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

1. 'Management, drugs and prescribing issues in Acute Renal Failure’ David Bennett-Jones Emily Horwill

2. 'Management, drugs and prescribing issues in Acute Renal Failure’‘Acute Kidney Injury’ David Bennett-Jones Emily Horwill

3. 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. 0 of 70 10

4. 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.

5. Acute Kidney Injury is most commonly diagnosed in the following age-groups: • 1 <= 45 years • 2 46-60 years • 3 61-75 years • 4 76-90 years • 5 >= 91 years

6. Acute Kidney Injury is most commonly diagnosed in which age-group? • <= 45 years • 46-60 years • 61-75 years • 76-90 years • >= 91 years 0 of 70 10

7. NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)

8. The percentage of patients with AKI which was avoidable... • <= 5% • 6-10% • 11-15% • 16-20% • >= 21% 0 of 70 10

9. NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)

10. NCEPOD report: Acute Kidney Injury: Adding Insult to Injury (2009)

11. The commonest risk factor for AKI is: • 1 Age • 2 Co-morbidity • 3 Medication • 4 Previous chronic kidney disease • 5 Hypovolaemia

12. The commonest risk factor for AKI: • Age • Co-morbidity • Medication • Previous chronic kidney disease • Hypovolaemia 0 of 70 10

14. How would you classify AKI? • Acute tubular / acute cortical necrosis • Hypovolaemic/cardiogenic/septic • Nephrotoxic/Metabolic • Pre-renal, renal, post-renal • Hypovolaemic /nephritic /nephrotic /obstructive 0 of 70 10

15. Other important risk-factors for AKI are: • Vascular disease • Diabetes • Myeloma • Heart failure • Respiratory failure 0 of 70 10

16. Which of the following was the most commonly omitted investigation? • Ultrasound • Acid base balance • Volume status • Urinalysis • MEWS • Sepsis recognition • Biochemistry • Renal biopsy 0 of 70 10

18. 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

19. 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 0 of 70 10

21. Within how many days should a patient with AKI be referred to a nephrogist? • <1 day • 1-2 days • 3-4 days • 5-6 day • > 7days

22. Within how many days should a patient with AKI be referred to a nephrogist? • <1 day • 1-2 days • 3-4 days • 5-6 day • > 7days 0 of 70 10

24. The syndrome of established acute renal failure with normal-sized kidneys

25. 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

26. Team Scores

27. Prescribing in patients with acute kidney injury Emily Horwill Renal Pharmacist

28. 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?

29. Points to consider • Some nephrotoxic drugs affect the kidney in several ways • If in doubt – stop drug and seek specialist advice

30. Pre-renal causes • Diuretics • Laxatives – can exacerbate dehydration • NSAIDs - remember COX-2 inhibitors • ACEis • Low BP – stop antihypertensives! • Lithium toxicity can cause intravascular depletion

31. 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!

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

33. Post-renal causes • Anti-muscarinics – may cause retention of urine leading to hydronephrosis

34. Problem drugs • Metformin – will need to switch to alternative • Tetracyclines – doxycycline OK • Nitrofurantoin – not effective • Gentamicin – caution, see intranet guidelines

35. 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

36. 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.

37. Answer

38. Answer

39. 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.

40. 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

41. 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.

42. 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.

44. 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

45. 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

46. 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