Renal insufficiency, Patients with

Renal insufficiency Patients with advanced renal insufficiency (Ccr less than or equal to 30 mL/min/1.73 m ) and end-stage renal insufficiency (Ccr less than or equal to 10 mL/min/1.73 m ) should receive 500 mg daily. 

Lower doses should be used in patients with renal insufficiencies Patients with hepatic impairment may have a higher risk of developing renal insufficiency... 

Dosing is 0.10 mg/kg followed by 0.15 mg/kg for 18-24 hr. Renal insufficiency patients with a creatinine clearance <30mL/min should receive half the dose. Adverse reactions could include thrombocytopenia (<100,000) in 0,5% of patients (39),... 

Renai function - Monitor renal function in all patients during treatment with adefovir, particularly for those with preexisting or other risks for renal impairment. Patients with renal insufficiency at baseline or during treatment may require dose adjustment. Evaluate the risks and benefits of adefovir treatment prior to discontinuing adefovir in a patient with treatment-emergent nephrotoxicity. 

Gastric distress (nausea and vomiting) is one of the most frequently reported adverse reactions. Bladder irritation (e.g., dysuria, polyuria, hematuria, and urgency) may occur. The mandelic salt can crystallize in urine if there is inadequate urine flow and should not be given to patients with renal failure. Patients with preexisting hepatic insufficiency may develop acute hepatic failure due to the small quantities of ammonia formed during methenamine hydrolysis. 

Fibrate monotherapy of hyperlipidemia may predispose to rhabdomyolysis with acute renal insufficiency. Patients using fibrates should be cautioned regarding strenuous exertion, dehydration, and the need for prompt evaluation of myalgia. 

In the first patient and the fourth patient in our initial series (p. 7), the association of ALPE with anaerobic exercise had not yet been recognized, and their medical histories may have been insufficient, or the patients may not have reported intense exercise over a short duration. In acute renal failure patients with loin pain of unknown etiology, the presence or absence of anaerobic exercise should always be ascertained when taking their medical history. Erley et al. [28] did not comment on exercise in their study. However, when Sato et al. inquired about exercise in 1998 [34], Erley et al. reported that the patient had undertaken exercise. 

Of 63 adults with advanced renal insufficiency, those with biopsy-proven primary proliferative glomerulonephritis and those whose clinical presentation was consistent with glomerulonephritis had significantly greater exposure to organic solvents than patients with a variety of other renal diseases (37). 

In a retrospective study of 64 patients, mean age 71 years, with acute renal insufficiency associated with an ACE inhibitor, over 85% presented with overt dehydration due to diuretics or gastrointestinal fluid loss (69). Bilateral renal artery stenosis or stenosis in a solitary kidney was documented in 20% of cases. In seven patients dialysis was required, but none became dialysis dependent. After resolution of acute renal insufficiency, the plasma creatinine concentration returned to baseline and renal function was not significantly worsened. Two-year mortality was the highest in a subgroup of patients with pre-existing chronic renal insufficiency. 

Epoetin causes or aggravates hjq)ertension in about 20-35% of dialysis patients (56-60). It can be accompanied by encephalopathy or seizures (61). In 44 children with chronic renal insufficiency treated with epoetin 150 U/kg/week, hjq)ertension was mostly observed in patients on hemodialysis (66%) compared with peritoneal dialysis (33%) and predialysis patients (16%) (62). 

Headache, probably due to intracranial hypertension, has been reported in 15% of patients with renal insufficiency treated with epoetin (23). Analysis of the safety of epoetin in cancer patients is often hampered by toxicity of the concomitant chemotherapy. In a prospective open study, three of 183 anemic cancer patients who did not receive chemotherapy complained of headache, possibly or probably related to epoetin (22). Complaints of dizziness and headache, possible due to epoetin, occurred in two of 44 cancer patients during cisplatin-containing chemotherapy (67). 

Anuric renal insufficiency occurred with losartan in a 70-year-old man with a solitary kidney (18). An interesting feature was that the patient s blood pressure could be controlled with captopril without the development of anuria. 

Of 29 patients with chronic renal insufficiency treated with high doses of muzolimine, five developed a neurological syndrome very similar to multiple sclerosis (1). Other reports of severe neurotoxicity with muzolimine have appeared (SEDA-16, 225). 

Because LMWHs are eliminated renally and patients with renal insufficiency generally have been exclnded from clinical trials, some practice protocols recommend UFH for patients with creatinine clearance rates of less than 30 mL/min. (Creatinine clearance is calculated based on total patient body weight.) However, recent recommendations for dosing adjnstment of enoxaparin in patients with creatinine clearances between 10 and 30 mL/min are now listed in the product manufacturer s label (see Table 16 ). Administration of LMWHs should be avoided in dialysis patients. UFH is monitored and the dose adjusted to a target aPTT, whereas LMWHs are administered by a fixed, weight-based dose. Other dosing information and contraindications are described in Table 16. ... 

The adverse effects of ACE inhibitors are excessive hypotension associated with volume or salt depletion. All ACE inhibitors commonly cause a dry cough and rarely may cause angioedema. Renal failure can occur in patients with bilateral renal artery stenosis. Hyperkalemia may occur in patients with renal insufficiency, diabetics with even mild renal impairment, and patients taking potassium supplements or potassium-sparing diuretics. ACE inhibitors are fetotoxic and are not recommended for use during pregnancy. 

Nausea and vomiting are the most common side effects. Seizures have been noted in up to 1.5% of patients, especially when high doses are given to patients with CNS lesions or with renal insufficiency. Patients who are allergic to other jS-lactam antibiotics may have hypersensitivity reactions to imipenem. 

In clinical chemistry, the variations of the Na concentration level in the extracellular fluid are interpreted as follows [3] (1) The level of Na" is elevated in dehydration (water deficit), central nervous system trauma or disease, and hyperadrenocorticism with hyperaldosteronism or corticosterone of corticosteroid excess. (2) A decrement of the Na level is observed in adrenal insufficiency, in renal insufficiency (especially with inadequate Na intake), in renal tubular acidosis as a physiological response to trauma and bums (Na shifts into cells), in unusual losses via the gastrointestinal tract as in acute or chronic diarrhea or intestinal obstruction or fistula, and in unusual sweating with inadequate sodium replacement. In some patients with edema associated with cardiac or renal disease, seram Na concentration is low, even though total body sodium content is greater than normal water retention (excess antidiuretic hormone, ADH) and abnormal distribution of sodium between intracellular and extracellular fluid contribute to this paradoxical situation. Hyperglycemia occasionally results in a shift of intracellular water to the extracellular... 

Urinaiy tract The incidence of acute renal insufficiency associated with dextrans is estimated to be 4.3% in dehydrated patients [3 ]. 

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. 

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. 

Potassium is contraindicated in patients who are at risk for experiencing hyperkalemia, such as those with renal failure, oliguria, or azotemia (file presence of nitrogen-containing compounds in the blood), anuria, severe hemolytic reactions, untreated Addison s disease (see Chap. 50), acute dehydration, heat cramps, and any form of hyperkalemia Potassium is used cautiously in patients with renal impairment or adrenal insufficiency, heart disease, metabolic acidosis, or prolonged or severe diarrhea. Concurrent use of potassium with... 

Sodium is contraindicated in patients with hypernatremia, fluid retention, and when the administration of sodium or chloride could be detrimental. Sodium is used cautiously in surgical patients and those with circulatory insufficiency, hypoproteinemia, urinaiy tract obstruction, congestive heart failure, edema, and renal impairment. Sodium is a Pregnancy Category C drug and is used cautiously during pregnancy. 

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. 

Lorazepam may be preferred over other benzodiazepines in patients with renal and/or hepatic insufficiency... 

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