Renal - continued

A marked improvement is generally noted after 4—8 weeks of treatment. Treatment is often continued until a total dose of 3 g is reached. In the case of coccidioidomycosis, for example, treatment with 0.4—0.8 mg/kg/d may last months. The polyene is adrninistered intrathecaHy to treat Coccidioides meningitis. However, the results are only moderate. It is very important to check renal and hepatic function during treatment with amphotericin B. 

PTH has a dual effect on bone cells, depending on the temporal mode of administration given intermittently, PTH stimulates osteoblast activity and leads to substantial increases in bone density. In contrast, when given (or secreted) continuously, PTH stimulates osteoclast-mediated bone resorption and suppresses osteoblast activity. Further to its direct effects on bone cells, PTH also enhances renal calcium re-absorption and phosphate clearance, as well as renal synthesis of 1,25-dihydroxy vitamin D. Both PTH and 1,25-dihydroxyvitamin D act synergistically on bone to increase serum calcium levels and are closely involved in the regulation of the calcium/phosphate balance. The anabolic effects of PTH on osteoblasts are probably both direct and indirect via growth factors such as IGF-1 and TGF 3. The multiple signal transduction... 

Renal replacement by an artificial device providing continuous filtration of plasma based on the physical principle of convection. 

Continual cardiac monitoring assists the nurse in assessing the patient for adverse drug reactions. If the patient is acutely ill or is receiving one of these drugs par-enterally, the nurse measures and records the fluid intake and output. The primary health care provider may order subsequent laboratory tests to monitor the patient s progress for comparison with tests performed in the preadministration assessment, such as an ECG, renal and hepatic function tests, complete blood count, serum enzymes, and serum electrolytes. The nurse reports to the primary care provider any abnormalities or significant... 

Achilefu S, Dorshow RB (2002) Dynamic and Continuous Monitoring of Renal and Hepatic Functions with Exogenous Markers. 222 31-72 Albert M, see Dax K (2001) 215 193-275... 

Morphine and its derivatives continue to be considered the gold standard for alleviating pain. Morphine is metabolized in the liver via N-dealkylation and glu-coronidation at the third (M3G) or sixth position (M6G). Although M3G are the most common metabolites (accounts for 50% of the metabolites produced), they elicit no biological activity when bound to MOR. It is the M6G metabolite (accounts for 10% of the metabohtes produced) that elicits the nociceptive/analgesic effect upon binding to the p opioid receptor (Dahan et al. 2008). M6G is predominately eliminated via renal excretion. 

The above water deficit equation does not take into consideration continuous free water losses (i.e., insensible, renal, or gastrointestinal)... 

Dosing of Selected Intravenous Anti-Infectives in Patients Receiving Continuous Renal Replacement Therapy... 

National and international trends over the past 15 years depict modest improvements in the treatment and/or control of blood pressure (BP) for hypertensive patients. This observation is made despite efforts to promote awareness, treatment, and the means available to aggressively manage high blood pressure. Over 65 million Americans have hypertension, which was listed as the primary cause of death for over 261,000 individuals in the United States in 2002.1 Hypertension is also a significant cause of end-stage renal disease and heart failure. National and international organizations continually refine their recommendations of how... 

Based on the results of the ANZICS trial, the lack of conclusive evidence in many earlier studies, and several meta-analyses, routine use of low-dose dopamine solely for increasing renal blood flow is not recommended. While recent surveys continue to show that low-dose dopamine is used in many ICUs, benefits of low-dose dopamine in the prevention or treatment of ARF remain unproven. 

With either type of dialysis, studies suggest that recovery of renal function is decreased in ARF patients who undergo dialysis compared with those not requiring dialysis. Decreased recovery of renal function may be due to hemodialysis-induced hypotension causing additional ischemic injury to the kidney. Also, exposure of a patient s blood to bioincompatible dialysis membranes (cuprophane or cellulose acetate) results in complement and leukocyte activation which can lead to neutrophil infiltration into the kidney and release of vasoconstrictive substances that can prolong renal dysfunction.26 Synthetic membranes composed of substances such as polysulfone, polyacrylonitrile, and polymethylmethacrylate are considered to be more biocompatible and would be less likely to activate complement. Synthetic membranes are generally more expensive than cellulose-based membranes. Several recent meta-analyses found no difference in mortality between biocompatible and bioincompatible membranes. Whether biocompatible membranes lead to better patient outcomes continues to be debated. 

In PD, prewarmed dialysate is instilled into the peritoneal cavity where it dwells for a specified length of time (usually one to several hours, depending on the type of PD) to adequately clear metabolic waste products. At the end of the dwell time, the dialysate is drained and replaced with fresh dialysate. The continuous nature of PD provides for a more physiologic removal of waste products from the bloodstream, which mimics endogenous renal function by decreasing the fluctuations seen in serum concentrations of the waste products. Similarly, water is removed at a more constant rate, lessening the fluctuations in intravascular fluid balance and providing for more hemodynamic stability. 

The preferred route of administration is intraperitoneal (IP) rather than IV to achieve maximum concentrations at the site of infection. Antibiotics can be administered IP intermittently as a single large dose in one exchange per day or continuously as multiple smaller doses with each exchange. Intermittent administration requires at least 6 hours of dwell time in the peritoneal cavity to allow for adequate systemic absorption and provides adequate levels to cover the 24-hour period. However, continuous administration is better suited for PD modalities that require more frequent exchanges (less than 6-hour dwell time). The reader should refer to the ISPD guidelines for dosing recommendations for IP antibiotics in CAPD and automated PD patients.49 The dose of the antibiotics should be increased by 25% for patients with residual renal function who are able to produce more than 100 mL urine output per day. 

Once the loading dose of the AED is administered, it is important to remember to initiate maintenance doses to ensure that therapeutic levels are sustained. Chronic and idiosyncratic side effects as well as potential drug interactions should be considered if the patient will continue AED therapy indefinitely. All drug therapy should be adjusted for any hepatic or renal disease states. Table 28-1 summarizes the drug doses used in SE, and Table 28-2 provides an example of an algorithm for the treatment of patients in SE. Published studies comparing these treatment strategies are summarized in Table 28-3. 

A loading dose of 0.2 mg/kg (repeated up to a maximum of 2 mg/kg) followed by a continuous infusion of 0.05 to 2 mg/kg per hour is recommended in RSE.29-31 The dose must be adjusted during prolonged infusions, especially in patients with renal impairment, as the active metabolite can accumulate.32 Breakthrough seizures are common with midazolam infusions and usually respond to a bolus and a 20% increase in the rate. Despite this, tachyphylaxis can occur and the patient should be switched to another agent if seizure activity continues. 

ESRD end-stage renal disease for information on obtaining continuing education credit for... 

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