Pharm-D candidate (KSU)

Transcription

1 Topic review & case presentation Noor Naif Al-Hakami Pharm-D candidate (KSU) 2014

2 According to The National Kidney Foundation Kidney Disease Outcome Quality Initiative (KDOQI): Kidney damage for more than 3 months, as defined by structural or functional abnormality of the kidney, with or without decreased GFR, manifested by either pathologic abnormalities or markers of kidney damage, including abnormalities in the composition of blood or urine or abnormalities in imaging tests OR GFR less than 60 ml/minute/1.73m2 for 3 months, with or without kidney damage ACCP Updates in Therapeutics 2013

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4 It has been estimated that more than 10% of adults in the United States more than 20 million people may have CKD, of varying levels of seriousness The number of people in each stage of CKD is unknown in Saudi Arabia, however patients in ESRD on dialysis is an exception as data is collected by Saudi Center for Organ transplantation (SCOT) The dialysis statistics prepared by (SCOT) at the end of year 2011 showed a total of 13,356 dialysis patients, 12,116 of them are treated by Hemodialysis and the remaining 1,240 by peritoneal dialysis Dialysis in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 May 17];23: Available from:

5 1. Diabetes (40% of new cases of ESKD in the United States) 2. Hypertension (25% of new cases) 3. Glomerulonephritis (10%) 4. Others Urinary tract disease, polycystic kidney disease, lupus, analgesic nephropathy, unknown Glomerulonep hritis 10% Others 25% Hypertension 25% Diabetes 40% ACCP Updates in Therapeutics 2013

6 Dialysis in the Kingdom of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 May 17];23: Available from:

7 Susceptibility (associated with an increased risk, but not proved to cause CKD): Advanced age, reduced kidney mass, low birth weight, racial/ethnic minority, family history, low income or education, systemic inflammation, and dyslipidemia; mostly not modifiable Initiation (directly cause CKD): Diabetes, hypertension, autoimmune disease, polycystic kidney diseases, and drug toxicity; may be modifiable by drug therapy ACCP Updates in Therapeutics 2013 Progression (result in faster decline in kidney function): Hyperglycemia, elevated BP, proteinuria, and smoking

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10 Copyright McMaster Pathophysiology Review (MPR).

11 Mark Rosenberg, MD (2014) Overview of the management of chronic kidney disease in adults, Available at: (Accessed: 21st May 2014). The general management of the patient with chronic kidney disease (CKD) involves the following issues: Treatment of reversible causes of renal failure Adjusting drug doses when appropriate for the level of estimated glomerular filtration rate (egfr) Treatment of the complications of renal failure Identification and adequate preparation of the patient in whom renal replacement therapy will be required

12 Mark Rosenberg, MD (2014) Overview of the management of chronic kidney disease in adults, Available at: (Accessed: 21st May 2014). Patients with CKD with a recent decrease in renal function may be suffering from an underlying reversible process, which, if identified and corrected, may result in the recovery of function Hypovolemia (such as vomiting, diarrhea, diuretic use, bleeding) Treatment of reversible causes of renal failure Hypotension (due to myocardial dysfunction or pericardial disease) Infection (such as sepsis) The administration of drugs which lower the egfr such as [NSAIDs] and [ACE] inhibitors

13 Copyright McMaster Pathophysiology Review (MPR). Treatment of the complications of renal failure

14 Initially Dietary restriction of phosphate intake Po4 Calcium-based (when initial serum calcium level is <9.5 mg/dl)or noncalcium-based (when initial serum calcium is >9.5 mg/dl) phosphate binders can be administered. Vit.D <30 ng/ml PTH Treatment with ergocalciferol can be added as long as serum calcium does not exceed 10.2 mg/dl Orally active vitamin D analog can be added to the regimen.these should not be given if the serum calcium is >9.5 mg/dl or when the serum phosphate levels are elevated. Finally Calcimimetic-like cinacalcet may be considered Severe hyperparathyroidism that fails to respond to medical therapy may require parathyroidectomy. El-Kishawi AM, El-Nahas A M. Renal Osteodystrophy: Review of the Disease and its Treatment. Saudi J Kidney Dis Transpl 2006;17:373-82

15 ACCP Updates in Therapeutics 2013 Adjusting drug doses when appropriate for the level of estimated glomerular filtration rate (egfr)

16 Indications for RRT : 1. A acidosis (not responsive to bicarbonate) 2. E electrolyte abnormality (hyperkalemia; hyperphosphatemia) Identification and adequate preparation of the patient in whom renal replacement therapy will be required 3. I intoxication (boric acid; ethylene glycol; lithium; methanol; phenobarbital; salicylate; theophylline) 4. O fluid overload (symptomatic [pulmonary edema]) 5. U uremia (pericarditis and weight loss) ACCP Updates in Therapeutics 2013

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18 General information: M.S. is a 53 years old female known case of ESRD on HD Chief compliant: Admitted electively due to access failure

19 History of presenting illness: Pt. has a history of CKD, ESRD on dialysis since 3 years, she has swelling in her right elbow at the site of dialysis in the right arm The dialysis was from right arteriovenous fistula (AVF), and she has history of failed left AVF

20 Past medical history : End stage renal disease on hemodialysis with multiple access failure Hypertension Obesity Hypothyroidism Sudden cardiac arrest

21 Past family history: Non Past surgical history: Cholecystectomy Tubal ligation Allergies: Cefazolin allergy and cross sensitivity to ceftazidime

22 Medication history Montelukast Alphacalcidol Aspirin Bisoprolol Calcium carbonate + Vit.D3 Cinacalcet Erythropoietin Folic acid Hydroxyzine Levothyroxine Pantoprazole warfarin 10 MG PO HS 0.25 MCG PO OD 81 MG PO OD 5 MG PO OD 600 MG PO TID 60 MG PO OD 4000 U INJ TIW 5 MG PO OD 25 MG PO OD 100 MCG PO OD 40 MG PO OD 3 MG PO OD

23 Physical examination GENERAL HEENT CHEST ABDOMIN EXTREMETIES NEURO No SOB, no facial swelling, no other symptoms, look well, obese not in distress or pain Normal no peritoneal edema Lungs: clear bilateral airentery Heart: S1+ S2+ 0 regular rhythm Soft, lax, no tenderness (+) bowel sounds The patient has ecchymosis and swelling at dialysis site in right arm No signs of active bleeding or signs of compartment syndrome, no limitation on range of motion

24 Laboratory Lab Normal range 12/5/ /5/ /5/ /5/ /5/ /5/2014 BUN ( ) Na ( ) K ( ) Cl (98-108) Scr (44-80) Glucose ( ) C. Ca ( ) Po ( ) ALT (10-35) AST (10-35) ALKP (35-104) WBC (3.5-11) RBC ( ) Hgb ( ) Plt ( ) Aptt ( ) Pt ( ) INR FT4 (9-19) TSH ( ) PTH (15-65) HIGH LOW

25 Assessment: ESRD pt. with multiple dialysis access failure, looking well and vitally stable Temp 37 BP 140/85 P 94 Labs Plan: For elective angiography and angioplasty Montelukast 10 MG PO HS Alphacalcidol 0.25 MCG PO OD Aspirin 81 MG PO OD (hold) Bisoprolol 5 MG PO OD Calcium carbonate + Vit.D3 600 MG PO TID Cinacalcet 60 MG PO OD Erythropoietin 4000 U INJ TIW Folic acid 5 MG PO OD Hydroxyzine 25 MG PO OD Levothyroxine 100 MCG PO OD Pantoprazole 40 MG PO OD Warfarin 4 MG PO OD (hold)? Loratadine 10 MG PO HS Ranitidine 150 MG PO TID Enoxaparin 40 MG INJ OD

26 Assessment: looking well and vitally stable Liver function tests are increasing APTT is going up Labs Temp 36 BP 135/74 P 76 Plan: Give Vit.K 2 MG IV STAT Insert femoral PermCath Transient, asymptomatic elevations of liver transaminases (AST and ALT) to greater than three times the upper limit of normal has been observed in up to 6% of patients taking enoxaparin. This is a consistent finding with all members of the LMWH class, as well as with unfractionated heparin. The mechanism associated with the increased levels of liver transaminases has not been elucidated. No consistent irreversible liver damage has been observed. Transaminase levels returned to normal within 3 to 7 days after discontinuation of enoxaparin Montelukast 10 MG PO HS Alphacalcidol 0.25 MCG PO OD Aspirin 81 MG PO OD (hold) Bisoprolol 5 MG PO OD Calcium carbonate + Vit.D3 600 MG PO TID Cinacalcet 60 MG PO OD Erythropoietin 4000 U INJ TIW Folic acid 5 MG PO OD Hydroxyzine 25 MG PO OD Levothyroxine 100 MCG PO OD Pantoprazole 40 MG PO OD Warfarin 4 MG PO OD (hold) Loratadine 10 MG PO HS (D/C) Ranitidine 150 MG PO TID (D/C) Enoxaparin 40 MG INJ OD

27 Assessment: Doing fine with the PermCath and vitally stable Liver function tests & APTT are decreasing Labs Temp 36.5 BP 110/60 P 75 Plan: To discharge home Continue the same medications Readmission after 3 weeks for femoral AV graft Montelukast 10 MG PO HS Alphacalcidol 0.25 MCG PO OD Aspirin 81 MG PO OD (hold) Bisoprolol 5 MG PO OD Calcium carbonate + Vit.D3 600 MG PO TID Cinacalcet 60 MG PO OD Erythropoietin 4000 U INJ TIW Folic acid 5 MG PO OD Hydroxyzine 25 MG PO OD Levothyroxine 100 MCG PO OD Pantoprazole 40 MG PO OD Warfarin 4 MG PO OD (hold) Enoxaparin 40 MG INJ OD (D/C) Rubicalm cream BID

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