Renal dysfunction

Congestive heart failure Throm bocy topenia Renal dysfunction... 

INEFFECTIVE TISSUE PERFUSION RENAL The patient taking an aminoglycoside is at risk for nephrotoxicity. The nurse measures and records the intake and output and notifies the primary health care provider if the output is less than 750 ml/day. It is important to keep a record of the fluid intake and output as well as a daily weight to assess hydration and renal function. The nurse encourages fluid intake to 2000 ml/day (if the patient s condition permits). Any changes in the intake and output ratio or in the appearance of the urine may indicate nephrotoxicity. The nurse reports these types of changes to the primary health care provider promptly. The primary health care provider may order daily laboratory tests (ie, serum creatinine and blood urea nitrogen [BUN]) to monitor renal function. The nurse reports any elevation in the creatinine or BUN level to tiie primary health care provider because an elevation may indicate renal dysfunction. 

Niacin is contraindicated in patients with known hypersensitivity to niacin, active peptic ulcer, hepatic dysfunction, and arterial bleeding. The drug is used cautiously in patients with renal dysfunction, high alcohol consumption, unstable angina, gout, and pregnancy (Category C). 

HMG-CoA REDUCTASE INHIBITORS AND FlBRIC ACID DERIVATIVES. The antihyperlipidemic drugp, particularly die HMG-CoA reductase inhibitors, have been associated with skeletal muscle effects leading to rhab-domyolysis. Rhabdomyolysis is a very rare condition in which muscle damage results in die release of muscle cell contents into die bloodstream. Rhabdomyolysis may precipitate renal dysfunction or acute renal failure The nurse is alert for unexplained muscle pain, muscle tenderness, or weakness, especially if tiiey are accompanied by malaise or fever. These symptoms should be reported to die primary health care provider because the drug may be discontinued. 

Thiazides and related diuretics are used in the treatment of hypertension, edema caused by CHF, hepatic cirrhosis, corticosteroid and estrogen therapy, and renal dysfunction. 

Loop diuretics are used cautiously in patients with renal dysfunction. The loop diuretics are Pregnancy Category B (ethacrynic acid and torsemide) and C drugp (furosemide and bumetanide) and must be used cautiously during pregnancy and lactation. Furosemide is used in children but should be used cautiously. The loop diuretics are used cautiously in patients with liver disease, diabetes, lupus erythematosus (may exacerbate or activate the disease), or diarrhea. Patients with... 

The oral antidiabetic drugs are contraindicated in patients with known hypersensitivity to tiie drugs, DKA, severe infection, or severe endocrine disease. The first generation sulfonylureas (chlorpropamide, tolazamide, and tolbutamide) are contraindicated in patients with coronary artery disease or liver or renal dysfunction. Other sulfonylureas are used cautiously in patients with impaired liver function because liver dysfunction can prolong the drug s effect. In addition, the sulfonylureas are used cautiously in patients with renal... 

Bellomo R. Chapman M, Finfer S, Hickhng K, Myburth J Low-dose dopamine in patients with early renal dysfunction a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Chnical Trials Group. Lancet 2000 356 2139-2143. 

The condition known as fatal infantile mitochondrial myopathy and renal dysfunction involves severe diminution or absence of most oxidoreductases of the respiratory chain. MELAS (mitochondrial encephalopathy, lactic acidosis, and stroke) is an inherited condition due to NADHiubiquinone oxidoreductase (complex I) or cytochrome oxidase deficiency. It is caused by a muta-... 

Low molecular weight heparins (adjust dose for renal dysfunction [i.e., creatinine clearance <30 mL/min])... 

Low molecular weight heparins (adjust doses for renal dysfunction)... 

Chronic or large ingestions of propylene glycol have been associated with the development of hyperosmolar anion-gap metabolic acidosis, renal dysfunction, hemolysis, cardiac arrhythmias, and seizures. 

Magnesium oxide 300 mg enterally tid-qid ° Milk of magnesia 5 mL tid-qid ° Adjust dose until serum magnesium normalizes ° Cautious dosing in patients with renal dysfunction... 

There is growing evidence of a link between renal disease and HF.8 Renal insufficiency is present in one-third of HF patients and is associated with a worse prognosis. In hospitalized HF patients, the presence of renal insufficiency is associated with longer lengths of stay, increased in-hospital morbidity and mortality, and detrimental neurohormonal alterations. Conversely, renal dysfunction is a common complication of HF or results from its treatment. Renal failure is also a common cause for HF decompensation. 

Serum creatinine May be increased owing to hypoperfusion preexisting renal dysfunction can contribute to volume overload. 

Two types of diuretics are used for volume management in HF thiazides and loop diuretics. Thiazide diuretics such as hydrochlorothiazide, chlorthalidone, and metolazone block sodium and chloride reabsorption in the distal convoluted tubule. Thiazides are weaker than loop diuretics in terms of effecting an increase in urine output and therefore are not utilized frequently as monotherapy in HF. They are optimally suited for patients with hypertension who have mild congestion. Additionally, the action of thiazides is limited in patients with renal insufficiency (creatinine clearance less than 30 mL/minute) due to reduced secretion into their site of action. An exception is metolazone, which retains its potent action in patients with renal dysfunction. Metolazone is often used in combination with loop diuretics when patients exhibit diuretic resistance, defined as edema unresponsive to loop diuretics alone. 

The current values for ruling out a cardiac etiology for dyspnea are a BNP less than 100 pg/mL (100 ng/L) or an NT-proBNP less than 300 pg/mL (300 ng/L or 35.4 pmol/L). BNP measurements require cautious interpretation, as numerous conditions can also elevate BNP concentrations. These include older age, renal dysfunction, pulmonary embolism, and chronic pulmonary disease. Nesiritide, a recombinant BNP drug, has an identical structure to native BNP and will interfere with the commercial BNP assay, resulting in a falsely elevated level. Therefore, blood for BNP determination should be obtained 2 hours after the end of a nesiritide infusion, or alternatively the NT-proBNP assay should be utilized. 

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... 

Fondaparinux has been used for the treatment of DVT and PE in two large Phase III trials and is approved by the FDA for these indications. Fondaparinux is as safe and effective as IV UFH for the treatment of PE and SC LMWH for DVT treatment.36,40 The recommended dose for fondaparinux in the treatment of VTE is based on the patient s weight (Table 7-3). Fondaparinux is renally eliminated and accumulation can occur in patients with renal dysfunction. Due to the lack of specific dosing guidelines, fondaparinux is contraindicated in patients with severe renal impairment (CrCl less than 30 mL/minute). Baseline renal function should be measured and monitored closely during the course... 

The dose of lamivudine is 100 mg orally once daily for treatment of chronic hepatitis B. The dose must be adjusted in patients with renal dysfunction [creatinine clearance (CrCl) less than 50 mL/minute]. 

The side-effect profile for entecavir is similar to lamivudine and adefovir dipivoxil and comparable to placebo. Patients treated with entecavir should be monitored for signs and symptoms associated with lactic acidosis and severe hepatomegaly with steatosis, because some cases have been fatal. Dosage adjustments are required in patients with renal dysfunction. 

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. 

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