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MD3002 GI/GU/Renal > Drugs and the Kidney > Flashcards

Drugs and the Kidney Flashcards

1
Q

What is the mechanism of action of loop diuretics and some examples?

A
  • inhibits Na-K-2Cl co-transporter in luminal membrane of thick ascending limb of Henle’s loop
  • inhibiting salt transport out of tubule and into interstitial tissue reducing the osmotic gradient in the medulla causing diuresis
  • eg. furosemide, bumetanide
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2
Q

What are the indications for loop diuretics?

A
  • oedema (heart failure/pulmonary/ascites/nephrotic syndrome/renal failure)
  • resistant hypertension
  • hypercalcaemia
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3
Q

What are the side effects of loop diuretics?

A
  • hypovolaemia
  • hypotension
  • electrolyte disturbances
  • can produce metabolic alkalosis due to loss of H+
  • hyperuricaemia (gout)
  • renal impairment
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4
Q

What is the mechanism of action of thiazide diuretics and some examples?

A
  • inhibits NaCl co-transporter in distal tubule resulting in less Na and Cl absorbed, resulting in moderate diuresis (reduces oedema and BP)
  • direct relanant effect on vascular smooth muscle
  • eg. bendroflumethiazide, indapamide
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5
Q

What are the indications for thiazide diuretics?

A
  • hypertension
  • mild heart failure
  • severe resistant oedema (plus loop diuretic)
  • nephrogenic diabetes insipidus
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6
Q

What are the side effects of thiazide diuretics?

A
  • hypotension
  • hypovolaemia
  • low Na, K and Mg
  • calcium retention
  • metabolic alkalosis
  • gout
  • erectile dysfunction
  • hyperglycaemia, hyperlipidaemia
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7
Q

What is the mechanism of action of aldosterone antagonists and some examples?

A
  • in CT, antagonise aldosterone receptor

- eg. spironolactone, epleronone

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8
Q

What are the indications for aldosterone antagonists?

A
  • oedema
  • hypertension
  • Conn’s syndrome
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9
Q

What are the side effects of aldosterone antagnosists?

A
  • renal impairment
  • hyperkalaemia
  • hyponaturaemia
  • GI upset
  • metabolic acidosis
  • gynaecomastia (with spironolactone)
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10
Q

What is the mechanism of action of osmotic diuretics, its indications and an example?

A
  • modify filtrate content to increase amount of water excreted
  • indicated in cerebral oedema and raised intra-ocular pressure
  • eg. mannitol (IV)
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11
Q

What is the mechanism of action of carbonic anhydrase inhibitors, its indications and an example?

A
  • very weak diuretic
  • indicated in glaucoma and altitude sickness
  • eg. acetazolamide
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12
Q

What is the mechanism of action of amiloride?

A
  • potassium-sparing weak diuretic
  • acts directly by blocking epithelial Na channels in collecting tubule so less Na reabsorbed causing diuresis
  • usually combined with thiazide or loop diuretic
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13
Q

What are the indications and side effects of amiloride?

A
  • indicated in oedema including ascites and hypertension

- side effects: high potassium, GI upset, metabolic acidosis, renal impairment

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14
Q

What happens with the syndrome of inappropriate ADH secretion (SIADH)?

A
  • excess ADH secreted by posterior pituitary gland
  • hyponaturaemia (<135)
  • low plasma osmolality
  • inappropriately elevated urine osmolality
  • euvolaemia
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15
Q

What are the symptoms of SIADH?

A

Mild:
- nausea, vomiting, headaches, anorexia

Moderate:
- muscle cramps, weakness, tremor, mental health disorders

Severe:
- drowsiness, seizures, coma

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16
Q

What are the causes of SIADH?

A
  • neurological causes (tumour, trauma, meningitis)
  • pulmonary causes (lung small cell carcinoma, pneumonia)
  • malignancy
  • hypothyroidism
  • drugs (thiazide and loop diuretics, ACEIs, SSRIs, PPIs)
17
Q

How would you treat SIADH?

A
  • correct underlying cause, monitor plasma osmolality, serum sodium and bodyweight
  • fluid restriction
  • declocycline (antibiotics, inhibits ADH action on kidney)
  • tolvaptan (vasopressin V2 antagonist in renal collecting ducts)
  • hypertonic NaCl in severe cases
18
Q

What happens in anaemia of renal disease?

A

kidneys produce less EPO (hormone that promotes RBC formation in bone marrow) resulting in anaemia

19
Q

How would you treat anaemia of renal disease?

A
  • erythropoietin stimulating agents (ESA)
  • eg. epoetin, alfa, darbpoetin
  • IV/SC route
20
Q

What are the advantages of ESAs?

A
  • reduce need for blood transfusions
  • boost production of RBCs
  • improve survival
  • reduce CV morbidity
  • enhance quality of life
21
Q

Why is it important to prescribe safely in renal impairment?

A
  • reduced renal excretion of the drug and metabolites can cause build up resulting in toxicity
  • kidneys sensitivity to some drugs is increased
  • increased risk of adverse reactions
  • some drugs not effective due to reduced renal function
  • chronic kidney disease increases risk of drug induced kidney disorders
22
Q

What are the considerations before prescribing for renal impairment

A
  • degree of renal impairment
  • whether acute or chronic kidney disease
  • proportion of drug renally excreted
  • does drug have narrow or wide therapeutic window
  • is drug potentially nephrotoxic
  • is patient established on renal replacement therapy
23
Q

What are some potentially nephrotoxic drugs?

A
  • ACEis
  • angiotensin II blockers
  • diuretics
  • lithium
  • digoxin
  • aminoglycosides
  • vancomycin
  • metformin
  • iodinated contrast media
  • opiods
24
Q

What ways can you estimate renal function?

A
  • creatinine clearance (good for narrow therpeutic index drugs)
  • eGFR (good for chronic kidney disease and most patients and drugs)
25
Q

What are the risks of giving the wrong dose of drug?

A
  • too high: bleeding risk

- too low: increase in embolic events and strokes

26
Q

What are the principles of prescribing in renal impairment?

A
  • check U’s and E’s, including eGFR and creatinine
  • look at baseline and trends in renal function
  • consider stopping or with-holding nephrotoxic drugs
  • check resources
  • choose non-nephrotoxic if possible
  • reduce size of dose or increase dosing interval or stop or withhold
  • use therapeutic drug monitoring to guide dose/frequency
  • continue to monitor Us and E’s, BP and clinical response
27
Q

How would you manage acute kidney injury?

A
  • treat any sepsis/uro obstruction
  • aim for good fluid/electrolyte balance
  • optimise BP
  • with-hold/stop toxins
  • review drug doses/side effect profile
  • monitor Es and Es, refer nephrology/urology if worsening

MD3002 GI/GU/Renal (64 decks)

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