Drug induced Kidney Disease

Question 1

What are the 2 most common manifestations of drug induced kidney disease?

Answer 1

1. GFR decrease

2. CR and BUN increase

Question 2

What causes acute tubular necrosis (tubular epithelial cell damage)?

Answer 2

1. Aminoglycosides
2. Radiocontrast
3. Cisplatin (chemo)
4. Amphotericin B
5. Cyclosporine

Question 3

Causes of hemodynamically mediated kidney injury?

Answer 3

1. ACE
2. ARB
3. NSAIDs

Question 4

Medications that are affected by edema which increase the volume of distribution (3)

Answer 4

1. Vancomycin
2. Aminoglycosides
3. Heparin (low-molecular weight)

Question 5

Most common electrolyte disorder?

Answer 5

Hyperkalemia

Question 6

Name aminoglycosides by order or toxicity (related to number of cationic groups)

Answer 6

Neomycin > gentamicin > tobramycin > amikacin

Question 7

How are aminoglycosides adjusted?

Answer 7

based on serum levels

Question 8

Aminoglycoside nephrotoxicity: clinical presentation

Answer 8

• Nonoliguria
• reversible, full recovery
• 5-10 days after therapy initiation

Question 9

What do aminoglycosides have synergistic toxicity with?

Answer 9

NSAIDs

Question 10

What is important to recommend to a patient who is about to take aminoglycoside?

Answer 10

avoid volume depletion (stay hydrated)***

Question 11

In pre-existing kidney disase (GFR <60ml/min) what two meds should be avoided?

Answer 11

1. NSAID

2. ACE

Question 12

Since contrast-induced nephrotoxicity is a problem with renal blood flow, who is at higher risk?

Answer 12

• CHF
• Dehydration
• Hypotension
• Diabetes*

Question 13

Amphotericin B Nephrotoxicity: Key presentation

Answer 13

1. Potassium, sodium, magnesium wasting*
2. Dysfunction apparent in 1-2 weeks
3. Decrease in GFR
4. Damage may be irreversible!***

Question 14

When will contrast-induced nephrotoxicity present?

Answer 14

within 24-48 hours
(peaks at day 3-5)
(recovery in 7-10 days)

Question 15

What can be done to help prevent amphotericin B nephrotoxicity? (2)

Answer 15

1. Switch to liposomal form (high risk patients)

2. Increase infusion time

Question 16

Cyclosporine nephrotoxicity

Answer 16

1. Dose dependent

2. Kidney biopsy may be needed to determine transplant rejection versus cyclosporine toxicity

Question 17

ACE and ARB - nephrotoxicity

Answer 17

• decrease in urine output (oligouria)
• GFR reduced, creatinine increase up to 30% within 3 to 5 days (stabilizes in 1-2 weeks)
• Reversible

Question 18

Where does ACE medication work on the glomerulus?

Answer 18

keeps the efferent arteriole dilated

Question 19

Risk fator for ACE and ARB nephrotoxicity

Answer 19

1. Renal artery stenosis

2. Hypovolemic

Question 20

How to prevent ACE nephrotoxicity?

Answer 20

-Choose shorter acting agent in high risk patients

Captopril, enalapril > lisinopril, benazepril

Question 21

Where do NSAIDs affect the glomerulus?

Answer 21

afferent arteriole

inhibit synthesis of protaglandins which are vasodilatory –>promotes renal ischemia and GFR reduction

Question 22

NSAID nephrotoxicity: presentation

Answer 22

• within days of hypovolemia
• oligouria
• weight gain or edema
• Creatinine, BUN, K+, BP are elevated

Question 23

NSAID nephrotoxicity: risk factor?

Answer 23

Age >60

Question 24

NSAID nephrotoxicity: prevention

Answer 24

• Avoid indomethacin (for gout) in high risk

- Use acetaminophen (less PGE inhibition)

Question 25

Name the drugs that cause acute allergic interstitial nephritis (5)

Answer 25

1. Penicillins (Methicillin) 2. Ciprofloxacin 3. NSAIDs, COX2 4. PPIs (ex. lanoprazol) 5. Loop diuretic (furosemide)

Question 26

Which drug is notorious for causing chronic interstitial nephritis?

Answer 26

cyclosporine

Question 27

Which drug is notorious for causing papillary necrosis?

Answer 27

NSAIDs

Question 28

Methicillin-Induced Allergic Interstitial Nephritis: clinical

Answer 28

- 14 days after starting antibiotics - Fever - Rash - Eosinophilia - Arthralgia - Oligouria

Question 29

Methicillin-induced Allergic interstitial nephritis: treatment

Answer 29

STEROIDS!

Question 30

Which drugs/conditions are associated with intratubular obstruction via crystal preciptiates?

Answer 30

1. Acyclovir 2. Sulfonamides (can also cause nephrolithiasis!) [ex. prostatitis] 3. Methotrexate 4. Hyperuricemia

Question 31

Which drugs can cause precipitation of myoglobin from rhabdo?

Answer 31

HMG-CoA reductase inhibitors (lipophilic) Ex. Simvastatin, Lovastatin

Question 32

Which drugs can cause nephrolithiasis?

Answer 32

1. Ciprofloxacin 2. Amoxicillin 3. Nitrofurantoin (Macrobid)

Question 33

Which drugs (2) can cause vasculitis and thrombosis?

Answer 33

1. Hydralazine (vasodilator) | 2. Methamphetamines

Question 34

Which 2 drugs are associated with cholesterol emboli?

Answer 34

1. Warfarin 2. Thrombolytic agents * *Purple discoloration of the toes and mottled skin on the legs***

Question 35

Which drugs cause glomerular disease and nephrotic range proteinuria?

Answer 35

1. NSAIDs** 2. Gold 3. Lithium 4. Pamidronate