Renal

Question 1

Indication/MOA for Carvedilol

Answer 1

CHF
CAD
HTN

MOA - rate and BP control

Question 2

Indication/MOA for Lisinopril

Answer 2

CHF
CKD
HTN

MOA - RAAS inhibitor/ BP control

Question 3

Indication/MOA for Furosemide

Answer 3

CHF

MOA - diuretic

Question 4

Indication/MOA for Coumadin

Answer 4

A fib

MOA - “blood thinner”

Question 5

Indication/MOA for Digoxin

Answer 5

CHF
Afib

MOA - inotrope/rate control

Question 6

What can happen if you combine digoxin and furosemide?

Answer 6

Loop diuretics can cause hypokalemia

Hypokalemia —> increased risk of digoxin toxicity

Question 7

What can happen if you mix digoxin and carvedilol?

Answer 7

Risk of bradycardia and AV block

Question 8

What can happen if you mix furosemide, carvedilol, and lisinopril?

Answer 8

All can lower BP —> increased risk of hypotension

Question 9

What does digoxin toxicity look like?

Answer 9

CARDIAC ARRHYTHMIAS

GI - anorexia, N/V/D, abdominal pain

Neuro - confusion, weakness, lethargy, fatigue, delirium, disorientation

Visual disturbances

Question 10

What do we need to know about the pharmacodynamics of digoxin?

Answer 10

Cleared RENALLY

Half-life = 1.5-2 days, 3.5-5 days if anuric

NARROW MARGIN OF SAFETY

Question 11

Does serum digoxin level correlate with toxicity?

Answer 11

Not necessarily

Ideally, sample should be collected >6 hours after last dose

Toxic level >2ng/mL

Possible to have the following:
• Asymptomatic pt with toxic level
• Significant toxicity with a therapeutic range serum level

Question 12

How do you manage a digoxin-induced AKI?

Answer 12

Appropriate fluid resuscitation
Monitor I&Os
Replenish/monitor potassium

Question 13

Why do you get hyperkalemia with ACE inhibitors?

Answer 13

B/c of decreased potassium excretion

Question 14

What drugs can affect GFR?

Answer 14

Lisinopril and Ibuprofen

Question 15

How do ACE inhibitors affect GFR?

Answer 15

Vasodilator Effect on the EFFERENT arteriole —> causes back up in the glomerulus

Question 16

How do NSAIDs affect GFR?

Answer 16

Vasoconstriction of the AFFERENT arteriole —> more flow through the glomerulus

Question 17

How will you manage an ibuprofen/lisinopril induced AKI?

Answer 17

Begin IVF with NSs
Monitor I&Os
Management of hyperkalemia (including d/c lisinopril)
Consult nephrology - dialysis?
D/c ibuprofen

Question 18

Name the stage of renal disease:

Kidney damage w/ normal or inc GFR (≥90)

Answer 18

Stage 1

Question 19

Name the stage of renal disease:

Kidney damage with normal or decreased GFR (60-89)

Answer 19

Stage 2

Question 20

Name the stage of renal disease:

Mild-mod reduced GFR (45-59)

Answer 20

Stage 3a

Question 21

Name the stage of renal disease:

Moderate to severe reduced GFR (30-44)

Answer 21

Stage 3b

Question 22

Name the stage of renal disease:

Severely reduced GFR (15-29)

Answer 22

Stage 4

Question 23

Name the stage of renal disease:

Kidney failure (<15 or on dialysis)

Answer 23

Stage 5

Add “D” if on dialysis

Question 24

What is the CURB-65 criteria?

Answer 24

For determining if you patient with PNA needs admission

Confusion
Urea >7 (or BUN >20)
Respiratory rate ≥30 
BP <90/60
65 years or older

Question 25

Would a patient with PNA be considered uncomplicated or complicated if they also have DM?

Answer 25

Complicated

Question 26

What do you need to think about when prescribing abx for a patient’s PNA if they have kidney disease/injury?

Answer 26

Allergies Route (IV vs PO) Renal dosing

Question 27

What do we use to determine renal dosing?

Answer 27

Use different equations to measure estimated creatinine clearance or eGFR • CKD-EPI (newest) • MDRD • Cockcroft and Gault (oldest)

Question 28

What would be a good option for outpatient CAP for a diabetic patient?

Answer 28

Levofloxacin, adjusted for CrCl (if GFR<50, give q48 hours instead of qd b/c not cleared as quickly)

Question 29

What are we worried about in a patient taking metformin in the setting of kidney disease/impairment?

Answer 29

Lactic Acidosis Advise the patient to stop taking it in cases of N/V or dehydration

Question 30

What medications for acute cystitis require renal dosing?

Answer 30

Bactrim - for CrCl <30 ml/min reduce dose by 50% (avoid in pt with CrCl <15 ml/min) Pyridium - for CrCl 50-80 give q 12-16 hours, contraindicated if CrCl<50 Nitrofurantoin (Macrobid)

Question 31

What is the Beers Criteria?

Answer 31

Use bactrim with caution in patients with decreased kidney function who are receiving ACE/ARBs b/c elevated risk of hyperkalemia

Question 32

Common meds that require renal dosing

Answer 32

``` Nitrofurantoin Allopurinol Acyclovir Gabapentin Preganglionic Metoclopramide Ranitidine Rivaroxaban Enoxaparin Lithium Clarithromycin Gentamicin Vancomycin ```