Chronic Renal Failure

Pharmacotherapeutics of Chronic renal failure

1. Chronic Renal Failure Dr. V. S. Swathi Assistant Professor

2. Definition It is a chronic renal condition in which glomerular filtration rate decreases along with structural abnormalities of renal tract

3. Epidemiology In the world, prevalence of chronic kidney disease is 23.4% and CKD at stage 5 is 10.6% In India, prevalence of chronic kidney disease is 17.2%

4. Types Stage Glomerular Filtration rate ( ml/min) I ≥ 90 II 60-89 III A 45-59 III B 30-44 IV 13-29 V ≤15

5. Risk factors Older age Smoking Family history of renal diseases Hypertension Diabetes Cardiovascular diseases Obesity Abnormal kidney structure

6. Etiology Type I and II diabetes High blood pressure Glomerularnephritis Interstitial Nephritis Polycystic kidney disease Benign prostate hyperplasia Renal calculi Prostate cancer Vesicoureteral reflux Recurrent kidney infections

7. Pathogenesis

8. Pathogenesis Continued….

9. Pathogenesis Continued….

10. Pathogenesis Continued….

11. Clinical Presentation Polyuria Nocturia Frothy urine Blood in urine Peripheral oedema Shortness of breath Chest pain Weight gain/ Weight loss Pain in bones Pain in muscles Bleeding Rashes Nausea Vomiting Foul taste Paleness of skin Skin discoloration Pruritis Dryness of skin Fatigue Loss of libido Somnolence Confusion Seizures Coma

12. Complications Hypertension Cardiovascular diseases Anaemia Thrombocytopenia Osteodystrophy Gout Hyperkalemia Hyperphosphatemia Metabolic acidosis Erectile dysfunction Amenorrhea Pulmonary oedema Infertility Depression Sleep disorders Infectious Pericarditis End stage renal diseases

13. Diagnosis Medical history Family history Clinical presentation Complete blood count Renal function tests Urine microscopy Urine culture Ultrasound Computed tomography Magnetic resonance imaging Intravenous urography Plain abdominal radiography Renal biopsy

14. Non Pharmacological Treatment Avoid risk factors Fluid restriction Sodium restriction Avoid potassium rich food Smoking cessation Counselling Renal replacement therapy Renal transplantation

15. Treatment Algorithm Blood pressure control ACE inhibitors/ ARBs Volume overload Diuretics Renal replacement therapy Hyperparathyroidism Vitamin D supplementation

16. Treatment Algorithm Continued… Subclinical Hypothyroidism Levothyroxine Anaemia Ferrous sulphate Iron sucrose Iron dextrose Hypocalcaemia Calcium supplementation

17. Treatment Algorithm Continued… Metabolic acidosis Alkali supplementation Uremic manifestation Renal replacement therapy Cardiovascular complications Beta blockers

18. Treatment Algorithm Continued… Growth failure in children Growth hormone supplementation Adults with CKD Stations

19. Indications for renal replacement therapy Severe metabolic acidosis Hyperkalemia Pericarditis Encephalopathy Intractable volume overload Failure to thrive and malnutrition Peripheral neuropathy Intractable gastrointestinal symptoms

20. Drugs used in treatment of chronic kidney disease Drug Category Mode of action Dose Adverse drug reactions Ramipril Angiotensin converting Enzyme inhibitor Inhibit vasoconstriction by inhibiting formation of Angiotensin II 1.25-5mg-PO-OD Cough Hypotension Angina Dizziness Syncope Telmisartan Angiotensin II blocker Inhibit vasoconstriction by blocking the actions of Angiotensin II 40-80mg-PO-OD Upper urinary tract infections Back pain Diarrhea Myalgia Sinusitis Ferrous sulphate Iron supplementation Improves oxygen supply to the cells 100-200mg-PO-OD Vomiting Diarrhea Dark stools Urine discolouration Superficial tooth discoloration

21. Iron Sucrose Iron supplementation Improves oxygen supply to the cells 100mg-IV-3 doses/week for dialysis patients 200mg-IV-Thrice weekly for non dialysis patients Hypotension Muscle cramps Head ache Peripheral oedema Pruritis Epoietin alpha Erythropoiesis stimulating agent Increases RBC production 50-100 Units/kg/IV/SC- thrice weekly Pyrexia Hypertension Vomiting Pruritis Arthralgia Calcium carbonate Calcium supplementation Restores calcium levels in the blood 1-1.2g-PO-OD Anorexia Constipation Hypercalcemia Hypophosphatemia Milk alkali syndrome Calcium acetate Phosphate scavenger Chelates phosphate in intestine and forms insoluble calcium phosphate which is excreted via faeces 1334mg-PO-TID Arrhythmias Hypomagnesaemia Hypophosphatemia Hypotension Pruritis

22. Calcitriol Vitamin D supplementation Improves calcium absorption 0.25mcg-PO-OD Abdominal pain Apathy Abnormal renal function tests Arrhythmias Dehydration Sodium bicarbonate Alkaniser Neutralises excess acidity 2-5MEQ/kg-IF for 4-8 hours Aggravation of CHF Cerebral Haemorrhage Oedema Hypernatremia Metabolic alkalosis Atorvastatin Statins Decreases synthesis of cholesterol by inhibiting the actions of HMG CoA reductase 10-80mg-PO-OD Diarrhea Nasopharyngitis Arthralgia Urinary tract infection Dyspepsia

23. Resources https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325814/pdf/40359_2018_Article_264.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280168/pdf/0104-1169-rlae-26-e3091.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283671/pdf/nihms-994044.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091174/pdf/12882_2018_Article_988.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436482/pdf/CLC-42-21.pdf