Introduction to Renal Therapeutics

Introduction to Renal Therapeutics Introduction to Renal Therapeutics Edited by Caroline Ashley MSc, BPharm (Hons), MRPharmS Lead Specialist Pharmacist, Renal Services Royal Free Hospital Royal Free Hampstead NHS Trust London, UK Clare Morlidge BPharm (Hons), DipClinPharm, MRPharmS Cardiothoracic Directorate Pharmacist Lister Hospital East and North Hertfordshire NHS Trust Hertfordshire, UK On behalf of the UK Renal Pharmacy Group London • Chicago Published by the Pharmaceutical Press An imprint of RPS Publishing 1 Lambeth High Street, London SE1 7JN, UK 100 South Atkinson Road, Suite 200, Grayslake, IL 60030–7820, USA © Pharmaceutical Press 2008 is a trade mark of RPS Publishing RPS Publishing is the publishing organisation of the Royal Pharmaceutical Society of Great Britain First published 2008 Typeset by Photoprint, Torquay, Devon Printed in Great Britain by Cambridge University Press, Cambridge ISBN 978 0 85369 688 9 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, without the prior written permission of the copyright holder. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. The right of Caroline Ashley and Clare Morlidge to be identified as the authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act, 1988. A catalogue record for this book is available from the British Library Contents Preface xi About the editors xiii Contributors xv Abbreviations xvii 1 What are the functions of the kidney? 1 The functional anatomy of the kidney 1 Other functions of the kidneys 5 Conclusion 7 2 Laboratory tests and investigations 9 Standard tests and investigations for the general adult patient population 9 Haematological tests and investigations 13 Urine tests 14 Renal biopsy 15 Immunological tests 15 Serum and urine electrophoresis 15 Radiological tests 16 Describing and measuring renal function 16 References 18 3 Acute renal failure 21 Definition 21 Incidence 21 Clinical features 22 Causes 22 Symptoms/signs 27 Distinguishing acute from chronic renal impairment 28 v vi Contents Management 28 Additional points 31 Outcome 31 Conclusion 31 References 33 Further reading 34 4 Chronic renal failure 35 Definition 35 Clinical features 35 Incidence 37 Causes 37 Symptoms and consequences 38 Influence of chronic renal disease on drug handling 41 Renal replacement therapies 42 Conclusion 42 References 43 Further reading 44 5 Renal anaemia 45 Maintenance of serum haemoglobin in the healthy individual 45 The development and consequences of anaemia of chronic kidney disease 47 Assessing the anaemia of chronic kidney disease 49 Iron and erythropoiesis-stimulating agents available for the correction of renal anaemia 51 Iron preparations 53 Initiating iron and erythropoiesis-stimulating agents therapy 53 Failure to respond to therapy 54 Summary 54 References 55 6 Renal bone disease 57 Pathophysiology 57 Complications for the skeleton and progression of renal bone disease 60 Treatment with phosphate binders 63 Treatment with vitamin D 65 The role of parathyroidectomy 66 Contents vii Therapeutic targets 68 New management strategies and new therapeutic agents for renal bone disease 69 References 74 Further reading 74 7 Hypertension and hyperlipidaemia 77 Hypertension 77 Hyperlipidaemia 81 References 84 8 Renal replacement therapy 85 Haemodialysis 85 Continuous renal replacement therapies 91 Haemodiafiltration 95 Peritoneal dialysis 96 References 105 9 Renal transplantation 107 The donor organ 107 Transplant rejection and its prevention 108 Transplant immunosuppression 109 Post-transplant complications 117 The pharmacist’s role in caring for transplant patients 121 References 124 10 Drug dosing in patients with renal impairment and during renal replacement therapy 127 Drug handling considerations in patients with renal impairment 127 Assessment of renal function 129 Adjusting doses for patients with renal impairment 132 Drug handling considerations in patients undergoing renal replacement therapy 133 Adjusting drug doses for patients undergoing renal replacement therapy 135 Summary 136 References 137 Further reading 137 viii Contents 11 Drug-induced kidney disease 139 Pre-renal (or haemodynamic) acute renal failure 139 Intrinsic renal toxicity 141 Post-renal damage (obstructive uropathy) 142 Conclusion 143 References 144 12 Autoimmune kidney disease 145 Pathogenesis 145 Clinical manifestations 145 Principles of treatment 147 Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis 148 Goodpasture’s syndrome 153 Systemic lupus erythematosus 154 IgA nephropathy 156 Membranous glomerulonephritis 158 Membranoproliferative glomerulonephritis 159 Cryoglobulinaemic glomerulonephritis 159 Conclusions 160 References 161 13 Paediatric kidney disease 163 Creatinine and glomerular filtration rate 163 Monitoring and treatment of children with chronic renal failure 164 Transplantation 169 Dialysis 173 Drug prescribing in renal disease 178 References 179 Further reading 180 14 Renal pharmacy in critical care 181 Preventing acute renal failure 181 Renal replacement therapy in the intensive care unit 182 Drug therapies specific to critical care areas 184 General comments on administering drugs to patients with renal impairment 188 References 189 Contents ix 15 Pain control in renal impairment 191 Assessing pain 191 The analgesic ladder 191 Analgesics and renal impairment 191 Individual agents 192 References 201 Further reading 204 16 Diabetes management in kidney disease 205 Definitions of diabetic renal disease 205 The actual structural changes that occur in the diabetic kidney 206 The diagnosis of diabetic renal disease 206 The prevention of diabetic renal disease 206 The screening and referral process for diabetic renal disease 207 The management of diabetes in kidney disease 207 References 216 17 Myeloma and kidney disease 217 Clinical presentation of multiple myeloma 218 Investigation and diagnosis of myeloma 218 Myeloma kidney 218 Treatment options 219 Summary 223 References 224 18 Palliative care 225 Prescribing for symptom control in patients with stage 5 chronic kidney disease managed without dialysis 226 Prescribing in the last few days of life 233 Conclusions 235 References 237 19 Dietary management of kidney disease 239 Historic pre-dialysis dietary intervention 239 Pre-dialysis dietary management 239 Dietary management of renal replacement therapy 244 Vitamin and minerals 247 x Contents Malnutrition 248 References 252 20 Travelling and vaccines 253 Planning holidays 253 General travel health advice 254 Travelling abroad with medication 257 Malaria 259 Travel vaccinations 261 Conclusion 263 References 264 Further information 265 Case study answers 267 Glossary 289 Index 295 Preface Welcome to the first edition of the Introduction book is to help pharmacy students, pharmacists to Renal Therapeutics. In 1995, the UK Renal and other healthcare workers to understand and Pharmacy Group recognised that there was a promote the safe and effective use of drug ther- lack of readily accessible information for phar- apies in renal failure. macists, either with an interest in renal medi- The case studies and questions have been cine, or newly appointed as specialist kept separate from the answers in order to practitioners in the renal field. As a result, mem- encourage readers to formulate their own bers of the RPG wrote and produced the answers before reading the author’s. The Beginner’s Guide to Renal Pharmacy. It was answers section illustrates how the questions designed to be a comprehensive introductory should be approached and what factors need to guide to the causes, effects and management of be taken into consideration when formulating a renal failure, and as such, a copy has since been response. The answers are based on clinical given to each new member of the RPG. In addi- opinion at the time of writing, but they also tion, the Beginner’s Guide has become required represent, to some degree, the opinions of the reading for some post-graduate pharmacy authors themselves. As time passes and new courses. drugs and new information become available, The Beginner’s Guide has now been updated some readers may disagree with the decisions and expanded to become the Introduction to arrived at by the authors, which is entirely Renal Therapeutics. This guide has been written appropriate. by practising renal pharmacists and other We would like to take this opportunity to healthcare professionals who work in renal thank all those pharmacists, dieticians and units. The mix of authors and the depth of their nurses who have contributed chapters for this ‘hands on’ experience has been used to provide book. Writing these chapters requires an enor- a text that directs the reader to the important mous amount of time and effort, and everyone factors in renal therapies. It highlights points has given unstintingly of both. We hope that that may not be readily accessible in any other this book will be of use to all those pharmacists single text, but still bears in mind the practi- who aspire to become a specialist renal phar- tioner new to renal pharmacy. macist, as well as those who just wish to This book is not meant to be exclusive to improve their renal knowledge. pharmacists working in renal units, but should be used by all those who wish to familiarise

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