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Prescribing in Renal Disease (Nephrotoxicity (Ciclosporin (↓ GFR:…
Prescribing in Renal Disease
Nephrotoxicity
Gentamicin
Renal tubular damage
→ Accumulation → ↑ nephro-/oto-toxicity
Must monitor drug levels
Li
Inhibits Mg-dependant enzymes
e.g. adenylate cyslase
ADH requires adenylate cyclase so
Li → nephrogenic DI
Also causes direct tubular damage
Must monitor drug levels
Ciclosporin
↓ GFR: reversible
Damages renal tubules: irreversible
P450 substrate
Consider monitoring
ACEi / ARB
↓GFR: inhibit efferent arteriorlar vasoconstriction
May be profound in RAS or CoA
NSAIDs
↓ GFR: prevent afferent arteriolar vasodilatation
Papillary necrosis
Important Drugs Affected by Renal Impairment
Digoxin
T½: 36 → 90hrs
Low therapeutic index: should be monitored
Toxicity
Nausea, xanthopsia, gynaecomastia
A / V tachyarrhythmias, heart block
Gentamicin
T½: 2.5 → >50hrs
Must be monitored
Toxicity
↑ risk of toxicity if ↓ Na (e.g. diuretics) or dehydration
Ototoxic: hearing + vestibular
Nephrotoxic tubules
Atenolol
T½: 6 → 100hrs
Toxicity
Bradycardia, hypotension
Worsening of PVD and heart failure
Confusion
CI
Asthma / bronchospasm
Severe heart failure
PVD
Amoxicillin
T½: 2 → 14hrs
Toxicity
Seizures (in meningitis: impaired BBB)
Rashes
Captopril
T½: 2 → 14hrs
Toxicity
Hypotension
Taste disturbance
Cough
↓ GFR
Angioedema
Vitamin D
Forms
Colecalciferol / D3: formed in skin and found in food
Ergocalciferol / D2: produced by UV light in fungi from ergosterol
Calcifediol: 25 OH-Vit D3 produced by the liver
Calcitriol: 1, 25, (OH)2 Vit D3, produced by the kidney
Alfacalcidol: 1 OH-Vit D3
Pathophysiology
25 OH-Vit D3 undergoes renal 1α-hydroxylation to the active form: 1, 25, (OH)2 Vit D3
Impaired 1α-hydroxylase function in renal disease
In Renal Impairment
Use alfacalcidol (1α-hydroxylated)
:check:
Calcitriol rarely used