Dialysis adverse effects

Although EPO deficiency is the primary cause of CKD anemia, iron deficiency is often present, and it is essential to assess and monitor the CKD patient s iron status (NKF-K/DOQI guidelines). Iron stores in patients with CKD should be maintained so that transferrin saturation (TSAT) is greater than 20% and serum ferritin is greater than 100 ng/mL (100 mcg/L or 225 pmol/L). If iron stores are not maintained appropriately, epoetin or darbepoetin will not be effective, and most CKD patients will require iron supplementation. Oral iron therapy can be used, but it is often ineffective, particularly in CKD patients on dialysis. Therefore, intravenous iron therapy is used extensively in these patients. Details of the pharmacology, pharmacokinetics, adverse effects, interactions, dose, and administration of erythropoietin and iron products have been discussed previously. 

A 30-year-old male with a two-year history of chronic renal failure requiring dialysis consents to transplantation. A donor kidney becomes available. He is given cyclosporine to prevent transplant rejection just before surgery What is the most likely adverse effect of this drug ... 

At plasma nickel concentrations of about 3 mg/L, patients had adverse effects including headaches, nausea, vomiting, and weakness recovery occurred 3 to 13 h after cessation of dialysis... 

Rhabdomyolysis is a problem with several lipid-lowering drugs (SEDA-13, 1325 SEDA-13, 1328 SEDA-13, 1330 SEDA-19, 409), especially when they are used in combination (37). In individuals with pre-existing renal insufficiency this can lead to an earlier need for chronic dialysis (38). All statins can cause myopathy and rhabdomyolysis, but not all statins are alike. For example, the evidence to date, based on almost 2 decades of experience, points to an extremely low risk of myopathy and rhabdomyolysis with lovastatin, and lovastatin 20 mg tablets are being considered for non-prescription availability in several countries (39). Furthermore, muscle adverse effects do not necessarily occur after a change from one statin to another (40). Interactions between various hypolipidemic drugs and other drugs also sometimes cause rhabdomyolysis (SEDA-18, 426). For instance, itraconazole markedly increases plasma concentrations of lovastatin, and in one subject plasma creatine kinase was increased 10-fold within 24 hours of administration of this combination (41). 

Fluoxetine is a potential drug of abuse.136 Overdose with sertraline causes suicidal tendencies, whereas citalopram causes fatal reactions such as cardiac dysfunction.137 The adverse effects could be treated with stomach wash, administration of activated charcoal, dialysis, and hemoperfusion. 

Reversible psychiatric adverse effects have been described in three dialysis patients receiving intravenous aciclovir (8-10 mg/kg/day) (1). 

Adverse effects. A dose-dependent increase in arterial blood pressure follows the rise in red cell mass and encephalopathy may occur in some previously hypertensive patients. Arteriovenous shunts of dialysis patients, especially those that are compromised, may thrombose as a result of increased blood viscosity. 

The authors explained that akinetic mutism occurs when bilateral frontal lobe or diencephahc-mesencephalic dysfunction interrupts the limbic circuitry. As symptoms were observed immediately after the start of treatment and resolved completely after withdrawal, the condition was probably caused by baclofen. It is not known why baclofen in this case impaired neuronal activity specifically in these areas. The authors found only one previous report describing the case of a 57-year-old woman with end-stage renal insufficiency, who developed akinetic mutism after a single dose of baclofen (2). In this case, the sjmptoms resolved after dialysis. Therefore, adverse effects of baclofen should be suspected if neuropsychiatric symptoms occur after baclofen treatment has been started. Electroencephalography and computerized tomography may be necessary to exclude other causes. 

The safety of carbon dioxide in vena cavography has been investigated in 119 patients (aged 17-89 years, 65 men). Patients with intracardiac shunts, severe pulmonary compromise, or non-dialysis-dependent renal insufficiency were excluded. Two patients developed mild adverse effects one had nausea that resolved spontaneously and the other vomited several minutes after the administration of carbon dioxide but needed no treatment. The diagnostic quality of the venography was comparable to that with iodinated contrast media. The authors concluded that carbon dioxide cavography is well tolerated and is especially valuable in patients with a history of a reaction to iodinated contrast material or renal insufficiency. 

Anaphylaxis as an adverse effect of hemodialysis has been analysed from records of about 260 000 courses of dialysis... 

The adverse effects of peritoneal dialysis fluids on the peritoneum have been succinctly summarized by authors arguing the case for a new, less toxic, and less acidic fluid for peritoneal dialysis (7). A low pH, high osmolality and lactate concentration, and the presence of several toxic contaminants may all contribute to impaired cellular function in the peritoneal membrane. In conventional peritoneal dialysis pH is dehberately lowered to 5.0-5.6... 

The safety profiles of epoetin and darbepoetin are similar. Adverse effects of darbepoetin include hypertension, injection site pain (generally mild and transient) in the case of subcutaneous administration, cardiovascular events, headache, vascular disorders (vascular access thrombosis), flu-like sjmptoms, and skin rashes (20,53,54). Adverse effects such as hypertension and thrombophlebitis are observed in uremic patients requiring dialysis but not in patients with hematological malignancies (55). 

The adverse effects of iron formulations have resulted in trials to optimize dose regimens. A large database of clinical variance reports from Fresenius Medical Care North America (FMCNA) has been analysed to determine the incidence of suspected adverse drug reactions of iron dextran and the associated patient characteristics, dialysis practice patterns, and outcomes (8). A case-cohort design was used, comparing individuals who had suspected adverse drug reactions with the overall population. Out of 841 252 intravenous iron dextran administrations over 6 months, there were 165 reported suspected adverse drug... 

Large doses of intravenous iron dextran and iron saccha-rate have been compared in a retrospective study of 379 patients who had attended peritoneal dialysis clinics in the past 5 years (12). Of these, 62 were selected to receive intravenous iron based on ferrokinetic markers of iron deficiency, non-adherence to oral iron, ineffectiveness of oral iron, or increased erythropoietin requirements. Intravenous iron was given as two injections of 500 mg each 1 week apart in 61 patients, 33 of whom received iron dextran, 23 iron saccharate, and five both iron dextran and iron saccha-rate. One patient developed anaphylaxis to a test dose of iron dextran and was excluded from further therapy. Blood samples were collected before and 3 and 6 months after iron infusions. Five of the 34 patients who received iron dextran developed minor adverse effects and one had an anaphylactic reaction to the test dose. Of the 23 patients who received iron saccharate, one had an anaphylactic reaction and two had transient chest pain, which subsided without therapy. There were more adverse effects with iron dextran (7.4% of injections) compared with iron saccharate (4.3% of injections), but this difference was not statistically significant. The number of episodes of peritonitis also increased during the 6 months after intravenous iron infusion, especially with iron dextran, compared with the number of episodes during the 6 months before iron infusions, although the difference was not statistically significant. 

Losartan was evaluated in 406 patients with end-stage renal insufficiency undergoing hemodialysis (24). Only 15 patients discontinued losartan because of adverse effects. In seven the adverse reaction was hypotension. Two patients reported a possible anaphylactoid reaction on treatment with AN69 dialysis membranes. However, nine patients with a history of previous anaphylactoid reactions on treatment with AN69 have not shown this complication with losartan and AN69. 

Based on a study of 10 patients with automated peritoneal dialysis, it was recommended that for empirical treatment of dialysis-related peritonitis, the dosage of intermittent intraperitoneal tobramycin must be 1.5 mg/ kg for one exchange during the first day and then 0.5 mg/ kg thereafter, to reduce the risk of adverse effects (47). 

In two placebo-controUed trials, 90% of dialysis patients with moderate to severe secondary hyperparathyroidism who received doxercalciferol for 16-24 weeks had about a 70% reduction in parathyroid hormone concentrations. The most frequently reported adverse effects include edema, headache, and malaise. 

Penicillin G 2-3 million Units IV q. 4 hr 70% q.4-6 hr q. 6 hr q.8hr Adverse effects seizures, false positive urine protein reactions 6 million units/ dav upper limit dose in ESRD Dose after dialysis Dose for GFR<10 ml/min Dose for GFR 10-50 ml/min... 

Lithium carbonate 0.9-1.2gq.24hr Renal 100% 50-75% 25-50% Nephrotoxic adverse effects include nephrogenic diabetes insipidus, nephrotic syndrome, renal tubular acidosis, and interstitial fibrosis acute toxicity when serum levels > 1.2 mEq/L serum levels should be measured periodically 12 hr after dosing half life does not reflect extensive tissue accumulation plasma levels rebound after dialysis toxicity enhanced by volume depletion, NSAIDs, and diuretics Dose after dialysis NC Dose for GFR 10-50 ml/min... 

Although furosemide (fmsemide) is administered commonly in oliguric ARF, there is controversy over whether this drug decreases the incidence of ARF in high-risk human patients or enhances recovery (Dishart Kellum 2000). In fact, there have been few studies that have addressed this question in a prospective, blinded fashion in comparison to placebo treatment. In a recent report that compared furosemide (fmsemide, 3mg/kg i.v. four times a day for 21 days) or torasemide (another loop diuretic) with placebo treatment in 92 humans patients with ARF, the administration of a loop diuretic had a positive effect on urine output during the initial 24 h of treatment but did not shorten the dialysis times or improve the patient outcome (Shilliday et al 1997). Nevertheless, because the adverse effects associated with furosemide (fmsemide) use are few, it remains a common treatment in oliguric ARF. 

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