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L&K - Dialysis
Terms in this set (13)
At what eGFR and CKD stage would dialysis be considered
CKD stage 5
eGFR < 15ml/min/1.73 m2
As a pharmacist on dialysis unit, how would you check suitability of drugs for a patient receiving hemodialysis?
Depending on how well a medicine is dialysed and the type of RRT, additional doses or even administration post-RRT can be required to avoid subtherapeutic levels.
-Check SPC, Renal drug handbook
-offer dosage advice based on creatinine clearance rather than eGFR
-Take extra care with medicines that have narrow therapeutic indices
-Check for interactions, adverse effects, allergies, compliance, etc
A dialysis patient in your ward asks what their "quinine" tablet is for?
For relief of nocturnal leg cramps.
to be taken od at night.
A 58 year old man on dialysis has to take 6 phosphate binders a day. He tends to have scrambled eggs on toast for breakfast, a light lunch, and grilled fish for tea, or equivalent. He doesn't tend to snack. Recommend a dosing regimen.
Egg yolk is high in phosphate, take 3-4 tablets with this meal or choose lower phosphate breakfast. 1-2 binders with lunch & tea.
Patients may vary their binder doses based on phosphate in food; for example, can take four binders with a large phosphate meal, and one with
each of the other meals.
Adherence to binders tends to be poor....phosphorus is found in almost all foods...if you always eat at the kitchen table, try to keep some binders in a pill box on the kitchen table so they are always in sight. Keep binders stashed in different places like car, wallet.
Annie has stage 5 CKD and receives hemodialysis. Should atenolol be given before or after dialysis :
Molecular weight: 266.3 daltons
Protein binding: 3%
Volume of distribution: 1.1L/kg
% Excreted unchanged in the urine: over 90%
Atenolol likely to be dialysed due to fairly small MW (hemodialysis is efficient at removing small molecules), low protein binding, high % unchanged in urine, so you would give it after.
monitor BP as too much atenolol will cause low blood pressure & drowsiness
The patient says that the phosphate binder leaves a taste like vinegar. Which phosphate binder does he take?
Calcium acetate (acetic=vinegar)
So these tablets shouldn't be chewed (bitter taste).
Dialisability Q: Is amlodipine likely to be dialysed if it is
95% protein bound,
approx 10% excreted unchanged in urine
volume of distribution 20L/kg ?
****She has dialysis three times a week from 11:00 - 13:00 hours. Should she take her Amlodipine before or after dialysis sessions?
-Not likely to be dialysed as the MW is high and it's highly protein bound etc.
-Either before or after is fine, it's up to the patient.
if MW is too high drugs won't be filtered through the semi permeable membrane, hemodialysis is efficient at removing small molecules.
If a patient's kidney function declines to creatinine clearance 15ml/min which medicine should be stopped?
A. Amlodipine 5mg daily orally
B. Aspirin 75mg daily orally
C. Glicazide Modified Release 30mg daily orally
D. Metformin 1000mg twice a day orally
Metformin, due to lactic acidosis risk
Mr PQ, a 76 year old man, has been admitted to hospital for renal impairment. He has a history of hypertension, atrial fibrillation and gout. He is taking enalapril at the normal dose 5mg od, any recommendations?
Enalapril is an ACEi, Hyperkalaemia and other side-effects of ACE inhibitors are more common in those with impaired renal function and the dose may need to be reduced. - suggest reducing from 5mg to 2.5mg, a dose reduction is appropriate
A 76 year old man on dialysis is taking dabigatran as he has atrial fibrillation. any recommendations?
Dabigatran is the worst DOAC for renal impairment as it's 80% excreted unchanged by kidney. Alternative anticoagulant to choose- consider apixaban or rivaroxiban.
A patient has a query for you, how does peritoneal dialysis differ from haemodialysis?
Blood is pumped out of the body in haemodialysis and filtered so it is done in hospital (3x week) & it requires anticoagulation such as heparin. it can leave you feeling quite fatigued after but is the most common RRT.
peritoneal dialysis uses the patients own abdominal cavity for dialysis - fluid called dialysate is infused. can be done from home but is less commonly used. there is a risk of infection called peritonitis.
A patient at your pharmacy tells you they are "so drained" after receiving hemodialysis and they are dreading going in to the dialysis unit again tomorrow... what might be causing this and what management could be suggested
•Fatigue is one of the most common symptoms in dialysis
-Reduced cardiac output
-Review of medicines
*small amount of potassium&glucose in dialysate
Annie is a 33-year-old woman with type 1 diabetes, cataracts, and Stage 5 CKD who receives haemodialysis. She was admitted for hyperglycemia and management of medications. she is so fatigued post-dialysis , how can you optimise her therapy?
note her Hb is a bit low at 10g/dL
•insulin glargine (Lantus® insulin) 28 units a.m. and p.m.
•Atenolol 50 mg twice a day
•Calcium acetate 500 mg three times a day
•Epoetin alfa 100 units/kg three times a week
•Ferrous sulfate 325 mg twice a day
•Alprazolam 0.25 mg twice a day when required
•Lactulose 15 ml twice a day
•Calcitriol 0.25 mg daily
•Atorvastatin 20 mg daily
•Venlafaxine 150 mg daily
-This can be removed during dialysis
-Required for cellular uptake of glucose, protein & electrolytes
-Poorly functioning cells leads to fatigue
•Epoetin & ferrous sulfate
-Is this optimised (Hb 10.1g/dl)?
-Is she absorbing iron orally? or needs IV?
-Can cause drowsiness
-Depression associated with dialysis fatigue
-Is this working well enough?
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