Pharmacologic Aspects of Renal Drug Clearance

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Pharmacologic Aspects of Renal Drug Clearance - #7

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Review pharmacologic aspects of renal drug clearance.

Assessment

Pharmacological considerations

PDF of Table

 

Considerations

Adverse Effects

Action

ACE-Inhibitors and ARB's

Interferes with autoregulation of renal blood flow

Hyperkalemia, decreased GFR

Check K+ and GFR one week after starting medication.

Antibiotics (Aminoglycosides, Vancomycin)

Chronic comorbidities such as CHF, HTN, and DM predispose to development of severe tubular injury.

Decreased GFR (elevated SCr), ATN, ototoxicity

Evaluate renal function prior to starting therapy (MDRD). Consider pharmacologic profiling. Avoid combinations with potentially nephrotoxic mediations.

NSAID

Interferes with autoregulation of renal blood flow

Decreased GFR, ATN, falls, GI bleeding

Consider alternative analgesic or adjuvant therapy (ice/heat packs), monitor renal function

Opiates

Morphine, meperidine, dextroporoxyphene  or their metabolites can accumulate.

Altered mental status, respiratory depression, hyponatremia (SIADH)

Consider regular doses of long acting +/- prn breakthrough doses.

Reassess every 3-5 days

Preferred opiates include hydromorphone and fentanyl.

Oral Hypoglycemics (Glyburide, extended release glipizide)

Long acting sulfonylureas

Hypoglycemia

Consider using shorter acting sulfonylurea (glimepiride)

Radiocontrast

Chronic comorbidities such as CHF, HTN, and DM predispose to development of severe tubular injury.

Decreased GFR (elevated SCr), ATN

Evaluate renal function prior to use of contrast. Consider pre-procedure IV hydration, N-acetylcysteine, Vitamin C, or iso-osmolar contrast.
 
 

Context

Patient in a hospital or other healthcare facility.

Action

Elderly patient requires pharmacotherapy.

Incidence / Prevalence

According to the CDC, just over 40% of the US population over 65 has chronic kidney disease1.

Underlying Sciences

Genetic factors, replicative senescence and oxidative stress are all felt to "age" the kidney so that there is arterial sclerosis with hypoxic and ischemic injury that lead to glomerular sclerosis, tubular atrophy, and interstitial fibrosis. The net effect is the decline in renal function (decrease in GFR, decreased diluting capacity and concentrating ability).

  • The abbreviated version or four variable version of the Modification of Diet in Renal Disease (MDRD) equation (ml/min per 1.73 m2)
  • Estimated Glomerular Filtration Rate (eGFR) = 186 x (SCr) -1.154  x (Age) -0.203x 0.742 (if patient is female) x1.212 (if patient is black)
  • The Cockcroft-Gault (C & G)equation:

Est. Creatinine Clearance = [[140 - age(yr)] x weight(kg)]/[72 x serum Cr(mg/dL)]
(multiply by 0.85 for women).

Science Principles

Impaired homeostasis

Objectives

  1. To ascertain patient’s current renal function prior to adding/changing pharmacotherapy.
  2. To recognize common adverse effects by drug type/class related to renal function.

Keywords/Tags

Review of Systems (ROS)

Gastrointestinal
Renal and Urinary

Geriatric Topics

Medication Management

ACGME Compentencies

Medical Knowledge
Patient Care
Systems-based Practice

Science Principles

Impaired homeostasis

References

  1. National Chronic Kidney Disease Fact Sheet
  2. Online Geriatrics Curriculum - American Society of Nephrology
  3. Zhou XJ, Rakheja D, Yu X, Saxena R, Vaziri, ND, Silva FG. The Aging Kidney. Kidney International (2008) 74(6):710–720.
  4. PHARMACIST’S LETTER / PRESCRIBER’S LETTER, September 2007 ~ Volume 23 ~ Number 230907, Treatment of type 2 diabetes mellitus 2006 ~Volume 22(11) ~ Number221103
This GFF ___ my competence in geriatrics.

Authors

Edmund Duthie, MD, Christopher J Anderson, Brahm Vasudev

Author Affiliation

Medical College of Wisconsin, Milwaukee, Wisconsin.

Copyright

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