Transcript `Management, drugs and prescribing issues in Acute Renal Failure`

'Management, drugs and
prescribing issues in
Acute Renal Failure’
David Bennett-Jones
Emily Horwill
'Management, drugs and
prescribing issues in
Acute Renal Failure’
‘Acute Kidney Injury’
David Bennett-Jones
Emily Horwill
Please select a Team.
1. Before starting my medical
studies at WUMS I had
significant previous experience
in clinical work such as
nursing/AHP/pharmacy.
2. I had no previous relevant
experience before starting at
WUMS.
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The definition of AKI:
• Acute kidney injury is a clinical syndrome characterised by a rapid
reduction in renal excretory function underpinned by a variety of
causes. RA website 02/01/10
• SUMMARY OF CLINICAL PRACTICE GUIDELINES
•
• 1. Acute Kidney Injury (AKI) (Guidelines AKI 1.1 – 1.2)
• Guideline 1.1 – AKI : Definition and Epidemiology
• An internationally accepted and agreed uniform definition of acute kidney
injury (AKI) should be adopted to enable comparisons of incidence and
outcomes, assess the utility of severity of illness scoring systems, and
interpret the efficacy of therapeutic interventions
• Guideline 1.2 – AKI : Definition and Epidemiology
• Serum creatinine and urine output should continue to be viewed as the
best existing markers for AKI.
Acute Kidney Injury is most
commonly diagnosed in the
following age-groups:
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<= 45 years
46-60 years
61-75 years
76-90 years
>= 91 years
Acute Kidney Injury is most commonly
diagnosed in which age-group?
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<= 45 years
46-60 years
61-75 years
76-90 years
>= 91 years
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NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)
The percentage of patients with
AKI which was avoidable...
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<= 5%
6-10%
11-15%
16-20%
>= 21%
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NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)
NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)
The commonest risk factor for AKI
is:
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1 Age
2 Co-morbidity
3 Medication
4 Previous chronic kidney disease
5 Hypovolaemia
The commonest risk factor for AKI:
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Age
Co-morbidity
Medication
Previous chronic
kidney disease
5. Hypovolaemia
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How would you classify AKI?
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Acute tubular / acute cortical necrosis
Hypovolaemic/cardiogenic/septic
Nephrotoxic/Metabolic
Pre-renal, renal, post-renal
Hypovolaemic /nephritic /nephrotic /obstructive
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Other important risk-factors for AKI are:
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Vascular disease
Diabetes
Myeloma
Heart failure
Respiratory failure
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Which of the following was the most
commonly omitted investigation?
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Ultrasound
Acid base balance
Volume status
Urinalysis
MEWS
Sepsis recognition
Biochemistry
Renal biopsy
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What is the most important
intervention in AKI:
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Correction of hypovolaemia
Administration of inotropes
Administration of diuretics
Stop nephrotoxic drugs
Adjust drug doses for renal failure
What is the most important intervention in AKI:
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Correction of hypovolaemia
Administration of inotropes
Administration of diuretics
Stop nephrotoxic drugs
Adjust drug doses for renal failure
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Within how many days should a
patient with AKI be referred to a
nephrogist?
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<1 day
1-2 days
3-4 days
5-6 day
> 7days
Within how many days should a patient
with AKI be referred to a nephrogist?
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<1 day
1-2 days
3-4 days
5-6 day
> 7days
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The syndrome of established acute renal
failure with normal-sized kidneys
If a patient has ARF with normal sized kidneys you
should...
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Consider a diagnosis of cardiac failure
Consider nephrotoxic renal failure
Consider glomerulonephritis
Consider vasculitis
Consider hypercalcaemia
Consider myeloma
Consider diabetes
Consider early specialist referral for biopsy
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Prescribing in patients with
acute kidney injury
Emily Horwill
Renal Pharmacist
Points to consider
• What is the suspected cause of the patient’s
renal failure?
• What medication is the patient currently taking?
Is it appropriate for their renal function?
• Are any drugs contraindicated in renal
impairment/failure?
• What do I need to give the patient? Is it
appropriate for their renal function?
Points to consider
• Some nephrotoxic drugs affect the kidney
in several ways
• If in doubt – stop drug and seek specialist
advice
Pre-renal causes
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Diuretics
Laxatives – can exacerbate dehydration
NSAIDs - remember COX-2 inhibitors
ACEis
Low BP – stop antihypertensives!
Lithium toxicity can cause intravascular
depletion
Intra-renal causes
• Many drugs can cause direct damage to
kidney – often caused by high levels and
accumulation
• Gentamicin, furosemide ,iodine contrast
• Analgesic nephropathy
• High levels of immunosuppressants can
cause ATN – do not stop!
• Obstructive uropathy – blockage of tubules
• Statins – rhabdomyolysis causing
myoglobinuria
• Allergic/hypersensitivity reactions – lots of
drugs
Post-renal causes
• Anti-muscarinics – may cause retention of
urine leading to hydronephrosis
Problem drugs
• Metformin – will need to switch to
alternative
• Tetracyclines – doxycycline OK
• Nitrofurantoin – not effective
• Gentamicin – caution, see intranet
guidelines
Problem Drugs
• Drugs that may increase Na+ or K+
• Potassium sparing diuretics,
spironolactone, ACEis
• Some laxatives e.g. Fybogel and Movicol
contain K+ and Na+
• Soluble tablets – beware Na+ content
• A patient is transferred from an
orthopaedic ward with acute kidney injury
and a potassium of 6.7. The hospital
guidelines state you should prescribe
calcium resonium 15g tds and 50ml of
glucose 50% with 10 units of actrapid
insulin. Prescribe these on the appropriate
sections of the chart.
Answer
Answer
• A patient is admitted with acute kidney
injury and nephrotic syndrome and is fluid
overloaded. The consultant asks you to
prescribe furosemide 120mg IV as a stat
dose. Prescribe in a suitable volume and
diluent and at a suitable rate.
From e-BNF (Appendix 6)
• Furosemide/Frusemide (as sodium salt)
• (Lasix®)
• Continuous in Sodium chloride 0.9% or
Ringer's solution
• Infusion pH must be above 5.5 and rate
should not exceed 4 mg/minute; glucose
solutions are unsuitable
From e-BNF (Appendix 6)
• Drugs for continuous infusion must be diluted
in a large volume infusion. Penicillins and
cephalosporins are not usually given by
continuous infusion because of stability
problems and because adequate plasma and
tissue concentrations are best obtained by
intermittent infusion. Where it is necessary to
administer them by continuous infusion, detailed
literature should be consulted.
From NHS IV administration guide
(on intranet)
• The infusion volume is not critical,
provided the maximum rate (4mg per
minute) is not exceeded.
• Therefore if patient overloaded can give in
minimum volume of saline to allow to give
over at least 30 mins.
Useful sources of info
• South West Medicines Information Centre
• A regional centre specialising in drugs in
renal failure
• Can be contacted through UHCW MI
• www.swmit.nhs.uk/Renal.htm
• Renal pharmacist if your hospital has a
renal unit
Useful sources of info
• Renal Drug Handbook (3rd Ed)
• Published by Renal Pharmacist Group, a
“renal” BNF, also contains information on
unlicensed indications – on google books
• Copies kept at UHCW
Useful sources of info
• Medicine Summary of Product
Characteristics
• www.medicines.org.uk
• Technical data provided by drug company
• Gives detailed information about drug
• Company medical information details