Renal insufficiency

Patients with renal insufficiency are often found to be affected by multiple metabolic problems. Anaemia is often present and some of its causes are well identified, but can only partly explain the anaemia of such a severe degree as found in uremia. It is known that a certain degree of decreased erythropoiesis is present. Often occurs blood loss due to bleeding tendency. A third mechanism by which anaemia might develop is hemolysis, in fact the life-span of erythrocytes from uremic patients is shortened, but normal survival is noted when erythrocytes are injected into healthy persons. Erythrocytes from healthy subjects have a shortened survival time when injected into uremic patients. Thus, it seems that extracorpuscular factors account for the development of hemolysis. 

According to some investigators, uremic toxins affect erythrocytes [110] several groups of investigators have described abnormalities of cell metabolism in uremic erythrocytes. However, the results are very controversial. Both increased and decreased erythrocyte glycolysis have been found and an increase of reduced-glutathione concentration and G-6-PD activity have been noted in erythrocytes from uremic subjects. 

Patients on regular haemodialysis treatment lose considerable quantities of carnitine in the dialysate. Depletion of carnitine during haemodialysis has therefore been implicated as a possible cause of disturbances of metabolism and 

Twenty-eight haemodialysis patients were randomized to L-carnitine, 2 g i.v. three times a week, and saline over a 6-week period. After carnitine administration the muscle carnitine level increased about 60% (see Table 23). 

Concentration of total carnitine in muscle of haemodialysis patients, before and after administration of carnitine. Control subjects received placebo. Median values. Source reference 111. 

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Cortisol-Cortisone Conversion. Under normal conditions, this equilibrium slightly favors the oxidized compound. Similarly, the conversion of corticosterone to 11-deoxycorticosterone is also mediated by the liP-hydroxysteroid dehydrogenase enzyme system and requites NAD(P) /NAD(P)H. This conversion is especially important both in the protection of the human fetus from excessive glucocorticoid exposure, and in the protection of distal nephron mineral ocorticoid receptors from glucocorticoid exposure (14). The impairment of this conversion is thought to result in hypertension associated with renal insufficiency (15). 

Generally, nephrotoxicity is not a problem. Some cephalosporins, especially those with the 3-methylthiotetrazole side chain, such as moxalactam (48), show a tendency to promote bleeding. This appears to be due to a reduction in the synthesis of prothrombin and can be a problem especially in elderly patients, patients with renal insufficiency, or patients suffering from malnutrition (219). The same side chain seems to promote a disulfiramlike reaction in patients consuming alcohol following a cephalosporin dose (80,219). 

Muzolimine (710), a 1-substituted 2-pyrazolin-5-one derivative, is a highly active diuretic, differing from the structures of other diuretics since it contains neither a sulfonamide nor a carboxyl group. It has a saluretic effect similar to furosemide and acts in the proximal tubule and in the medullary portion of the ascending limb of the loop of Henle. Pharmacokinetic studies in dogs, healthy volunteers and in patients with renal insufficiency show that the compound is readily absorbed after oral administration (B-80MI40406). 

Criteria for initiation of drug treatment now take into consideration total cardiovascular risk rather than blood pressure alone, such that treatment is now recommended for persons whose blood pressure is in the normal range but still bear a heavy burden of cardiovascular risk factors. Thus, the role of simultaneous reduction of multiple cardiovascular risk factors in improving prognosis in hypertensive patients is stressed. In addition, more aggressive blood pressure goals are recommended for hypertensive patients with comorbid conditions such as diabetes mellitus or renal insufficiency. 

PI (adenosine) receptors were explored as therapeutic targets before P2 receptors. Adenosine was identified early and is in current use to treat supraventricular tachycardia. A2a receptor antagonists are being investigated for the treatment of Parkinson s disease and patents have been lodged for the application of PI receptor subtype agonists and antagonists for myocardial ischaemia and reperfusion injury, cerebral ischaemia, stroke, intermittent claudication and renal insufficiency. 

Nausea, vomiting, epigastric distress, heartburn, fatigue, dizziness, rash, hematologic changes, and renal insufficiency may be seen witii administration of rifampin. Rifampin may also cause a reddish-orange discoloration of body fluids, including urine, tears, saliva, sweat, and sputum. 

B. urinary retention, which indicates renal insufficiency... 

Loop diuretics are used in the treatment of edema associated with CHF, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. These drug s are particularly useful when a greater diuretic effect is desired. Furosemide is the drug of choice when a rapid diuresis is needed or if the patient has renal insufficiency. Furosemide and torsemide are also used to treat hypertension. Ethacrynic acid is also used for the short-term management of ascites caused by a malignancy, idiopathic edema, or lymphedema. 

The uses of the various anabolic steroids include management of anemia of renal insufficiency, control of metastatic breast cancer in women, and promotion of weight gain in those with weight loss after surgery, trauma, or infections. Stanozolol is used prophylactically... 

This complex contains 11 polypeptide subunits of which only one is encoded by mtDNA. Defects of complex III are relatively uncommon and clinical presentations vary. Fatal infantile encephalomyopathies have been described in which severe neonatal lactic acidosis and hypotonia are present along with generalized amino aciduria, a Fanconi syndrome of renal insufficiency and eventual coma and death. Muscle biopsy findings may be uninformative since abnormal mitochondrial distribution is not seen, i.e., there are no ragged-red fibers. Other patients present with pure myopathy in later life and the existence of tissue-specific subunits in complex III has been suggested since one of these patients was shown to have normal complex 111 activity in lymphocytes and fibroblasts. 

The study of the mechanism of urinary excretion of amylase and the amylase clearance has been the subject of many studies in recent years. Levitt et. al (79) studied the renal clearance of amylase in renal insufficiency, acute pancreatitis and macro-amylasemia. In acute pancreatitis, the kidney cleared amylase at a markedly increased rate. The ratio of the amylase clearance rate to the creatinine clearance rate (Cgm/Ccr) averaged 3 times normal early in the course of acute pancreatitis, and this elevation could persist after the serum amylase returned to normal. Comparison of an lase clearance to creatinine clearance was to minimize irrelevant changes due to variation in renal function. The increased clearance of amylase makes the urinary amylase a more sensitive indicator of pancreatitis. 

Replace with 8-10 g albumin/L of ascitic fluid removed o Avoid large-volume paracentesis in patients with pre-existing hemodynamic compromise, acute renal insufficiency, active infection, or active upper gastrointestinal bleed. Cautious large-volume paracentesis in patients with tense... 

Creatinine clearance < 60 mL/min/1.73 m2 (stages III-V chronic kidney disease), diabetes mellitus (with renal insufficiency), hypertension, chronic heart failure, cirrhosis, nephrosis, age >75 yr, cholesterol emboli syndrome, multiple myeloma (questionable)... 

Loop diuretics (dose depends on severity of renal insufficiency) ° Not directly beneficial in established acute tubular necrosis. 

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. 

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. 

Despite their clear benefits, ACE inhibitors are still underutilized in HF. One reason is undue concern or confusion regarding absolute versus relative contraindications for their use. Absolute contraindications include a history of angioedema, bilateral renal artery stenosis, and pregnancy. Relative contraindications include unilateral renal artery stenosis, renal insufficiency, hypotension, hyperkalemia, and cough. Relative contraindications provide a warning that close monitoring is required, but they do not necessarily preclude their use. 

In patients without contraindications, spironolactone is initiated at a dose of 12.5 to 25 mg daily, or occasionally on alternate days for patients with baseline renal insufficiency. Eplerenone is used at a dose of 25 mg daily, with the option to titrate up to 50 mg daily. Doses should be halved or switched to alternate-day dosing if creatinine clearance falls below 50 mL/minute. Potassium supplementation is often decreased or stopped after aldosterone antagonists are initiated, and patients should be counseled to avoid high-potassium foods. At anytime after initiation of therapy, if potassium concentrations exceed... 

Severe renal insufficiency (creatinine clearance less than 30 mL/minute)... 

Multisystem disease (e.g., chronic renal insufficiency, especially due to diabetes)... 

Patients with previously stable cirrhosis who develop acute encephalopathy often have an identifiable precipitating event that can account for the increased production and/or decreased elimination of these toxins. Infections, variceal hemorrhage, renal insufficiency, electrolyte abnormalities, and increased dietary protein have all been associated with acute development of HE. 

The dose of adefovir dipivoxil is 10 mg once daily. The most common side effects include asthenia, abdominal pain, diarrhea, dyspepsia, headaches, nausea, and flatulence. Lactic acidosis, pancreatitis, and hepatomegaly have been reported rarely. Unlike lamivudine, adefovir dipivoxil is associated with dose-related nephrotoxicity, which was most commonly seen in HIV patients receiving doses larger than 60 mg. Therefore, the dose of adefovir dipivoxil must be adjusted in patients with renal insufficiency (CrCl less than 50 mL/minute). 

Monitor serum creatinine because patients with renal insufficiency (CrCl less than 50 mL/minute) may have reduced ribavirin elimination resulting in increased drug accumulation and toxicity (e.g., hemolytic anemia). 

Obtain a thorough past medical history focusing on psychiatric disorders, cardiac disorders, endocrine disease, and renal insufficiency. 

Chronic kidney disease (CKD), also known as chronic renal insufficiency, progressive kidney disease, or nephropathy, is defined as the presence of kidney damage or decreased... 

The tonicity of crystalloid solutions is directly related to their sodium concentration. The most commonly used crystalloids include normal saline, hypertonic saline, and lactated Ringer s solution. Excessive administration of any fluid replacement therapy, regardless of tonicity, can lead to fluid overload, particularly in patients with cardiac or renal insufficiency. 

Sitegliptin Januvia N 25, 50, 100 100 1 Not applicable 100 24 Reduce dosage for renal insufficiency... 

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