'Management, drugs and prescribing issues in Acute Renal Failure’

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'Management, drugs and prescribing issues in
Acute Renal Failure

• David Bennett-Jones
• Emily Horwill

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'Management, drugs and prescribing issues in
Acute Renal FailureAcute Kidney Injury

• David Bennett-Jones
• Emily Horwill

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Please select a Team.

• Before starting my medical studies at WUMS I had
  significant previous experience in clinical work
  such as nursing/AHP/pharmacy.
• 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.

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Acute Kidney Injury is most commonly diagnosed in
the following age-groups

• 1 lt 45 years
• 2 46-60 years
• 3 61-75 years
• 4 76-90 years
• 5 gt 91 years

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Acute Kidney Injury is most commonly diagnosed in
which age-group?

• lt 45 years
• 46-60 years
• 61-75 years
• 76-90 years
• gt 91 years

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NCEPOD report Acute Kidney Injury Adding Insult
to Injury (2009)
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The percentage of patients with AKI which was
avoidable...

• lt 5
• 6-10
• 11-15
• 16-20
• gt 21

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NCEPOD report Acute Kidney Injury Adding Insult
to Injury (2009)
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NCEPOD report Acute Kidney Injury Adding Insult
to Injury (2009)
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The commonest risk factor for AKI is

• 1 Age
• 2 Co-morbidity
• 3 Medication
• 4 Previous chronic kidney disease
• 5 Hypovolaemia

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The commonest risk factor for AKI

• Age
• Co-morbidity
• Medication
• Previous chronic kidney disease
• Hypovolaemia

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How would you classify AKI?

• 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

• Vascular disease
• Diabetes
• Myeloma
• Heart failure
• Respiratory failure

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Which of the following was the most commonly
omitted investigation?

• 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

• Correction of hypovolaemia
• Administration of inotropes
• Administration of diuretics
• Stop nephrotoxic drugs
• Adjust drug doses for renal failure

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What is the most important intervention in AKI

• 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?

• lt1 day
• 1-2 days
• 3-4 days
• 5-6 day
• gt 7days

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Within how many days should a patient with AKI be
referred to a nephrogist?

• lt1 day
• 1-2 days
• 3-4 days
• 5-6 day
• gt 7days

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The syndrome of established acute renal failure
with normal-sized kidneys
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If a patient has ARF with normal sized kidneys
you should...

• 1 Consider a diagnosis of cardiac failure T
  F D
• 2 Consider nephrotoxic renal failure T F
  D
• 3 Consider glomerulonephritis T F D
• 4 Consider vasculitis T F D
• 5 Consider hypercalcaemia T F D
• 6 Consider myeloma T F D
• 7 Consider diabetes T F D
• 8 Consider early specialist referral for biopsy
  T F D

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Team Scores
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Prescribing in patients with acute kidney injury

• Emily Horwill
• Renal Pharmacist

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Points to consider

• What is the suspected cause of the patients
  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?

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Points to consider

• Some nephrotoxic drugs affect the kidney in
  several ways
• If in doubt stop drug and seek specialist advice

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Pre-renal causes

• Diuretics
• Laxatives can exacerbate dehydration
• NSAIDs - remember COX-2 inhibitors
• ACEis
• Low BP stop antihypertensives!
• Lithium toxicity can cause intravascular
  depletion

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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!

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• Obstructive uropathy blockage of tubules
• Statins rhabdomyolysis causing myoglobinuria
• Allergic/hypersensitivity reactions lots of
  drugs

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Post-renal causes

• Anti-muscarinics may cause retention of urine
  leading to hydronephrosis

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Problem drugs

• Metformin will need to switch to alternative
• Tetracyclines doxycycline OK
• Nitrofurantoin not effective
• Gentamicin caution, see intranet guidelines

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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

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• 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.

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Answer
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Answer
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• 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.

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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

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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.

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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.

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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

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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

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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