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ABIM Nep Drugs

ABIM NEP Drugs in Renal Failure

QuestionAnswer
FDA requires use of ___ for drug dosing. Creat clearance. GFR not validated!
______ determines loading dose of medication. Volume of distribution
______ determines maintenance dose of medication. creatinine clearance, half life.
T/F uremia decreases plasma protein binding of mycophenolic acid, thereby increasing free drug concentration. TRUE. Those patients with poor CrCl more likely to have diarrhea
Rx acute dabigatran ingestion? Activated charcoal. Hemodialysis is effective, removing 50-60% of dabigatran over a 2- to 4-hour dialysis session. However, lg vol of distribution (50-70 L) results in "rebound" levels after HD. May consider CVVH.
Renal effects of dasatinib, a protein-tyrosine kinase inhibitors? nephrotic-range proteinuria from dasatinib but not imatinib (Gleevec) or nilotinib (Tasigna). Poss mech of action? disruption of the VEGF signaling pathway. dasatinib also assoc w pulm HTN, pleural effusions, myelosuppression.
Acidosis from NSAIDS caused by? blockade of prostaglandins and is usually hyperchloremic w/o anion gap.
nucleoside reverse transcriptase inhibitors (NRTI) adjustments for dialysis? give after dialysis, may cause of lactic acidosis.
Non-nucleoside reverse transcriptase inhibitors (NNRRTI) adjustments for dialysis? no adjustments needed for renal failure. have P450 3A4 interactions
T/F Venlafaxine (Effexor) overdose has been associated with seizures, serotonin syndrome, neuroleptic malignant syndrome, and rhabdomyolysis. TRUE
Sodium thiosulfate is used for? calcific uremic arteriolopathy. The drug is a strong acid, & causes +AGMA. In rare circumstances, the metabolic acidosis can be severe, requiring a dosage reduction.
How does acetaminophen toxicity causes AG? when there’s depletion of glutathione, pyroglutamic acid is overproduced in the presence of large amounts of acetaminophen
Renal effects of tenofovir? AKI and proximal tubular injury (fanconi syn) via mitochondrial toxicity.
Renal effects of indinavir? no adjustment needed. May cause Stones and interstitial nephritis
Renal effects of ritonavir? no adjustments needed. May cause AKI.
Renal effects of gentamicin? AKI, Fanconi syndrome, and Bartter-like syndrome.
Renal effects of Rosiglitazone (thiazolidinedione) increased renal salt retention and the development of edema.
Renal effects of Cisplatin? causes AKI, tubulopathies, Fanconi syndrome, salt wasting, and magnesium wasting, NDI, CKD
Renal effects of Amphotericin B? AKI and a distal renal tubular acidosis (RTA).
Renal effects of Mitomycin C? causes a thrombotic microangiopathy.
Renal effects of bevacizumab Anti-VGEF: anti-angiogenic agents that inhibit vascular endothelial growth factor (VEGF) signaling pathways regularly produce a rise in arterial pressure, often associated with HTN, proteinuria and renal dysfunction
Renal effects of IVIG AKI, hypoNa, pseudohypnatremia, + osm gap from maltose accumulation
Renal effects of Ifosfamide? Fanconi syndrome, proximal phosphate wasting, AKI, and nephrogenic diabetes insipidus. Renal tubular dysfunction can develop months after completing chemotherapy.
Renal effects of Paclitaxel? NONE! Not associated with any significant renal toxicity.
Renal effects of ciprofloxacin? - crystalline nephropathy d/t crystal precipitation in the renal tubules. Risk factors: excessive dose, alkaline urine, underlying kidney injury, and old age.
Renal effects of HES ? AKI, sometimes requiring dialysis, is more common when this drug is used in critically ill patients with sepsis and acute lung injury/acute respiratory distress syndrome (ARDS)
Renal effects of NSAIDS? HTN, edema, AKI (esp w/ vol depletion, lower renal blood flow or hyperCa), nephropathy (MCD or MGN), hyperK, hypoNa, AIN.
Mechanism of action of NSAIDs in kidney? Lower renin production through inh of PGs. Cause HYPORENIN/HYPOALDO (RTAIV)+ hyperK. Also, enhance [urine] ability via PGE2 that usu attenuates ADH effect—>counteract diuretic effect via lower RBF, inc UNa reabsorption in PCT,
Renal effects of Pentamidine? like amiloride, triamterene, and trimethoprim, pentam is associated with hyperkalemia by blocking the epithelial sodium channel in the principal cell in the cortical collecting duct.
Renal effects of linezolid therapy? lactic acidosis by disrupting mitochondrial function.
Renal effects of Acetaminophen? oxoproline acidosis in alcoholics and patients with poor nutrition due to the underlying glutathione and deficiencies these patient maintain.
Renal effects of Interferon? nephrotic syndrome (usu MCD) and AKI from AIN. Other glomerular lesions include FSGS and MGN.
The drugs most often noted in the published literature as causing AIN? antimicrobial agent. PPIs are likely the overall leading cause of drug-induced AIN, based on their massive use.
pts with HIV starting cART can develop ___. IRIS: restoring protective immune responses —> pathological inflammatory response (AIN)
Describe Acute phosphate nephropathy. Intense ppt of CaPhos in medulla>>cortex. The serum phosphate levels likely >7, resulting in phosphaturia. Recall crystals are needle-like. CaPhos stained using von Kossa stain, which will not stain calcium oxalate.
Hormonal effects of ACEIs ? raise plasma renin activity and renin levels, but lower AII and aldosterone
Hormonal effects of ARBs ? raise plasma renin activity, renin levels and AII levels, but lower aldosterone.
Hormonal effects of Aldosterone antagonists ? raise the levels of all of the hormones, but antagonize the mineral corticoid receptor.
Metformin requires adjustment and what stage of renal function? CKD4. Usual dosing acceptable in CKD 3/4 w/o increased incidence of lactic acidosis
Lithium nephrotoxicity may be prevented or treated by the use of ___. Amiloride is Rx of choice for NDI. (no hypoK & no need Na restrict thus less vol depletion). Also reduce Li uptake into cells. NOTE Li dosage may be affected by amiloride.
T/F Administration of activated charcoal is useful for lithium OD. FALSE because charcoal does not bind lithium ions. Consider polyethylene glycol
Preferred agent to bind lithium in G.I. tract? polyethylene glycol. especially important for patients who ingest a sustained-release lithium. Charcoal does not work.
Conventional hemodialysis can reduce plasma lithium by ___. 1 mEq/L per 4 h of treatment. High flux likely more effective, but unproven. HD does not clear intracellular lithium effectively, expect rebound.
Hemodialysis should be performed for lithium OD for what scenarios? coma, convulsions, respiratory failure, deteriorating mental status, or renal failure… or if lithium level fails to fall. Also strongly consider HD if level > 4 mEq/L, or levels 2.5-4 w CV or CNS symptoms. Seldom needed if lvl<2.5
Created by: ka1usg