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A2 ME3031 URINARY > W06: PHARMACOLOGY, RENAL REPLACEMENT, ORGAN DONATION > Flashcards

W06: PHARMACOLOGY, RENAL REPLACEMENT, ORGAN DONATION Flashcards

1
Q

Discuss the principles of drug therapy in the presence of renal insufficiency.

A

risk of rapdi build up of ACTIVE drug and TOXIC METABs.
* on the contrary = Benzylpenicillin wide range/low tox.

de novo renal impairment d/t sick, hypotensive, and polypharmacy

GFR dysfunc.

  • 1/2L prolonging = accumulation esp. w/ narrow therapeutic range
  • ⇩protein binding

BBB more permeable + greater sens + synergistic effects

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2
Q

State how drug-induced nephrotoxicity can be limited

A
  • infants, young children, elderly
  • pt with pre-existing dysfunction/ CVD therefore !hypotensive
  • use of drugs w/ WIDE therapeutic index
  • ⇩ loading & maintenance dose / frequency
  • ⇧therapeutic drug monitoring
  • non-renal clearance mode preferred
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3
Q

Give examples of drug induced renal disease

A

GENTAMICIN. = renal/ ototoxicitiy

DIGOXIN = arrhythmia, nausea, death

LITHIUM = renal tox and death

TACROLIMUS = renal and CNS tox.

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4
Q

Drug Induced Renal Effects

A
  • AKI
  • NEPHROTIC SYNDROME
  • RENAL TUBULAR DYSFUNCT. W/ POTASSIUM WASTING
  • CHRONIC RENAL FAILURE
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5
Q

Pre-Renal Causes of AKI

A
  • DIURETICS, laxatives, lithium, NSAIDS
  • Steroids, tetracyclines = ⇧catabolism
  • oestrogens/ OCP = vascular occlusion

= deterioration in renal function which results in a rapid rise in creatinine; fall in volume

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6
Q

Intrinsic causes of AKI

A
  • ACUTE TUBULAR NECROSIS d/t
    aminoglycoside antibiotics, cisplatin (chemoT), statin drugs + immunosuppr. (cyclosporin)
  • ACUTE INTERSTITIAL NEPHRITIS d/t
    onset after drug 3-5d; PENICILLLIN, CEPHALOSPORIN, NSAID, OMEPRAZOLE, CHINESE HERBS, COCAINE
  • THROMBOTIC MICROANGIOPATHY (thrombotic microvasc) d/t
    cyclosporin, tacrolimus, estrogen contraceptives, cocaine, clopidogrel
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7
Q

Post Renal Causes of AKI

A
  • OBSTRUCTIVE UROPATHY
    crystal formation within tubules or ureters OR retroperitoneal fibrosis (methysergide)
    ACYCLOVIR, SULFONAMIDES, METHOTREXATE, EXCESS VITAMIN C
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8
Q

Drug causes of Nephrotic Syndrome

A

NSAIDs
Gold
Interferon

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9
Q

Hospital Acquired Renal Insufficiency Drug Causes

A

AMINOGLYCOSIDES for gram-ve sepsis therefore TDrugMonitoring ensure good limits

NSAIDs = prerenal RFailure = haemodynamic/ acute tubular necrosis
OR immune mediated = acute interstitial nephritis
• HT, hyperkalaemia = arrythmia, papillary necrosis

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10
Q

Explain the principles of dialysis and its main modalities.

A

solute composition of a solution, A, is altered by exposing solution A to a second solution, B, through a SEMIPERMEABLE membrane.

+ Diffusion to achieve equilibrium w/ Pt and dialysate + ultrafiltration via oncotic pressure and gradient drag.

  • membrane, blood exposure, dialysis access, anticoag required
  • IJV line common

Primarily want to remove creatinine and urea, as well as small K+, and to correct and give HCO3-

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11
Q

Principles of management of the patient receiving dialysis

A

RESTRICTIONS include:
- Fluid restriction = based off residual urine output, and interdialytic weight gain (fluid gain)
500-800ml/24hr intake restriction (haemo)

more liberal in PDial.

  • Dietary restriction = potassium, sodium, phosphate

MEDICATIONS:
+ ERYTHROPOIETIN INJECTION
+ IV iron suppl.

+ ACTIVATED VITAMIN D (calcitriol)
+ Phosphate binders w/ meals

+HEPARIN

+VITAMINS (aq)

+ Antihypertensives to combat fluid-overload or hypovolaemia

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12
Q

Principles of renal replacement therapy (RRT)

A

indicated when eGFR <10 ml/min.

  1. Transplant
    best option as it resolves issues but not available for everyone
    *IN ILIAC FOSSA with anastomosis to iliac vessels while native kidneys remain in-situ - removal only indicated specifically

preservation
Patient and graft survival is better with living compared to deceased donation.

!bleeding risk; imm suppr sfx

  1. Haemodialysis: home / satellite
    * permanent access: arteriovenous fistula, AV proesthetic graft
    * temp: venous catheter
    * anticoag!
  2. Peritoneal: CAPD; intermittent peritoneal dialysis
    * ideally at pelvis via catheter using PERITONEAL MESOTHELIUM (membrane)
    * drain in w/ fresh dialysate to correct metabolites
    + glucose as osmotic agent for ultrafiltration
    * continuous
  3. Conservative Kidney Mgmt
    Supportive care: symptoms, holistic, anticipatory

Pt informed choice + factors

  • intraabdo surgeries affecting PD
  • vascular access issues affecting haemodial.
  • PD favoures better urine output
  • social factors

*increasing morbidity and mortality with dialysis

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13
Q

Advanced CKD

A

aka URAEMIA involving multi-organs, 1st sympt = MALAISE, FATIGUE

*CKD could be asymptomatic until stage 4 or 5

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14
Q

Complications of PD

A

!infection @ exit
PERITONITIS
gram+ (skin) more common than neg.
gram- (bowel)

  • failure of ultrafiltration
  • encapsulating peritoneal sclerosis

> intreperitoneal Vancomycin + Oral Ciproflox.

MECHANICAL malfunctions

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15
Q

Indications for dialysis in ESRD

A

Advanced uraemia, (GFR 5-10 ml/min)

Severe acidosis (bicarbonate <10 mmol/l)

Treatment resistant hyperkalaemia (K >6.5 mmol/l)

Treatment resistant fluid overload

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16
Q

Complications of haemodialysis

A

CV problems: hypotension and cramps (intra-dial.); arrythmias

COAGULATION: clotting of vascular access, heparin

ALLERGY

17
Q

Common bleeding complication of transplant

A

BLEEDING @ ANASTOMOTIC SITES, perirenal haematoma

18
Q

Immunosuppression SFX

A

CORTICO. - HT, hyperglc., infections, bone loss, GI bleeding

TACROLIMUS - hyperglc., AKI, tremor

19
Q

Transplant Imm Suppr. Protocol

A
  1. BASILIXIMAB
  2. maintained by TACROLIMUS + MYCOPHENOLATE + STEROIDS

Steroid-free is possible

20
Q

Brain-death criteria

A 
Coma, unresponsive to stimuli 
Apnoea off ventilator (with oxygenation) despite build up of CO2
Absence of cephalic reflexes
pupillary
oculocephalic
oculovestibular (caloric)
corneal
gag
purely spinal reflexes may be present
Body temperature above 34 C
Absence of drug intoxication
21
Q

Expanded criteria donors

A 
Donor aged > 60y
Donor aged 50-59 + 
history of hypertension
death from cerbrovascular accident
terminal creatinine of >133µmol/L
22
Q

Risks to Donor

A

Negligible/minor risk

Kidney function becomes normal, but chances of albuminuria esp in high BMIs and male donors.

23
Q

Main complications of transplant

A

REJECTION
- T-cell med. rejection = arteritis; art. fibrinoid necrosis

  • acute antibody mediated rejection = cap./glomerular inflamm.; arterial inflamm. (C4d+)

INFECTIVE
- cytomegalovirus common: active transmission / reactivation latent

> antiviral (cidofovir)
reduce imm. suprr.

CARDIOVASCULAR

MALIGNANCY

24
Q

Discuss the principles, practicalities and ethical considerations of organ donation

A

Duty to Inquire - ensure latest views are expressed and respected, ensures appt. checks undertaken

*if no written decision of donation, safeguards are in place to ensure transplantation can continue

CHILDREN UNDER 12 - parental + similar agreement
12-16y/o - record their own decision but parents should be consulted
+ nearest relative heirachy

  • Death by neurological criteria
  • Donation after cardiac death
25
Q

Describe the principles involved in renal replacement therapy and state the social, economic and psychological implications of dialysis and renal transplantation.

A

Renal transplantation much more symptomatically effective as well as economically.

A2 ME3031 URINARY (14 decks)

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