Clin Ther I Management Of Renal Diseases (AKI) 2024 PDF

CLINICAL THERAPEUTIC I MANAGEMENT OF RENAL DISORDERS Lecture by: Rara Merinda Puspitasari Bachelor of Pharmacy Faculty of Pharmacy and Health Science UNIVERSITI KUALA LUMPUR  LEARNING OUTCOME Evaluate the management...

CLINICAL THERAPEUTIC I MANAGEMENT OF RENAL DISORDERS Lecture by: Rara Merinda Puspitasari Bachelor of Pharmacy Faculty of Pharmacy and Health Science UNIVERSITI KUALA LUMPUR  LEARNING OUTCOME Evaluate the management of patient’s drug related problems in Renal disorders Demonstrate good communication, teamwork, critical thinking, problem solving and lifelong learning  DRUG RELATED PROBLEM “any undesirable event experienced by a patient which involves, or is suspected to involve, drug therapy and that interferes with achieving the desired goals of therapy”-Cipolle “A Drug-Related Problem is an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes”-PCNE  ASSESSMENT OF THE PATIENT’S DRUG-RELATED NEEDS Collecting, organizing, and integrating pertinent patient, drug, and Disease information PATIENT INFORMATION DISEASE INFORMATION DRUG INFORMATION Determine whether the patient’s drug therapy is appropriate, effective, safe, and convenient for the patient; Identify ACTUAL DRP Identify POTENTIAL DRP  DRUG RELATED PROBLEM 1. Inappropriate indication for drug use The patient requires additional drug therapy. The patient is taking unnecessary drug therapy. (unlegitimate indication and sould be discontinued 2. Ineffective drug therapy The patient is taking a drug that is not effective for his/her situation. The medication dose is too low. 3. Unsafe drug therapy The patient is experiencing an adverse drug reaction. The medication dose is too high. DDI 4. Inappropriate adherence or compliance The patient is unable or unwilling to take the medication as prescribed. PHARMACEUTICAL CARE PHARMACEUTICAL CARE RELATED QUESTIONS 1. Does the patient have a clinical indication for each of his or her drug therapies, and is each of the patient's indications being treated with drug therapy? 2. Are these drug therapies effective for the patient's medical condition? 3. Are the drug therapies as safe as possible? 4. Is the patient able and willing to take the medication as intended? PHARMACEUTICAL CARE The pharmacotherapy care plan has several key components for each problem: Current drug regimen Drug therapy problems Therapy goals, desired endpoints Therapeutic recommendations Rationale Therapeutic alternatives Monitoring Patient education PATIENT-FOCUSED APPROACH TO CASE PROBLEMS SYSTEMATIC APPROACH Identification of real or potential drug therapy problems Determination of the desired therapeutic outcome Determination of therapeutic alternatives Design of an optimal individualized pharmacotherapeutic plan Identification of parameters to evaluate the outcome Provision of patient education Communication and implementation of the pharmacotherapeutic plan IDENTIFICATION OF DRP Identifying the medical condition the drug therapy the cause of the associated with the involved in the problem problem problem, INTERVENTION prevent new drug resolve drug achieve the stated therapy problems therapy problems goals of therapy from developing Actions to Resolve the DRP INITIAL NEW DRUG THERAPY CHANGE THE DOSAGE REGIMEN CHANGE THE DRUG PRODUCT DISCONTINUE THE DRUG REGIMENT MONITORING PLAN (LABS) Examples of the Goals of Therapy for Common Medical Conditions MANAGEMENT OF RENAL DISORDER KIDNEY-FUNCTIONS EXCRETORY METABOLIC ENDOCRINE INFLUENCE OF RENAL IMPAIRED FUNCTION ALTERED PHARMACOKINETICS Drug Absorption Since CKD patients are frequently taking certain medications, the associated drug interactions will impact the absorption Example: antacids and vitamin supplements may decrease the bioavailability of some drugs as a result of the formation of insoluble salts or metal ion chelates. A decrease in gastric acidity, >>>GI pH, associated with the concomitant administration of antacids, H2-blockers, PPI, and phosphate binder à lower BA of several AB and digoxin INFLUENCE OF RENAL IMPAIRED FUNCTION ALTERED PHARMACOKINETICS DISTRIBUTION pathophysiologic alterations in body composition, fluid overload secondary to excessive fluid administration or intake, decreased protein binding, or increased tissue binding The VD of many drugs is increased in category G3a, G3b, G4, and G5 CKD patients as well as those with pre-existing CKD who develop AKI Decreased in serum drug concentrations Example: hydrophilic drugs, such as aminoglycosides and cephalosporins à the VD may be increased by up to 150%. INFLUENCE OF RENAL IMPAIRED FUNCTION ALTERED PHARMACOKINETICS ELIMINATION Decrease in GFR à decrease in renal drug clearance Particularly in Narrow therapeutic range drugs Determine renal function à estimate creatinine clearance Modifying the dose Increasing the dosage interval Giving the lower dose at the same interval Altering both, the dose and interval INFLUENCE OF RENAL IMPAIRED FUNCTION ALTERED PHARMACOKINETICS ENHANCEMENT OF ADR Digoxin à electrolyte abnormalities Hypercalcemia hypokalemia Diuretics à electrolyte abnormalities hyperkalemia INFLUENCE OF RENAL IMPAIRED FUNCTION ALTERED PHARMACOKINETICS WORSENING OF EXISTING CLINICAL CONDITION Avoid nephrotoxic drugs à …… Avoid drugs that cause fluid retention à …….  RENAL DISORDER ACUTE KIDNEY INJURY CHRONIC KIDNEY DISEASE END STAGE RENAL DISEASE ACUTE KIDNEY INJURY  ACUTE KIDNEY INJURY Decrease In Renal Function over a period of hours to days Accumulation of nitrogenous waste products (azotemia) and water Inability to maintain and regulate fluid, electrolyte, and acid–base balance. Oliguria  ACUTE KIDNEY INJURY Signs and Symptoms Clinical Presentations: Mild-moderate: asymptomatic Severe Fatigue, anorexia, NW, weight gain, oedema Development of uremic encephalopathy Decline in mental status, confusion, asterixis, or other neurological symptoms Anaemia, bleeding caused by uremic platelet dysfunction  ACUTE KIDNEY INJURY Signs and Symptoms Clinical findings: Raised blood level of Cr and/or Low urine output an increase in SCr ≥ 0.3 mg/dL within 48 hours, OR an increase in SCr ≥ 1.5 times baseline in 7 days OR less/a decrease in urine volume 20:1 functional—impairment of glomerular ultra-filtrate production or intra- glomerular hydrostatic pressure; No structural damage Common causes: Intravascular volume depletion à kidney hypoperfusion Liver disease Cardiac disease  ACUTE KIDNEY INJURY Classification PRERENAL AKI Physical examination findings Lab examination azotemia —decreased Weight loss renal blood flow; Orthostatic hypotension High urine osmolality Tachycardia Low urine sodium, High BUN : creatinine Poor skin turgor ratio  ACUTE KIDNEY INJURY- CLASSIFICATION INTRINSIC 50% of cases Prolonged pre-renal AKI Damage to the kidneys that can affect the structure of the nephron ; Acute Tubular Necrosis Acute Glomerulonephritis Acute Interstitial Nephritis  ACUTE KIDNEY INJURY- CLASSIFICATION POSTRENAL 5-10% of cases Outflow obstruction in the urinary tract (Anuric or polyuric) caused by inadequate drainage of urine distal to kidney Causes: benign prostatic hypertrophy, urethral obstruction, bladder dysfunction, pelvic tumors, precipitation of renal calculi (obstructing the ureter) Signs & Symptoms: urinary urgency or hesitancy, gross hematuria Lab examination BUN : creatinine ratio 9.7 mg/dL (4.0 mmol/L) Intractable acidosis: Diuretic- resistant fluid overload Pericarditis Pleuritis  ACUTE KIDNEY INJURY Follow-Up Evaluation Key Monitoring Parameters for Patients with Established AKI Monitor the patient’s urine output, acid–base balance Monitor SCr to evaluate whether kidney function is worsening or improving. THANK YOU