Renal Flashcards
Indication/MOA for Carvedilol
CHF
CAD
HTN
MOA - rate and BP control
Indication/MOA for Lisinopril
CHF
CKD
HTN
MOA - RAAS inhibitor/ BP control
Indication/MOA for Furosemide
CHF
MOA - diuretic
Indication/MOA for Coumadin
A fib
MOA - “blood thinner”
Indication/MOA for Digoxin
CHF
Afib
MOA - inotrope/rate control
What can happen if you combine digoxin and furosemide?
Loop diuretics can cause hypokalemia
Hypokalemia —> increased risk of digoxin toxicity
What can happen if you mix digoxin and carvedilol?
Risk of bradycardia and AV block
What can happen if you mix furosemide, carvedilol, and lisinopril?
All can lower BP —> increased risk of hypotension
What does digoxin toxicity look like?
CARDIAC ARRHYTHMIAS
GI - anorexia, N/V/D, abdominal pain
Neuro - confusion, weakness, lethargy, fatigue, delirium, disorientation
Visual disturbances
What do we need to know about the pharmacodynamics of digoxin?
Cleared RENALLY
Half-life = 1.5-2 days, 3.5-5 days if anuric
NARROW MARGIN OF SAFETY
Does serum digoxin level correlate with toxicity?
Not necessarily
Ideally, sample should be collected >6 hours after last dose
Toxic level >2ng/mL
Possible to have the following:
• Asymptomatic pt with toxic level
• Significant toxicity with a therapeutic range serum level
How do you manage a digoxin-induced AKI?
Appropriate fluid resuscitation
Monitor I&Os
Replenish/monitor potassium
Why do you get hyperkalemia with ACE inhibitors?
B/c of decreased potassium excretion
What drugs can affect GFR?
Lisinopril and Ibuprofen
How do ACE inhibitors affect GFR?
Vasodilator Effect on the EFFERENT arteriole —> causes back up in the glomerulus
How do NSAIDs affect GFR?
Vasoconstriction of the AFFERENT arteriole —> more flow through the glomerulus
How will you manage an ibuprofen/lisinopril induced AKI?
Begin IVF with NSs Monitor I&Os Management of hyperkalemia (including d/c lisinopril) Consult nephrology - dialysis? D/c ibuprofen
Name the stage of renal disease:
Kidney damage w/ normal or inc GFR (≥90)
Stage 1
Name the stage of renal disease:
Kidney damage with normal or decreased GFR (60-89)
Stage 2
Name the stage of renal disease:
Mild-mod reduced GFR (45-59)
Stage 3a
Name the stage of renal disease:
Moderate to severe reduced GFR (30-44)
Stage 3b
Name the stage of renal disease:
Severely reduced GFR (15-29)
Stage 4
Name the stage of renal disease:
Kidney failure (<15 or on dialysis)
Stage 5
Add “D” if on dialysis
What is the CURB-65 criteria?
For determining if you patient with PNA needs admission
Confusion Urea >7 (or BUN >20) Respiratory rate ≥30 BP <90/60 65 years or older
Would a patient with PNA be considered uncomplicated or complicated if they also have DM?
Complicated
What do you need to think about when prescribing abx for a patient’s PNA if they have kidney disease/injury?
Allergies
Route (IV vs PO)
Renal dosing
What do we use to determine renal dosing?
Use different equations to measure estimated creatinine clearance or eGFR
• CKD-EPI (newest)
• MDRD
• Cockcroft and Gault (oldest)
What would be a good option for outpatient CAP for a diabetic patient?
Levofloxacin, adjusted for CrCl (if GFR<50, give q48 hours instead of qd b/c not cleared as quickly)
What are we worried about in a patient taking metformin in the setting of kidney disease/impairment?
Lactic Acidosis
Advise the patient to stop taking it in cases of N/V or dehydration
What medications for acute cystitis require renal dosing?
Bactrim - for CrCl <30 ml/min reduce dose by 50% (avoid in pt with CrCl <15 ml/min)
Pyridium - for CrCl 50-80 give q 12-16 hours, contraindicated if CrCl<50
Nitrofurantoin (Macrobid)
What is the Beers Criteria?
Use bactrim with caution in patients with decreased kidney function who are receiving ACE/ARBs b/c elevated risk of hyperkalemia
Common meds that require renal dosing
Nitrofurantoin Allopurinol Acyclovir Gabapentin Preganglionic Metoclopramide Ranitidine Rivaroxaban Enoxaparin Lithium Clarithromycin Gentamicin Vancomycin
