Renal failure, acute monitoring

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... 

Monitoring changes in UOP can help diagnose the cause of ARF. Acute anuria (less than 50 mL urine/day) is secondary to complete urinary obstruction or a catastrophic event (e.g., shock). Oliguria (400 to 500 mL urine/day) suggests prerenal azotemia. Nonoliguric renal failure (more... 

Key Monitoring Parameters for Patients with Established Acute Renal Failure... 

Foxall PJD, Bending MR, Gartland KI, et al. 1989. Acute renal failure following accidental cutaneous absorption of phenol Application of NMR urinalysis to monitor the disease process. Human Toxicol 9 491-496. 

Renal function impairment Renal impairment, including cases of acute renal failure and Fanconi syndrome, has been reported in association with the use of tenofovir. Avoid tenofovir with concurrent or recent use of a nephrotoxic agent. Carefully monitor patients at risk for, or with a history of, renal dysfunction and patients... 

Concomitant use with sympathomimetic drugs, p-adrenoceptor antagonists, calcium channel-entry blockers and other cardioactive drugs may result in bradyarrhythmias, bigemini, or tachyarrhythmias. Cardiac rhythm should be closely monitored and drug dosages carefully adjusted. Digoxin is mainly excreted by the kidneys and plasma levels should be closely monitored in patients with acute renal failure and in those whose renal function is compromised. 

Gastrointestinal complaints (eg, nausea, diarrhea, vomiting, flatulence) are the most common adverse effects but rarely require discontinuation of therapy. Other potential adverse effects include headache and asthenia. Tenofbvir-associated proximal renal tubulopathy causes excessive renal phosphate and calcium losses and 1-hydroxylation defects of vitamin D, and preclinical studies in several animal species have demonstrated bone toxicity (eg, osteomalacia). Monitoring of bone mineral density should be considered with long-term use in those with risk factors for or with known osteoporosis, as well as in children. Reduction of renal function over time, as well as cases of acute renal failure and Fanconi s syndrome, have been reported in patients receiving tenofovir alone or in combination with emtricitabine. For this reason, tenofovir should be used with caution in patients at risk for renal dysfunction. Tenofovir may compete with other drugs that are actively secreted by the kidneys, such as cidofovir, acyclovir, and ganciclovir. 

Giving intravenous phosphate is probably the fastest and surest way to reduce serum calcium, but it is a hazardous procedure if not done properly. Intravenous phosphate should be used only after other methods of treatment (pamidronate, calcitonin, saline diuresis with furosemide, and plicamycin) have failed to control symptomatic hypercalcemia. Phosphate must be given slowly (50 mmol or 1.5 g elemental phosphorus over 6-8 hours) and the patient switched to oral phosphate (1-2 g/d elemental phosphorus, as one of the salts indicated below) as soon as symptoms of hypercalcemia have cleared. The risks of intravenous phosphate therapy include sudden hypocalcemia, ectopic calcification, acute renal failure, and hypotension. Oral phosphate can also lead to ectopic calcification and renal failure if serum calcium and phosphate levels are not carefully monitored, but the risk is less and the time of onset much longer. Phosphate is available in oral and intravenous forms as the sodium or potassium salt. Amounts required to provide 1 g of elemental phosphorus are as follows ... 

Oral acyclovir is a remarkably safe drug. Common side effects include nausea, vomiting, diarrhea, and abdominal pains. Additional side effects include skin rash, photosensitivity, headaches, dizziness, hallucinations, lethargy, confusion, seizures, and coma. Side effects are most frequent in patients with renal impairment. Rarer complications include anemia, leukopenia, thrombocytopenia, increases in blood urea and creatinine, acute renal failure, reversible increases in bilimbin and liver enzymes, hepatitis, and jaimdice. Cautious dosing and monitoring are recommended in elderly and immunocompromised patients and in patients with renal or liver disease. 

Although acute renal failure is an infrequent com-phcation of IVIG therapy, clinicians should monitor renal function and sucrose-containing products should be avoided, especially in older patients with preexisting renal disease, dysfunction of other organs or volume depletion. 

Addition of sodium sulfate as a lavage solution may precipitate the very insoluble barium sulfate. As potassium deficiency occurs in acute poisoning, serum potassium and cardiac rhythm must be monitored closely. Administration of intravenous potassium appears beneficial. As renal failure is also a concern, urinary output also must be monitored closely. 

Monitor for symptoms of neuroleptic malignant syndrome (NMS) increased fever, pulse, and blood pressure, muscle rigidity, increased creatine phosphokinase, and WBC count altered mental status, acute renal failure, varying levels of consciousness pallor diaphoresis, tachycardia, and dysrhythmias. 

High plasma levels occur in renal failure, inflammation, and neoplasms, especially those associated with B lymphocytes. BMG assay may be used to test renal tubular function, particularly in kidney transplant recipients in whom rejection of the allograft manifests as diminished tubular function (see Chapter 45). Serial assays of BMG are also useful to monitor B-celi tumors. In acute leukemia and lymphoma with central nervous system (CNS) involvement, the level of BMG is increased in CSF and in Sjogren s syndrome with... 

H NMR spectroscopy has also been used, in conjunction with standard clinical biochemical analyses, to monitor renal function in an unusual case of phenol poisoning." A 41-year-old man fell into a shallow vat containing 40% phenol in dichloromethane, at his place of work. He did not ingest any solvent and was partially immersed for only a few seconds. However, he was found collapsed and badly burned in the nearby shower unit. Subsequently, his plasma creatinine levels began to rise, and he did not pass urine. This acute renal failure was treated by haemodialysis and the i.v. administration... 

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