Download Drug Doses in Renal Failure

Renal Replacement Therapy
Optimal Pre-ESRD Management
1. Preventing or slowing progression
2. Preventing complications of uremia such as
anemia, ROD & malnutrition
3. Preparing the patient for the RRT
4. Planning for the creation of a permanent
access for hemodialysis
5. Planning for hemodialysis initiation before
major symptoms of uremia arise
Renal Replacement Therapy

Dialysis

Hemodialysis
 In-center
 Home

Peritoneal dialysis
 IPD
 CAPD
 Cycler

dialysis
Transplantation
History



Dialysis is a Greek word meaning "loosening
from something else".
Dialysis is referred to as "selective diffusion."
Diffusion is the movement of material from
higher concentration to lower concentration
through a given membrane
Thomas Graham, Chairman of Chemistry at
University College, London, first discovered
this idea of selective diffusion
Dialysate

A chemical bath used in dialysis to draw
fluids and toxins out of the bloodstream
and supply electrolytes and other
chemicals to the bloodstream.
Composition of HD concentrate
solute
Acetate
dialysis
Bicarbonate
dialysis
Na (mEq/L)
K (mEq/L)
Chloride (mEq/L)
Mg (mEq/L)
Acetate (mEq/L)
Bicarbonate (mEq/L)
Glucose (g/dL)
130-145
0-4.0
96-111.5
0-4.0
33-42
0
0-0.25
137-143
0-4.0
100-111
0-2.5
2-4.5
30-35
0-0.25
10
AVF Creation in CRF
Cr clearance < 25 ml/min
 Serum Cr > 4 mg/dl
 Within 1 year of the anticipated need
for maintenance dialysis therapy

12
13
14
Starting HD IN CRF

HD should be initiated at a level of
residual renal function above which the
major symptoms of uremia usually
supervene:


9 < Cr cl < 14 ml/min
It may be necessary to initiate patients
even earlier in their course if they have
otherwise uncorrectable symptoms or
signs of renal failure
Hemodialysis Treatment
Progress in Therapy and
Technology Increases
Quality of Life for the
Patients
16
Hemodialysis Treatment
by Fresenius Medical Care
18
Initiation of dialysis in patients with
ARF
1. Refractory fluid overload
2. Hyperkalemia (plasma potassium
concentration >6.5 meq/L) or rapidly rising
potassium levels
3. Metabolic acidosis (pH < 7.1)
4. Azotemia (BUN > 80 to 100 mg/ dl)
Initiation of dialysis in patients with
ARF
5. Signs of uremia, such as pericarditis, or an
otherwise unexplained decline in mental
status
6. Severe dysnatremias (155 < Na < 120 meq/L)
7. Hyperthermia
8. Overdose with a dialyzable drug/toxin
Indications For Heparin-Free
dialysis


Pericaditis
Recent surgery, with bleeding complications or
risk. Especially:
 Vascular & cardiac surgery (within 7 days)
 Eye surgery (retinal & cataract)


Renal transplant
Brain surgery (within 14 days)
Indications For Heparin-Free dialysis





Coagulopathy
Thrombocytopenia
ICH
Active bleeding
Routine use for dialysis of acutely ill
patients by many centers
In Hospital Management of
Patients with CRF & ESRF
1. Diet regimen
2. Prevention of ARF
3. Restriction of blood sampling
4. Restriction of blood transfusion
5. Treatment of uremic bleeding
defects
6. Dose adjustments of drugs
7. Pre-operation dialysis
Risk Factors of ARF
1.
2.
3.
4.
5.
Renal Hypoperfusion
Preexisting Azotemia
Sepsis
Nephrotoxins
Electrolyte Disorders
Treatment of uremic bleeding
defects






Dialysis
DDAVP
0.3 μg/kg IV
3 μg/kg IN
Cryoprecipitate
RBC Transfusion
Conjugated estrogens
FFP
Drug Doses in Renal
Failure
Drug
Acetamin
ophen
Amikacin
Dose
GFR
method >50
I
D,I
GFR
Suppl
GFR
10after CAPD CRRT
<10
50
HD
q4h q6h q8h None
60 90%
q12h
30 70%
q1218h
Dose
for
None
GFR
10-50
Dose
20 for
2/3
15-20
30%
normal mg/l/ GFR
q2410-50
dose
d
48h
26
Renal Transplantation
Cadaveric Donor
Living Donor
Non related
Related
Spouse
28
29
30
Exclusionary Conditions for
Renal Transplantation







Patient will not live more than 1 year
Metastatic malignancy, not responsive
to therapy
Acute or chronic infections that are not
controlled
Severe psychiatric disease that impairs
patient's consent & compliance
Medical incompliance
Substance abuse
Immunologic incompatibilities
Criteria That Exclude a live Donor
Age < 18
Severe HTN
DM
Hx of nephrolithiasis
Impaired renal function
Morbid obesity
Strong family history of DM
FHx of hereditary nephritis or polycystic kidney
disease
9. Hypercoagulability
10. HIV, HB, HC infection
11. Uncontrolled psychiatric disorders
1.
2.
3.
4.
5.
6.
7.
8.
Drugs Used in Maintenance
Immunosuppression

Calcineurin Inhibitors
Cyclosporine
 Tacrolimus

Azathioprine
 Mycophenolate Mofetil
 Glucocorticoids

In Hospital Management of
Renal Transplant Patients
1. Diet regimen
2. Prevention of ARF
3. Restriction of blood sampling
4. Restriction of blood transfusion
5. Drugs interactions
6. Secondary adrenal insufficiency
7. Prevention of infection
8. Transplant drugs usage
HD in ARF
CAN DIALYSIS DELAY RECOVERY OF
RENAL FUNCTION?
 There is at least theoretical concern that
dialysis might have detrimental effects
on renal function. Three factors may be
important in this regard:



a reduction in urine output
induction of hypotension
complement activation resulting from a
blood-dialysis membrane interaction.
Dry Weight

The lowest weight a patient can
tolerate without the development of
signs or symptoms of intravascular
hypovolemia.
Dry Weight

Estimating dry Weight:
Liters of actual body water =
142 × liters of NTBW
Predialysis serum Na
= 142 × (60% × 60) = 38.72
132
38.72 – 36 = 2.72 lit
NTBW= Normal Total Body Water