hyperkalemia
FeNa>1%

Question 6

Aminoglycoside TDM

Answer 6

Extended interval dosing -> decreased risk of AKI

Measure trough 6-18hrs post dose

Goal Troughs:
- Gent & Tobra </= 2mg/L
- Amikacin </= 8mg/L

Question 7

Acute Tubular Necrosis Treatment

Answer 7

SUPPORTIVE
DC agent
hydration
electrolytes

Question 8

Contrast Induced Nephropathy (Risk factors)

Answer 8

• CKD
• GFR < 60
• DM
• Age
• LVEF < 40
• concomitant nephrotoxic agent
• Large volume contrast
• High osmolar contrast
• Ionic contrast
• short interval between 2 contrast admins

Question 9

Contrast Induced Nephropathy (Prevention)

Answer 9

Saline Hydration (gold standard)
- 0.9% NS 1-1.5mg/kg/hr 12hrs before and after
- maintain urine output >/= 150mL/hr after contrast

Sodium bicarb (conflicting evidence)
- 150mEq/L in D5W at 1-1.5 mL/kg/hr 12 hrs before and after

NAC (conflicting evidence)
- 600 to 1200 PO BID x4 doses
- 150mg/kg IV x 1 prior to procedure then 50mg/kg IV over 4 hrs post-procedure

Use contrast media that is:
- low or iso-osmolal
- nonionic
Ex.) Lodixanol, Lohexol

Question 10

Acute Interstitial Nephritis (patho + agents)

Answer 10

hypersensitivity/immune activation -> inflammation -> injury

Agents:
- Vancomycin *
- NSAIDs*
- Beta-lactams
- Sulfa drugs
- PPIs
- Diuretics
- Allopurinol
- anti-epileptics

Question 11

Acute Interstitial Nephritis Treatment

Answer 11

• DC offending agent
• avoid cross reacting drugs
• supportive care
• consider steroids

Steroid dosing :
- Methylprednisolone 250-500mg IV daily x 3-5 days
Prednisone 1 mg/kg/day tapered over 8-12w

Question 12

Preventing Vancomycin Associated AKI

Answer 12

Concomitant drugs:
- avoid aminoglycosides if possible
- use caution with pip/tazo

TDM:
- Avoid trough > 15-20mg/L
- Avoid AUC > 600

Question 13

2 types of Post-Renal (Obstructive) Injury

Answer 13

Nephrolithiasis
Rhabdomyolysis

Question 14

Nephrolithiasis Agents

Answer 14

• Topiramate
• Sulfonamides
• Furosemide
• alopurinol
• acyclovir
• calcium supp

Question 15

Nephrolithiasis Prevention and Management

Answer 15

Prevention:
- adequate hydration (urine output >/= 2.5L/day)
- thiazide diuretic if high urinary Ca

Treatment:
- hydration to induce diuresis
- pain management
- lithotripsy: shockwave disintegration of stone for passage

Question 16

Rhabdomyolysis Agents

Answer 16

Statins

Question 17

Rhabdomyolysis Prevention and Management

Answer 17

Prevention:
- avoid statin drug interactions
- counsel patients on muscular sx and changes in urine color

Management:
- DC agent
- aggressive IV fluid admin (target urine output: 3 mL/kg/hr)
- +/- urine alkalinization (pH <6.5: alternate NaCl and sodium bicarb IV fluids)

Question 18

Lithium- induced CKD

Answer 18

Risk factors:
- duration of therapy
- episodes of acute lithium toxicity
- CUMULATIVE LITHIUM EXPOSURE

Prevention:
- routine lithium TDM
- hydration
- monitoring renal function
- avoid DDI (HCTZ)

Treatment:
- DC litium
- hydration
- amiloride 5-20mg daily
- avoid nephrotoxic drugs
- monitor renal function