NEphrotoxic Drugs for BSc Nursing.

1. Nephrotoxic Drugs
FOR BSC NURSING
DR. PRAVIN PRASAD
1ST YR RESIDENT, MD CLINICAL PHARMACOLOGY
MAHARAJGUNJ MEDICAL CAMPUS
5TH AUGUST, 2015 (20TH SHRAWAN, 2072)

2. Introduction
 Is it necessary??
 Renal damage causes significant morbidity and mortality
 Acute Kidney Injury
 Acute Tubular Necrosis
 Chronic Kidney Disease
 Inflammatory Disorders
 Increasing healthcare expense
 Both to individual and nation
 Renal Damage due to drugs is preventable

3. Nephrotoxicity and Agents responsible
 Nephrotoxic injury is damage to one or both kidenys
that result from exposure to a toxic substance.
 Nephrotoxins are chemicals displaying nephrotoxicity.
 May lead to:
 More side effects
 Increased nephrotoxicity
 Change in the drug metabolism

4. Screening for Acute Kidney Injury

5. Common Drugs leading to
Nephrotoxicity
 Antibiotics:
 Aminoglycoside, Vancomycin
 Anti Fungals
 Amphotericin B
 Immunomodulators
 Calcineurin inhibitors
 Chemotherapeutic agents
 Cyclosporin, Tacrolimus
 Antivirals
 Acyclovir
 Anti Hypertensives
 ACE inhibitors, ARBs
 Diuretics
 β-blockers
 NSAIDs /cox-2 inhibitors
 Cocaine
 Ethylene glycol
 Occupational toxins (heavy metals,
organic solvents)
 Herbal remedies

6. Mechanisms of Nephrotoxicity
OUTER MEDULLA
INNER MEDULLA
CORTEX
ACUTE PRE-RENAL
FAILURE
AMPHOTERICIN,
ANTIHYPERTENSIVES,
DIURETICS,
DOXORUBICIN, NSAIDS,
CYCLOSPORIN-A
NEPHROTIC SYNDROME
NSAIDS, PENICILLAMINE
CAPTOPRIL
HEROIN/COCAINE
ATN(P): ACUTE TUBULAR
NECROSIS
AMINOGLYCOSIDES,
ANTINEOPLASTICS, GLYCOLS,
ATN(D): ACUTE TUBULAR
NECROSIS
AMPHOTERICIN,
CISPLATIN, GLYCOLS
CHRONIC INTERSTITIAL NEPHRITIS
ANALGESIC COMBINATIONS, CHINESE
HERBS, CYCLOSPORINE, METALS (PB, Cd, Li,
Ge), METHYL-CCNU
ACUTE INTERSTITIAL NEPHRITIS
ALLOPURINOL, RIFAMPIN,
VANCOMYCIN, NSAIDS
OBSTRUCTION
ACYCLOVIR, ANTICHOLINERGICS,
BROMOCRIPTINE, ERGOT ALKALOIDS,
FLUOROQUINOLONE, MTX
VASCULITIS
AMPHETAMINES, NSAIDS,
PENICILLINS,SULFONAMIDES

7. Renal Biomarkers

8. Renal Biomarkers
 Traditional tools:
 Diagnose AKI: Serum Creatinine
 Determine etiology:
 Clinical history, physical examination, renal ultrasound, fractional excretion of sodium [FeNa],
fractional excretion of urea, blood urea nitrogen [BUN], and urine microscopy)
 New Biomarkers: under research
 Cystatin C Marker
 Neutrophil Gelatinase- Associated Lipocaline (NAGL)( Lipocalin-2 or siderocalin)
 Kidney injury molecule (KIM-1)

9. Dose Adjustment of Drugs
 Cockcroft and Gault
 Estimated Creatinine Clearance (eCrCl)
 = ([140 – age (years)] × ideal body weight [kg]) ÷ (serum
creatinine [mg/dL] × 72)
 Male: eCrCl x 1
 Female: male eCrCl × 0.85
 To adjust drug dosing for renal function in adults

10. Renal Protective Strategies: Example
Exposure Strategy
Aminoglycoside antibiotics Once – daily dosing; Monitoring of drug levels ; Avoiding in CKD
and pts at risks; Maintain trough levels < 1mcg /ml.
Amphotericin B Use lipid formulation; Saline hydration pre and post administration;
Avoid high or rapid dose or prolonged duration
Ethylene glycol ingestion Ethanol/fomepizole; hemodialysis
Methotrexate IV hydration/urine alkalinization
Acyclovir IV hydration
Calcineurin inhibitors Monitoring drug levels; Lowering the doses; ± CCB
Acetaminophen, Aspirin, NSAIDs Avoid long-term use; More than one drug; Avoid in old age;
Monitor cumulative consumptions and avoid it; Avoid
combination wit RAS blockers
RAS inhibitors Fluid correction before drugs initiation; Monitoring s. creatinine
Acyclovir; Methotrexate
Sulfa ATB; Triamterene
Discontinue or reduce dose; Hydration; Oral route
Establish high urine flow

11. Thank You for
your attention!