Initial serum creatinine

Nausea/ vomiting Slight fever Initial serum creatinine (mg/dl) Maximum serum creatinine (mg/dl) Duration of ARF (days) Renal CT findings... 

Drag overdose The susceptibility factors for rhabdomyolysis after doxylamine overdose have been studied in 35 patients who had normal creatine kinase activities at admission [15 ]. Those who developed rhabdomyolysis differed from those who did not in the amount of doxylamine ingested, sex, heart rate, and the initial serum creatinine concentration and alanine aminotransferase activity. However, the only rehable predictors of rhabdomyolysis were the amount of doxylamine ingested and heart rate. 

Agents acting in the proximal tubule are seldom used to treat hypertension. Treatment is usually initiated with a thiazide-type diuretic. Chlorthalidone and indapamide are structurally different from thiazides but are functionally related. If renal function is severely impaired (i.e., serum creatinine above 2.5 mg/dl), a loop diuretic is needed. A potassium-sparing agent may be given with the diuretic to reduce the likelihood of hypokalemia. 

The major risk related to aldosterone antagonists is hyperkalemia. Therefore, the decision for use of these agents should balance the benefit of decreasing death and hospitalization from HF and the potential risks of life-threatening hyperkalemia. Before and within one week of initiating therapy, two parameters must be assessed serum potassium and creatinine clearance (or serum creatinine). Aldosterone antagonists should not be initiated in patients with potassium concentrations greater than... 

Prior to initiating treatment with a LMWH, baseline laboratory tests should include PT (prothrombin time)/INR, aPTT, complete blood cell count (CBC), and serum creatinine. Monitor the CBC every 3 to 4 days during the first 2 weeks of therapy, and every 2 to 4 weeks with extended use.5 Use LMWHs cautiously in patients with renal impairment. Specific dosing recommendations for patients with a creatinine clearance (CrCl) less than 30 mL/minute are currently available for enoxaparin but lacking for other agents of the class (Table 7-3). Current guidelines recommend the use of UFH over LMWH in patients with severe renal dysfunction (CrCl less than 30 mL/minute).8... 

Prior to initiating methotrexate therapy, obtain complete blood count, serum creatinine, liver function tests, chest x-ray, and pregnancy test (if female). Monitor blood counts weekly for 1 month, then monthly thereafter. 

Patients with CKD should be evaluated for anemia when the GFR falls below 60 mL/minute or if the serum creatinine rises above 2 mg/dL (176.8 mmol/L). If the Hgb is less than 11 g/dL (6.8 mmol/L), an anemia work-up should be performed. The work-up for anemia should rule out other potential causes for anemia (see Chapter 63). Abnormalities found during the anemia work-up should be corrected before initiating erythropoiesis-stimulating agents (ESA),... 

Initiation of dialysis is dependent on the patient s clinical status. Symptoms that may indicate the need for dialysis include persistent anorexia, nausea, vomiting, fatigue, and pruritus. Other criteria that indicate the need for dialysis include declining nutritional status, declining serum albumin levels, uncontrolled hypertension, and volume overload, which may manifest as chronic heart failure, and electrolyte abnormalities, particularly hyperkalemia. Blood urea nitrogen (BUN) and serum creatinine (SCr) levels may be used as a... 

ACE inhibitors and angiotensin-receptor blockers (ARB) have definite benefits in patients with nephropathy and are believed to have renoprotective effects in most patients. Due to their ability to cause an initial bump in serum creatinine, these agents should be used cautiously when employed in combination with the calcineurin inhibitors. The dihydropyridine calcium channel blockers have demonstrated an ability to reverse the nephrotoxicity associated with cyclosporine and tacrolimus (Table 52-8). In general, antihypertensive therapy should focus on agents with proven benefit in reducing the progression of cardiovascular disease and should be chosen on a patient-specific basis.55 See Chapter 2 for further recommendations for treating HTN. 

Nephrolithiasis/ urolithiasis/ crystalluria IDV Onset Any time after initiation of therapy, especially if 4- fluid intake Symptoms Flank pain and/or abdominal pain, dysuria, frequency pyuria, hematuria, crystallauria rarely, Tserum creatinine and acute renal failure 1. History of nephrolithiasis 2. Fhtients unable to maintain adequate fluid intake 3. High peak IDV concentration 4. tDuration of exposure Drink at least 1.5-2 L of non-caffeinated fluid per day Tfluid intake at first sign of darkened urine monitor urinalysis and serum creatinine every 3-6 months Increased hydration pain control may consider switching to alternative agent stent placement may be required... 

GFR typically decreases 25% to 30% within 3 to 7 days after starting ACEIs because this class reduces intraglomerular pressure. Sustained increases in the serum creatinine by more than 30% after starting ACEIs may be due to the ACEI and discontinuation should be strongly considered. Serum potassium should also be monitored to detect development of hyperkalemia after initiating or increasing the dose of an ACEI. 

Adverse reactions may include Stevens-Johnson syndrome pericardial effusion T-wave changes rebound hypertension (following gradual withdrawal in children) decreased initial hematocrit, hemoglobin and erythrocyte counts nausea vomiting temporary edema alkaline phosphatase/serum creatinine/BUN increase, hypertrichosis. 

Serum sodium less than 130 mEq/L or with serum creatinine greater than 1.6 mg/dL Initiate at 2.5 mg/day under close medical supervision. The dose may be increased to 2.5 mg twice daily, then 5 mg twice daily and higher as needed, usually at intervals of 4 days or more. The maximum daily dose is 40 mg. 

Renal status Ccr (mL/min) Serum creatinine (mg/dL) Initial dose (mg/day)... 

Ototoxicity Perform audiometric measurements and assessment of vestibular function prior to initiation of therapy and at regular intervals during treatment. Nephrotoxicity Perform regular tests of renal function throughout treatment, and reduce dose in patients with renal impairment. Renal injury with tubular necrosis, elevation of BUN or serum creatinine, and abnormal sediment have been noted. Reduce the dosage or withdraw the drug. 

Kidney transplantation The recommended starting oral dose is 0.2 mg/kg/day administered every 12 hours in 2 divided doses. The initial dose of tacrolimus may be administered within 24 hours of transplantation, but should be delayed until renal function has recovered (as indicated, for example, by a serum creatinine of 4 mg/dL or less). Black patients may require higher doses to achieve comparable blood concentrations. 

Enalapril may cause anemia. It has been used successfully in low doses for posttransplant polycythemia. ACE inhibitors may precipitate renal failure in patients with renal transplant artery stenosis. A rapid rise in serum creatinine after initiation of ACE inhibitor therapy may indicate renal transplant artery stenosis. 

Adverse effects Renal function may deteriorate with the decreased circulating fluid volume, especially after the addition of another diuretic drug acting on the RAAS system, and careful monitoring of serum creatinine is essential. Serum potassium should be monitored within one week of initiation and at least every four weeks for the first three months and every three months thereafter. It should also be monitored at any dose change in spironolactone or if there is a change in concomitant medications that affects the potassium balance. The spironolactone dose (standard 25 mg per day) should be reduced if potassium levels are <5.4 mEq/L, and treatment should be discontinued if painful gynecomastia or serious renal dysfunction or hyperkalemia result. 

On June 13,1998, this patient participated in 100-m, 400-m, and 1500-m time-trial races at 1400 hours. Left loin pain occurred at 1600 hours. He considered that he had caught a cold, and took a commercially available drug for colds and an analgesic agent. Initially, pain was marked in the sitting position, and became less marked in the supine position. However, it gradually became worse even in the supine position, and he attended the Emergency Outpatient Unit of our hospital at 0500 hours on June 14. His serum creatinine, total bilirubin, and CPK levels were increased to 2.1 mg/dl, 2.8 mg/dl (the reason for an increase in total bilirubin was unclear), and 329 U/L, respectively, and the patient was referred to our department. On June 14, CT 24, 48, and 96 h after the administration of contrast medium showed patchy lesions (Fig. 38)... 

Fig. 65. Relationship between urinary 8-isoprostane and serum creatinine levels. In the initial phase, when the serum creatinine level was high, there was no increase in urinary 8-isoprostane. In the recovery phase, the urinary 8-isoprostane level increased...

CM was started on intravenous insulin, fluids, and electrolyte replenishment. Her nausea and vomiting resolved and, although initially, she required 60-70 units of insulin intravenously per day to attain glycaemic control, her blood glucose dropped to 7.4 mmol/L after 4 days of intensive care. However, despite treatment of her diabetic ketoacidosis, including significant rehydration therapy, CM was still found to have an elevated but stable serum creatinine of 246 micromol/L, and so she was transferred from the intensive care unit to the renal unit for further management. 

Available evidence indicates that serum cystatin C is a better marker for GFR than serum creatinine, particularly for the identification of an initial small decrease in GFR, i.e., in the so-called creatinine-blind GFR range. The most efficient use of this knowledge in clinical practice requires that quantitative methods of good precision, undisturbed by sample turbidity, are used. At least some of the presently available particle-enhanced immunometric methods seem to fulfil the first criterion of acceptable precision, but nonturbid fasting samples should preferably be used until new methods undisturbed by turbidity are developed. 

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