Kidney Toxicity

Question 1

Which biomarkers indicate kidney damage?

Answer 1

• KIM1
• NGAL
• IGFBP7
• TIMP-2

Question 2

Which biomarkers show kidney function?

Answer 2

• SCr
• BUN
• eGFR
• Urinary output

Question 3

Which drug combo should you avoid in patients with CKD, heart failure, and/or liver disease?

Answer 3

NSAID + ACE/ARB

Question 4

Hemodynamic AKI treatment

Answer 4

1. Discontinue offending drug
2. Provide fluids to maintain effective circulating volume (IV NaCl 0.9%)
3. Monitor kidney function and electrolytes

Question 5

Acute Tubular Necrosis (ATN) causes

Answer 5

• Aminoglycosides*
• Amphotericin B* (conventional&raquo_space; liposomal)
• IV contrast media*

Question 6

ATN presentation

Answer 6

High SCr and BUN, low GFR and urine output
- Proteinuria, “muddy brown casts” (cellular debris)
- FeNa >1%

Question 7

T/F: Extended interval aminoglycoside dosing has a higher risk of nephrotoxicity (ATN)

Answer 7

FALSE

Question 8

ATN treatment

Answer 8

Supportive*
1. Discontinue agent
2. Maintain hydration and euvolemia (perfusion)
3. Electrolyte management
4. Dialysis?

Question 9

Contrast induced nephropathy risk factors

Answer 9

• Diabetes mellitus*
• Age
• CKD
• Low effective circulatory volume
• Concomitant nephrotoxic agents
• Large-dose
• High osmolality contrast
• Ionic contrast
• Short time interval between 2 contrast administrations

Question 10

Prevention of CIN

Answer 10

0.9% saline hydration* 12h before 12 after
1-1.5 mg/kg/hr

Consider PO NAC in addition for high risk patients
DO NOT use sodium bicarbonate

Question 11

Metformin in contrast media settings

Answer 11

Hold metformin before procedures, may cause lactic acidosis with contrast media

Question 12

Which drugs can cause AIN?

Answer 12

• Beta-lactams
• NSAIDS
• Sulfa-containing drugs
• Proton pump inhibitors

Question 13

AIN presentation

Answer 13

Fever, eosinophilia, rash

Question 14

Treatment of drug-induced AIN

Answer 14

1. Discontinue offending agent
2. Avoid cross-reacting drugs
3. Supportive care
4. Steroids*

Question 15

Vancomycin Associated AKI risk factors

Answer 15

24-hr AUC >600mcg*h/mL
Dose >4g
Duration >7 days
Weight >101.4 kg
Concomitant nephrotoxic agents
Elevated trough

Question 16

Vancomycin Associated AKI prevention

Answer 16

Stewardship
Avoid aminoglycosides, amphotericin, contrast (if possible)
Monitoring (avoid trough >15-20 mg/L and AUC>600)

Question 17

Nephrolithiasis-causing drugs

Answer 17

• Topiramate*
• Sulfonamides*
• Furosemide

Question 18

Nephrolithiasis prevention

Answer 18

Adequate hydration
Goal urine output >2.5L/day
Thiazide for high urinary calcium
Pay attention to calcium and uric acid

Question 19

Nephrolithiasis treatment

Answer 19

Pain management
Lithotripsy (shockwave disintegration)

Question 20

Rhabdomyolysis intra-tubular obstruction prevention

Answer 20

Avoid statin drug interactions, counsel on muscular symptoms/urine changes

Question 21

Rhabdomyolysis intra-tubular obstruction treatment

Answer 21

1. Stop drug
2. Aggressive fluid administration +/- urinary alkalinization
   - Target urine output 3mL/kg/hr
   - If pH<6.5 alternate NaCl and NaHCO3

Question 22

Lithium-induced CKD treatment

Answer 22

Avoid drug interactions (HCTZ)
D/C lithium
Hydration
Amiloride 5-20mg daily (for polyuria + polydipsia)
Avoid other nephrotoxic drugs and monitor renal function