DRUGs FOR KIDNEY.ppt

8/9/2019 DRUGs FOR KIDNEY.ppt

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DRUGS THERAPY

FOR KIDNEYBudi Raharjo


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Function of Kidne

! E"cretion of #a$te %roduct& e'('Hdo(en ion) *ater

! Bio$nthe$i$ and +eta,o-i. ofhor.one& e'(' Renin) In$u-in) Erthro%ietin

! Re(u-ation of ho.eo$ta$i$& e'(' F-uid) E-ectro-te and Acid/,a$e,a-ance


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Rena- Function Te$t


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Rena- Function Te$t

! Seru. 0reatinine

! 0reatinine 0-earance

! Urea 1B-ood Urea Nitro(en2

! +i$ce--aneou$


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Seru. 0reatinine1+a-e 3)4/5)6 .(7d89 Fe.a-e 3)6/3):

.(7d82

! B %roduct of .u$c-e .eta,o-i$.

! Rate of for.ation %ro%ortiona- to.u$c-e .a$$

! Free- ;-tered , (-o.ero-u$ 1-itt-e$ecretion or rea,$or%tion , tu,u-e2

! Indicator of rena- function) ,ut& Diet) ti.e of da) a(e) $e") e"erci$e)

dru($

! 0aution in un$ta,-e rena- function or

acute rena- di$ea$e


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0reatinine 0-earance

! +ea$ure.ent of creatininec-earance (i?e an e$ti.ate of GFR

1G-o.eru-ar Fi-tration Rate2! 0reatinine c-earance ?arie$ #ith

a(e) $e") and $i@e

! +ea$ure.ent>& Urine co--ection

& 0ocroft and Gau-t Euation


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0reatinine 0-earance

! Nor.a- reference C 563 .-7.in

! Rena- di$order if> 43 0r0- 563.-7.in $.%to.-e$$

! Rena- in$u;cienc>& +i-d 63 & 3 .-7.in

& +oderate 53 & 63 .-7.in

& Se?ere 53 .-7.in& ESRD .-7.in

1End State of Renal Disease2


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Urine 0o--ection

! Accurate co--ection of o?er 6: hour%eriode 1note %ro,-e.$ #ith %atientco.%-iance2

! P-a$.a $a.%-e .id#a throu(h 6: hour

%eriode U " 0-crC /////////////

S U C Urine 0reatinine concentration 1.(7d82 C Urine o# rate 1.-7.in2

S C Seru. 0reatinine concentration

1.(7d82


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0ocroft Gau-t Euation

F C 5)6 1.a-e$2 F C 5)3: 1fe.a-e$2

IB* 1Idea- Bod *ei(ht2+a-e$&TB J 56) c.IB* C 3 L1TB / 56):2 " 3)M

&TB 56) c.IB* C 3 / L156): / TB2 " 3)M

Fe.a-e$&TB J 56): c.IB* C :) L1TB / 56):2 " 3)M

&TB 56): c.IB* C :) / L156): / TB2 " 3)M

0r0- C F " 15:3 & a(e2 " IB*Seru. 0r 1.(7d82 " 6

.-7.in


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8i.itation of

0ocroft Gau-t Euation0annot ,e u$ed if

! A(e 5 ear$ o-d or a(e J 3 ear$ o-d

! Rena- function i$ chan(in( ra%id-

! Pre(nanc 1GFR 63 Q2

! Seru. creatinine J " nor.a- ran(e! A.%utated -i.,


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B-ood Urea Nitro(en1M & 5M .(7d82

! Urea Nitro(en i$ an end %roduct of%rotein .eta,o-i$.

! Produced , the -i?er) tran$%orted in,-ood and e"creeted , the idne

! Free- ;-tered , (-o.ero-u$) %art-rea,/$or,ed , the tu,u-e$

! u$e a$ a $creenin( te$t for rena-di$function) not uantif the e"tend ofrena- di$ea$e


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+i$ce--aneou$

! Increa$ed %ota$$iu.

! Decrea$ed ,icar,onate

! Increa$ed %ho$%hate! Decrea$ed ca-ciu.

! A-tered $odiu. -e?e-$

! Di$tur,ed uid ,a-ance


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Phar.acoinetic$! A,$or%tion

& Ora- a,$ortion reduce , ?o.ittin() nau$ea)diarrhoea) GI oede.a chan(e$ in ,-ood %H

& 8itt-e c-inica- $i(ni;cance

! Di$tri,ution

& o-u.e di$tri,ution 1d2 due tooede.a7a$cite$9 d due to dehdration18itt-e c-inica- $i(ni;cant> A.ino(-co$ide)

8ithiu.2& Protein ,indin( 1P,2 due to %rotein -o$$ or P,due to urae.ia9 increa$e free dru($9te.%orar e=ect9 caution in inter%rete dru(

-e?e- 10-inica- Si(ni;cant> Phentoin) *arfarin2


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Phar.acoinetic$

!+eta,o-i$.& He%atic .eta,' una=ected in rena- i.%air.ent

& 0-inica- $i(ni;cant of i.%aired rena-.eta,o-i$.>

! Accu.u-ation of acti?e .eta,o-ite! ita.in D re%-ace.ent

! In$u-in reuire.ent

! E"cretion

& E-i.ination of dru( or it$ .eta,o-ite$ .a ,edecrea$ed

& +o$t i.%ortant %ara.eter to con$ider #hen

.ain( do$a(e deci$$ion$


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Genera- Guide-ine$! On- u$e dru($ if a de;nite indication

! 0hoo$e dru($ #ith .ini.a- ne%hroto"ice=ect and a?oid %otentia-- ne%hroto"icdru($

! Increa$ed $en$iti?it to certain dru(e=ect$

! +onitor and act on %-a$.a -e?e-$

! 0hec a%%ro%riate do$a(e adju$t.ent

! A?oid %ro-on(ed cour$e$ of %otentia--to"ic dru($

! +onitor for c-inica- ecac and e?idence

of to"icit


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Dru($ in Rena- Di$ea$e>0-inica- Phar.ac Practice

Point!Identi;cation of %atient #ith

rena- di$ea$e 1Acute70hronicRena- Di$ea$e2

!+onitorin( of rena- function

1inc-udin( do$e adju$t.ent2!A$$e$$.ent of current and

%ro%o$ed dru( treat.ent


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Dosage Adjustment

Loading dose is usually unchanged (exceptfor digoxin and gentamycin)

The most common maintenance dosage

changes are to decrease the dosage orincrease the dosage interval or both

Refference sources:

B!

"ata #heet $ "rugs leaflet

Bennett: "rugs and renal desease


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Dosage Adjustment

"Rrf % "osing Rate in renal failure

"Rn % "osing Rate in normal state

R! % the extent of Renal !ailure!eu % !raction of drugs normally excreting unchage

in the urine

DRrf= DRnx [(1 - Feu) + (Feux RF)]

RF = Patient creatinine clearance (ml/mnt)Ideal creatinine clearance (120ml/mnt)


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RENA8 DISEASE

!Acute Rena- Fai-ure

!0hronic Rena-

Fai-ure

A t R -


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Acute Rena-Fai-ure

Pre-Renal ARF Intra-Renal ARF P!t-Renal ARF

"#i$%lemia

!&eatin'%mitin'

diare*ld l!!"ardiac ,ut$ut

AI #F

"Renal .$$erfu-!indru' induce

ARFDiureticAI

AID (P'2D2I2)

"Acute 3u*ular ecr!i!

(A3)icaemic 4 txin

(amin'l.c!idc.cl!$rincnt

ra!t media)" Inter!titial ne$riti! dru'

.$er!en!iti%e $enicillince$a-l!$rineall$urinla5ati$rin

"6lmerular le!!in ('l-

merulne$riti!)"P!t-renal *!truc-

tin urinar. !tne

ne$la!m7P#


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E"a.ination of ARF

18 Full i!tr. includin' medicatin i!tr.

28 P.!icall. xaminatin P!tural .$ten!in 4 !9in tur'r Pre-Renal

Dru' ra!e! / %a!culitic le!!in Intra-Renal

i5e! f *ladder 4 9idne.! P!t Renal

:8 xaminatin f 3e ;rine ncentrated urine Pre-Renal

Intra-Renal I!tnic urine$itel cell (A3)8 Radil'ical tud.


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Drugs that Alter Renal Hemodynamic

Glomerolus

Tekanan

Hidrostatik

Glomerolus

Ultrafiltrat

Tubulus Proximal

Aliran Darah

Arteri Afferent Arteri Efferent

Aliran Darah

Vasokonstriktor Afferent:

Inhibitor Prostaglandin

- !AID

- "#$-% inhibitor

Vasokonstriktor langsung

- "&'los(orine

- Am(hoteri'ine-)

- *ontras +edia ,ionik

- Vaso(resor

Vasodilator Efferent:

.enin-Angiotensin Aldosteron

- A"E Inhibitor

- Angiotensin II Antagonis

Vasokonstriktor langsung

- "") dih&dro(iridin- Diltia/em

- Vera(amil

T t t f ARF


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Treat.ent of ARF18arl. ana'ement

rrectin f fluid 4 lectrlide im*alanceIf nt re!$n! ?$ diuretic 4 anitl< r D$amine

28!ta*li! ARF

a8;raemia$rtein inta9e + Fat 4 # ata*li!m

*8#.$er9alaemia (@ excre!in+ ell dama'e)ardit-xic a 'lucnate i8%8< lu*le in!ulin + 'luc!e< a re!inin excan'e

c8Acid!i!

#+

excre!in

a *icar*nated8#.$calcaemia (a mala*!r$tin) a u$$lement

e8#.$er$!$ataemia (retentin) a car*nat

:8#aemdial.!i! Peritnial Dial.!i!

ron c ena


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ron c enaFai-ure

0au$e$ of 0RF>

! 0hronic G-o.eru-one%hriti$ 1ne%hrotic$ndro/.e2> Pittin( Oede.a9 Proteinuria /(ra.7da9 H%oa-,u.inae.ia 6/3 (r78

! H%erten$ion

! 0hronic Pe-one%hriti$! Urinar O,$truction> BPH) Rena- ca-cu-i)

eico/ureteric reu") ind#e--in( urinarcathether$

! Inter$titia- Ne%hriti$

! 0on(enita- A,nor.a-itie$

! +eta,o-ic Di$ea$e> D+) A.-oido$i$can

-ead to chronic (-o.eru-one%hriti$


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E"a.ination of 0RF5' Fu-- hi$tor) inc-udin( .edication hi$tor

6' Ph$ica-- E"a.ination> Nocturia) Fati(ue)Breath-e$$) Ane.ia) Sin co-oration #ithH%erten$ion) Oede.a

' E"a.ination of The Urine> Proteinuria:' E"a.ination of B-ood> 0reatinine Seru.

and7or 0-earence) E-ectro-te di$tur,ance1H%era-ae.ia)Seru. ,icar,onateAci/

do$i$)H%erca-cae.ia)H%er%ho$%atae.ia2

' Radio-o(ica- Stud> Intra?enou$ Uro(ra%h

1IU2 #ith 0ontra$t +edia


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0c-e of e?ent$ -eadin( to h%erten$ion in

0RF

H%erten$ion

Reduce a,i-itto e"crete Na

ion$

Acti?ationof RAAS$te.

Rena-I$chae.ic

Sodiu. anduid

Retention

Rena- Paren/ch.a-da.a(e


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R.A.A. SystemPerdarahan

+a$ifTD

I$hae.iaGinja-

u"ta(-o.ero-u$ A%%'RENIN

An(ioten$ino(en

An(ioten$in I

An(ioten$in II

An(ioten$in 0on?ertin( [email protected] 1A0E2

An(ioten$in III

TD

a$o%re$inA-do$teron

Reten$i Air Reten$i Na

o-'0airan

Stimulasi Prostaglandi


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Di$tur,ance of 0a-ciu. and Pho$%hate Ba-ance

in 0RF

Rena- Fai-ure

5)6 dihdro"cho-eca-cifero-

Pho$%hate e"cretion

Seru. %ho$%hate

Seru. ca-ciu.

H%er%arathroidi$.

OSTEOS08EROSISOSTEO+A8A0IA

Reduced +inera-i@ation of ,one

0aa,$or%tion

fro. GItract'


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Treat.ent of 0RF! H%ertention> Diuretic$) Beta ,-ocer) A0E

Inhi,itor) AT II Anta(oni$t) a$odi-ator$1hdra-a@in) %ra@o$in) .ino"idi-2

! Anae.ia> Tran$ PR0)Erthro%oietin 1Iron$u%-2

! Oede.a> F-uid and Sodiu. re$triction) IfH%oa-,u.ine.iaA-,u.in i'?') Diuretic$

! H%era-ae.ia> Re$in K ,inder

! Acido$i$> Sodiu. ,icar,onate! O$teod$tro%h> Pho$%hat ,inderA-OH

1to"ic $$tnot reco.'2) 10a0O29

it'D7%ro ?it'D


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DRUGs FOR KIDNEY.ppt