Download Clinical Pharmacy - PHARMACEUTICAL REVIEW

‫بسم هللا الرحمن الرحيم‬
Clinical Pharmacy in
Pediatric Nephrology
Ihab El-Hakim
Clinical Pharmacy
Is the branch of pharmacy in which
pharmacists provide patient care that
optimizes medication therapy and promotes
health, wellness, and disease prevention. Its
practice is centered inside the hospitals and
clinics in company with physicians for the
purpose of ensuring optimal medications’
prescription. A clinical pharmacist should
have a foundational understanding of the
biomedical,
pharmaceutical,
sociobehavioral, and clinical sciences (American
College of Clinical Pharmacy, www.accp.com).
Pediatric Nephrology
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Functional anatomy of the kidney
Physiological roles of the kidney and UT
Drug handling by the kidney
Clinical conditions (presentations, investigations, therapy)
– Glomerular: AGN, MLNS
– Tubular: deToni-Debré-Fanconi syndrome
– Hypertension
– UTI
• Chronic renal failure, drugs in CRF
• Dialysis, drugs and dialysis
• Transplantation
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the kidney
Functional anatomy of the UT
Physiology
• 1.3 million nephrons in each kidney
• The total area of the glomerular capillary
endothelium across which filtration occurs is
about 0.8 m2.
• The filtration slits are approximately 25 nm
wide and each is closed by a thin membrane.
They permit passage of neutral substances
up to 4 nm diameter and almost totally
exclude substances with 8 nm or greater
diameter. Also charges on the molecules
affect their passage.
Physiology
• Glomerular function FILTRATION
– Renal blood flow (RBF) about 25% of cardiac
output. More in cortex than medulla.
– Glomerular capillary pressure 40% of
systemic arterial pressure.
– Various substances affect the afferent or
efferent arterioles differently hence the net
effect on glomerular filtration pressure varies.
– Clearance of a substance: is the volume of
plasma cleared from that substance per
minute. Most commonly used is creatinine.
Clearance = (Ucrx V)/(Pcr)
(mg/ml x ml/min)/(mg/ml)
Physiology
• Tubular functions REABSORPTION and
SECRETION
Physiology
Physiology
• Bladder function STORAGE and
MICTURITION
Drug handling by the kidney
• Kidneys are involved in the process of
elimination of drugs.
• Drugs may be filtered, reabsorbed or
secreted by glomeruli and tubules in an
active or inactive form.
• Filtrtation is passive and nonsaturable.
Protein-bound drugs are poorly filtered.
• Weak acid drugs are secreted in PCT.
• Lipid soluble drugs are rapidly reabsorbed.
• Some drugs may be metabolized in the
kidney.
Some Clinical Conditions
Glomerular diseases
Acute glomerulonephritis
• Commonest cause is post streptococcal
• Triad of oliguria, gross hematuria and hypertension.
• In some cases there may be proteinuria or renal
impairment.
• Investigations: urine analysis, renal functions, ASOT,
serum electrolytes, serum C3.
• Therapy includes fluid and salt restriction,
antihypertensive drugs, antistreptococcal antibiotics.
In rare conditions dialysis may be required.
Some Clinical Conditions
Glomerular diseases
Minimal lesion nephrotic syndrome
• Age 2-8 years
• Albuminuria, hypoalbuminemia,
hypercholoesterolemia, generalized edema.
• In some cases there may be hematuria,
hypertension or renal impairment.
• Investigations: urine analysis, renal functions, serum
lipids and proteins, CBC.
• Therapy includes ample fluid intake, high protein
diet, diuretics and albumin transfusion are
controversial, corticosteroids in max dose except in
presence of hypertension or infection
Some Clinical Conditions
Tubular diseases
De Toni-Debré-Fanconi syndrome
• Generalized proximal renal tubular dysfunction with
impaired reabsorption of aa, bicarbonate, glucose,
P, urate, Na, K, Mg, Ca and low molecualr weight
proteins
• Either priamary or secondary.
• Polyuria, dehydration, metabolic acidosis and
glucosuria. Growth retardation and rickets
• Investigations: urine analysis, serum electrolytes,
ABG.
• Therapy includes replacement of all substances lost
in urine to keep their serum levels within normal.
Some Clinical Conditions
Systemic hypertension
Some Clinical Conditions
Systemic hypertension
• Non-pharmacological treatment
• Pharmacological treatment
• Investigations, prevention and treatment of
complications
Some Clinical Conditions
Urinary tract infection
• May be lower or upper UTI
• Symptoms of lower UTI include dysuria,
frequency, hematuria, suprapubic pain.
Upper UTI presents with fever, loin pain.
• Investigations: urine analysis, culture and
antibiotic sensitivity, CBC.
• Recurrence warrants investigation for
predisposing factors.
Chronic Renal Failure
• Progressive and usually irreversible loss of renal
function. GFR <= 60 ml/min/1.73m2
• End stage renal disease (ESRD) ehen life cannot be
maintained without renal replacement therapy
(dialysis or transplantation). GFR<10-15
ml/min/1.73m2
• Clinical symptoms:
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Oligo-polyhydramnios
Failure to thrive
Anorexia, nausea, vomiting, fatigue
Pruritis
Oliguria, polyuria
Delayed puberty
Pallor
Bone deformities
Hypertension
Edema
Chronic Renal Failure
• Metabolic abnormalities
– Hyponatremia
– Hyperkalemia
– Metabolic acidosis
– Hyperuricemia
– Hypocalcemia
– Hyperphosphatemia
• Renal osteodystrophy
– Hypovitaminosis D
– Hyperparathyroidism
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Anemia
Growth failure
Delayed puberty
Cardiovascular disease
GI bleeding
Platelet dysfunction
Treat hypertension
Reduce proteinuria
Correct anemia
Reduce salt and fluid intake
Control hyperlipidemia
Control hyperphosphatemia
Control hyperkalemia
Treat renal osteodystrophy
Revise drugs and their doses
Dialysis
• Principle
• Indications
– Clinical manifestations (encephalopathy,
pericarditis)
– Metabolic problems not responding to medical
treatment
– Fluid overload
– Rapid rise in parameters of renal function.
• Modalities
– Peritoneal dialysis (PD)
– Hemodialysis (HD)
Dialysis
Dialysis
PD
HD
Drugs in Chronic Renal Failure
and Dialysis
Drugs in Chronic Renal Failure
and Dialysis
Renal Transplantation
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Team
Donor
Recipient
Preparation
Procedure
Protocol
Follow up
Complications
Rejection