Nephrology
John M. Burke, Pharm.D., FCCP, BCPS
St. Louis College of Pharmacy
St. Louis, Missouri
Learning Objectives
1.
Categorize acute kidney injury (AKI) as prerenal,
intrinsic, or postrenal, based on patient history,
physical examination, and laboratory values.
2.
Identify risk factors for AKI.
3.
Formulate preventive strategies to decrease the risk
of developing AKI in specific patient populations.
4.
Formulate a therapeutic plan to manage AKI.
5.
Identify medications and medication classes asso
-
ciated with acute and chronic kidney damage.
6. Describe characteristics that determine the effi
-
ciency of removal of drugs by dialysis.
7.
Classify the stage or category of chronic kidney
disease (CKD) based on patient history, physical
examination, and laboratory values.
8.
Identify risk factors for the progression of CKD.
9.
Formulate strategies to slow the progression of
CKD.
10.
Assess for the presence of common complications
of CKD.
11.
Develop a care plan to manage the common com
-
plications observed in patients with CKD (e.g.,
anemia, secondary hyperthyroidism).
Self-Assessment Questions
Answers and explanations to these questions can be
found at the end of this chapter.
1.
A 75-year-old man (weight 92.5 kg, height 73
inches) presents to your institution with abdominal
pain and dizziness. He has a brief history of gas
-
troenteritis and has had nothing to eat or drink for
24 hours. His blood pressure (BP) reading while
sitting is 120/80 mm Hg, which drops to 90/60 mm
Hg when standing. His heart rate is 90 beats/min
-
ute. His basic metabolic panel shows sodium (Na)
135 mEq/L, chloride (Cl) 108 mEq/L, potassium
(K) 4.7 mEq/L, CO
2
26 mEq/L, blood urea nitro
-
gen (BUN) 40 mg/dL, serum creatinine (SCr) 1.5
mg/dL, and glucose 188 mg/dL. He has no known
drug allergies. Which is the best approach to treat
this patient?
A. Administer furosemide 40 mg intravenously × 1.
B.
Insert Foley catheter to check for residual
urine.
C. Administer fluid bolus (500 mL of normal
saline solution).
D.
Administer insulin lispro 3 units subcutaneously.
2.
A 44-year-old man is admitted with gram-nega
-
tive bacteremia. He receives 4 days of parenteral
aminoglycoside therapy and develops acute tubular
necrosis (ATN). Antibiotic therapy is adjusted on
the basis of culture and sensitivity results. Which
set of laboratory data is most consistent with this
presentation?
A.
BUN/SCr ratio greater than 20:1, urine sodium
less than 10 mOsm/L, fractional excretion of
sodium (FENa) less than 1%, specific gravity
more than 1.018, and hyaline casts.
B.
BUN/SCr ratio greater than 20:1, urine sodium
more than 20 mOsm/L, FENa more than 3%,
specific gravity 1.010, no casts visible.
C.
BUN/SCr ratio of 10–15:1, urine sodium more
than 40 mOsm/L, FENa more than 1%, spe
-
cific gravity less than 1.015, muddy casts.
D.
BUN/SCr ratio of 10–15:1, urine sodium less
than 10 mOsm/L, FENa less than 1%, specific
gravity more than 1.018, muddy casts.
3.
A patient with chronic kidney disease (CKD) cat
-
egory G4 (estimated creatinine clearance [eCrCl]
of 25 mL/minute) has received a diagnosis of
gram-positive bacteremia, which is susceptible
only to drug X. There are no published reports on
how to adjust the dose of drug X in patients with
impaired kidney function. Review of the drug X
package insert shows that it has significant renal
elimination, with 40% excreted unchanged in the
urine. The usual dose for drug X is 600 mg/day
intravenously and is provided as 100 mg/mL in a
6-mL vial. Which is the best dose (in milliliters of
drug X) to give this patient?
A. 3.6.
B. 4.1.
C. 4.5.
D. 5.5.
4.
A 45-year-old man (weight 59 kg, height 70 inches)
has a long history of cancer and malnutrition. His
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