The document provides a comprehensive overview of acute renal failure, detailing definitions, classifications, and etiologies, emphasizing the distinction between pre-renal, intrinsic renal, and post-renal causes. It outlines diagnostic approaches, potential treatments for acute renal failure including medications and dialysis modalities, as well as the management of chronic kidney disease and related complications. Additionally, it addresses the implications of obstructive renal disorders and renal calculi, including risk factors, symptoms, and treatment options.

1. ACUTE RENAL FAILURE
INTERN EMERGENCY
LECTURE SERIES 2005

2. ABRUPT DECREASE IN RENAL
FUNCTION RESULTING IN THE
ACCUMULATION OF
NITROGENOUS COMPOUNDS
SUCH AS UREA AND
CREATININE
DEFINITION

3. A

4. Acute vs Chronic Renal
Failure
 History
» Known Chronic
» Recent Toxic Exposure
» Recent Hypoxia
» Recent Trauma
» Known Diseases Associated with ARF
» Prev. Abnormal Lab Results Suggesting
Chronic

5. Acute vs Chronic Renal
Failure
 Rapidly Rising Creatinine = Acute
 Kidney Size
» Small = Chronic
 Renal Ultrasound
» Increased Echogenicity = Chronic
 Urine Flow Rate
» Oliguric or Anuric usually = Acute

6. ACUTE RENAL FAILURE
CLASSIFICATION BY URINE
VOLUME
OLIGURIC: <400 CC/ 24 Hrs
NON-OLIGURIC: >500 CC/24 Hrs
ANURIC <50 CC/24 Hrs

7. 03/05/2011 7

8. ETIOLOGY OF ACUTE RENAL
FAILURE
 PRE-RENAL 55-60%
 POST RENAL <5%
 RENAL 35-40%

9. Glomerular Disease
 Nephritis
– Inflammation seen on histologic exam
– Active sediment: Red cells, white cells, granular casts,
red cell casts
– Variable degree of proteinuria (< 3g/day)
 Nephrotic
– No inflammation
– Bland sediment: No cells, fatty casts
– Nephrotic range proteinuria (>3.5 g/day)
– Nephrotic syndrome = proteinuria + hyperlipidemia +
edema

10. Glomerular Disease --
Glomerulonephritis
 Postinfectious
glomerulonephritis
– Group A Strep Infection
 Membranoproliferative
glomerulonephritis:
– infective endocarditis
– Systemic lupus
erythematosus
– Hepatitis C virus
 Rapidly progressive
glomerulonephritis
– IgA nephropathy
 Infections: CMV, Staph.
Aureus, H. influenzae
– SLE
– Goodpasture syndrome
(anti-GBM)
– Henoch-Schönlein
purpura
– Wegener granulomatosis
– Polyarteritis nodosa
 Vasculitis
(cryoglobulinemia)

11. Chronic Kidney Disease
» = a GFR of < 60 for 3 months or more.
» Most common causes:
 Diabetes Mellitus
 Hypertension
» Management:
– Blood pressure control!
– Diabetic control!
– Smoking cessation
– Dietary protein restriction
– Phosphorus lowering drugs/ Calcium replacement
 Most patients have some degree of hyperparathyroidism
– Erythropoietin replacement
 Start when Hgb < 10 g/dL
– Bicarbonate therapy for acidosis
– Dialysis?

12. Assessing the patient with acute
renal failure – Urinalysis
 Hematuria
» Non-glomerular:
– Urinary sediment: intact red blood cells
– Causes:
 Infection
 Cancer
 Obstructive Uropathy
» Rhabdomyolysis
– myoglobinuria; Hematuria with no RBCs
» Glomerular:
– Urine sediment: dysmorphic red blood cells, red cell casts
– Causes:
 Glomerulonephritis
 Vasculitis
 Atheroembolic disease
 TTP/HUS (thombotic microangiopathy)

13. Treatment of Acute Renal
Failure
 Treat underlying cause
– Blood pressure
– Infections
– Stop inciting medications
– Nephrostomy tubes/ureteral stents if obstruction
– Treat scleroderma renal crisis with ACE inhibitor
 Hydration
 Diuresis (Lasix)
 Dialysis
 Renal Transplant

14. Indications for Hemodialysis
 Refractory fluid overload
 Hyperkalemia (plasma potassium concentration >6.5
meq/L) or rapidly rising potassium levels
 Metabolic acidosis (pH less than 7.1)
 Azotemia (BUN greater than 80 to 100 mg/dL [29 to 36
mmol/L])
 Signs of uremia, such as pericarditis, neuropathy, or an
otherwise unexplained decline in mental status
 Severe dysnatremias (sodium concentration greater than
155 meq/L or less than 120 meq/L)
 Hyperthermia
 Overdose with a dialyzable drug/toxin

15. Acute Renal Failure
 Causes
» Prerenal
– Hypovolemia, shock, blood loss, embolism, pooling of
fluid d/t ascites or burns, cardiovascular disorders, sepsis
» Intrarenal
– Nephrotoxic agents, infections, ischemia and blockages,
polycystic kidney disease
» Postrenal
– Stones, blood clots, BPH, urethral edema from invasive
procedures
03/05/2011 15

16. PRE-RENAL ACUTE RENAL
FAILURE
 MOST COMMON CAUSE OF ARF
 RESULTS FROM DECREASED RENAL
PERFUSION
 TREATMENT OF THE CAUSE RESTORES
RENAL FUNCTION TUBULAR FUNCTION
INTACT *
 PROLONGED PRE-RENAL FAILURE MAY
LEAD TO ATN

17. CAUSES OF PRE-RENAL
AZOTEMIA
 Intravascular volume depletion
 Decreased cardiac output
 Systemic vasodilation
» Antihypertensives
» Sepsis
 Renal vasoconstriction
 Drugs impairing autoregulation
» Ace inhibitors NSAID

18. MECHANISMIS OF PRE
RENAL ARF

19. POST-RENAL ACUTE RENAL
FAILURE
 ACCOUNTS FOR 2-15% OF ALL ARF
 OBSTRUCTION TO URINE FLOW
» INCREASED TUBULAR PRESSURE
» VASOCONSTRICTION
– DECREASED RENAL BLOOD FLOW
 MUST BE BILATERAL TO RESULT IN
ARF
» UNLESS : SINGLE KIDNEY OR PRIOR
CHRONIC RENAL FAILURE

20. POST RENAL ACUTE RENAL
FAILURE
 SUSPECT OBSTRUCTION IN ANURIA
 ETIOLOGY MAY BE AGE
DEPENDENT
» YOUNG = CONGENITAL ABNORMALITY
» OLDER MALE = PROSTATIC
ENLARGEMENT
 ARF MOST OFTEN ASSOCIATED
WITH LESIONS IN:
» BLADDER, PROSTATE OR URETHRA

21. RENAL-ACUTE RENAL FAILURE
 VASCULAR DISEASE
» VASCULITIS (SLE, POLYARTERITIS
ETC.)
» SCLERODERMA
» THROMBOEMBOLIC DISEASE
» HYPERTENSION

22. RENAL--ACUTE RENAL
FAILURE
 GLOMERULAR DISEASE
» ACUTE GLOMERULONEPHRITIS
–POST INFECTIOUS GN
–GOODPASTURE’S DIS.
 ANTI- GLOMERULAR BASEMENT
ANTIBODY

23. ACUTE INTERSTITIAL NEPHRITIS
DRUG INDUCED
 PENICILLINS
 SULFONAMIDES
 CEPHALOSPORIN
 RIFAMPIN ( 2ND
TIME)
 QUINOLONES
 NSAID
(FENOPROFEN)
 ALLOPURINOL
 PHENYTOIN
 THIAZIDES
 FUROSEMIDE
 CIMETIDINE

24.  Fever
 Rash
 Eosinophilia
 Pyuria
 Eosinophiluria
 WBC Casts
Acute Interstitial Nephritis

25. RENAL --ACUTE RENAL FAILURE
 ACUTE TUBULAR NECROSIS
» ISCHEMIC INJURY
» TOXIC INJURY
– ENDOGENOUS TOXINS
 HEMOGLOBINURIA
 MYOBLOBINURIA (RHABDOMYOLYSIS)
 ENDOTOXEMIA

26. RENAL-- ACUTE RENAL FAILURE
 ACUTE TUBULAR NECROSIS
» EXOGENOUS TOXINS
– AMINOGLYCOSIDES
– RADIOGRAPHIC CONTRAST
– HEAVY METAL COMPOUNDS
– ETHYLENE GLYCOL
– METHANOL
– CARBON TETRACHLORIDE
– CIS PLATIN

27. DIAGNOSTIC APPROACH TO ARF
 HISTORY
 PHYSICAL EXAMINATION
 ASSMENT OF URINE VOLUME
 URINE ANALYSIS
 BLOOD CHEMISTRY
 BLOOD AND URINE INDICES
 RADIOLOGIC STUDIES

28. Treatment of ARF

29. Hyperkalemia
 Never occurs in the absence of renal
excretory problem
 Pseudohyperkalemia
» Leukocytosis
» Thrombocytosis
» Prolonged Application of Tourniquet

30. Hyperkalemia
 Significance of urine output
 Role of increased catabolism or tissue
breakdown
 Factors affecting shift of Potassium out
of cells
 Etiololgy of the renal failure

31. Treatment of Hyperkalemia
 Urgency
 Role of the EKG in making the decision
 Clinical setting in which it occurs
» Acute renal failure
» Chronic renal failure

33. Table 5-3. Treatment of hyperkalemia
Medication Mechanism of action Dosage Peak effect
Calcium Antagonism of 10-30 ml of 10% solution IV -5 min
gluconate membrane over 2 min
Insulin and Increased K+entry Insulin, 10 U IV bolus 30-60 min
Glucose into the cells followed by 0.5 mU/kg of
body weight per minute in
50 ml of 20% glucose
Sodium Increased K+entry 44-50 mEq IV over 5 min; 30-60 min
bicarbonate into the cells can be repeated within 30
min
Albuterol Increased K+entry
into the cells 20 mg in the nebulized form 30-60 min
Kayexalate Removal of the 20 g of resin with 100 ml of 2-4 hr
excess K+ 20% sorbitol; can be
repeated every 4-6 hr
Hemodialysis Removal of the Dialysis bath K+ concentration 30-60 min
excess K+ variable

34. INDICATIONS FOR DIALYSIS IN
ACUTE RENAL FAILURE
 UREMIC SYMPTOMS
~ nausea
~ neurologic
 SEVERE FLUID OVERLOAD
 REFRACTORY ELECTROLYTE
DISORDERS
~hyperkalemia
 SEVERE REFRACTORY ACIDOSIS

35. INDICATIONS FOR DIALYSIS IN
ACUTE RENAL FAILURE
 PERICARDITIS
 NEUROPATHY
 MENTAL STATUS CHANGE
 SEIZURES
 BLEEDING
 TOXINS----ETHYLENE GLYCOL,
METHANOL
 PROPHYLACTIC
~recent studies fail to document benefit

36. Chronic Renal Failure
 Medical treatment
 IV glucose and insulin
 Na bicarb, Ca, Vit D, phosphate binders
 Fluid restriction, diuretics
 Iron supplements, blood, erythropoietin
 High carbs, low protein
 Dialysis - After all other methods have
failed
03/05/2011 36

37. Dialysis
 ½ of patients with CRF eventually
require dialysis
 Diffuse harmful waste out of body
 Control BP
 Keep safe level of chemicals in body
 2 types
» Hemodialysis
» Peritoneal dialysis
03/05/2011 37

38. Dialysis
 Peritoneal dialysis
» Semipermeable
membrane
» Catheter inserted through
abdominal wall into
peritoneal cavity
» Cost less
» Fewer restrictions
» Can be done at home
» Risk of peritonitis
» 3 phases – inflow, dwell
and outflow
 Automated peritoneal
dialysis
» Done at home at night
» Maybe 6-7 times /week
 CAPD
» Continous ambulatory
peritoneal dialysis
» Done as outpatient
» Usually 4 X/d
03/05/2011 38

39. Peritoneal Dialysis
 Abdominal lining filters blood
 3 types
» Continuous ambulatory
» Continuous cyclical
» Intermittent
03/05/2011 39

40. Hemodialysis
 3-4 times a week
 Takes 2-4 hours
 Machine filters
blood and
returns it to
body
03/05/2011 40

41. 03/05/2011 41

42. Chronic Renal Failure
 Post op care
» ICU
» I/O
» B/P
» Weight changes
» Electrolytes
» May have fluid volume deficit
» High risk for infection
03/05/2011 42

43. Transplant Meds
 Patients have decreased resistance to
infection
 Corticosteroids – anti-inflammarory
» Deltosone
» Medrol
» Solu-Medrol
 Cytotoxic – inhibit T and B lymphocytes
» Imuran
» Cytoxan
» Cellcept
 T-cell depressors - Cyclosporin
03/05/2011 43

44. Obstructive Renal Disorders
03/05/2011 44

45. Hydronephrosis,
Hydroureter, and Urethral
Stricture
 Outflow obstruction
» Urethral stricture
– Causes bladder distention and progresses to the ureters
and the kidneys
» Hydronephrosis –
– Kidney enlarges as urine collects in the pelvis and kidney
tissue due to obstruction in the outflow tract
– Over a few hours this enlargement can damage the
blood vessels and the tubules
» Hydroureter
– Effects are similar, but occurs lower in the ureter
03/05/2011 45

46. Causes of Obstruction
 Tumor
 Stones
 Congenital structural defects
 Fibrosis
 Treatment with radiation in pelvis
03/05/2011 46

47. Renal Calculi
 Called nephrolithiasis or urolithiasis
 Most commonly develop in the renal pelvis
but can be anywhere in the urinary tract
 Vary in size –from very large to tiny
 Can be 1 stone or many stones
 May stay in kidney or travel into the ureter
 Can damage the urinary tract
 May cause hydronephrosis
 More common in white males 30-50 years of
age
03/05/2011 47

48. Renal Calculi
 Predisposing factors
» Dehydration
» Prolonged immobilization
» Infection
» Obstruction
» Anything which causes the urine to be alkaline
» Metabolic factors
– Excessive intake of calcium, calcium based antacids or
Vit D
– Hyperthyroidism
– Elevated uric acid
03/05/2011 48

49.  Family or personal history. If someone in your
family has kidney stones, you're more likely to
develop stones, too. And if you've already had one or
more kidney stones, you're at increased risk of
developing another.
 Dehydration. Not drinking enough water each day
can increase your risk of kidney stones. People who
live in warm climates and those who sweat a lot may
be at higher risk than others.

50.  Certain diets. Eating a diet that's high in protein,
sodium (salt) and sugar may increase your risk of
some types of kidney stones. This is especially true
with a high-sodium diet. Too much salt in your diet
increases the amount of calcium your kidneys must
filter and significantly increases your risk of kidney
stones.
 Being obese. High body mass index (BMI), large
waist size and weight gain have been linked to an
increased risk of kidney stones.

51.  Digestive diseases and surgery. Gastric bypass
surgery, inflammatory bowel disease or chronic
diarrhea can cause changes in the digestive process
that affect your absorption of calcium and water,
increasing the levels of stone-forming substances in
your urine.
 Other medical conditions. Diseases and conditions
that may increase your risk of kidney stones include
renal tubular acidosis, cystinuria,
hyperparathyroidism, certain medications and some
urinary tract infections.

52. Symptoms
 Severe pain in the side and back, below the ribs
 Pain that radiates to the lower abdomen and groin
 Pain on urination
 Pink, red or brown urine
 Cloudy or foul-smelling urine
 Nausea and vomiting
 Persistent need to urinate
 Urinating more often than usual
 Fever and chills if an infection is present
 Urinating small amounts

53. Drug induced calculi

54. Types of stones
 Calcium stones. Most kidney stones are calcium
stones, usually in the form of calcium oxalate.
Oxalate is a naturally occurring substance found in
food and is also made daily by your liver. Some fruits
and vegetables, as well as nuts and chocolate, have
high oxalate content.
 Calcium stones may also occur in the form of calcium
phosphate. This type of stone is more common in
metabolic conditions, such as renal tubular
acidosis. It may also be associated with certain
migraine headaches or with taking certain seizure
medications, such as topiramate (Topamax).

55.  Struvite stones. Struvite stones form in response to
an infection, such as a urinary tract infection. These
stones can grow quickly and become quite large,
sometimes with few symptoms or little warning.
 Uric acid stones. Uric acid stones can form in people who don't
drink enough fluids or who lose too much fluid, those who eat a
high-protein diet, and those who have gout. Certain genetic
factors also may increase your risk of uric acid stones.
 Cystine stones. These stones form in people with a
hereditary disorder that causes the kidneys to excrete
too much of certain amino acids (cystinuria).

56. Treatment
 Small stones
 Drinking water. Drinking as much as 2
to 3 quarts (1.9 to 2.8 liters) a day may
help flush out your urinary system.
 Pain relievers.
 Medical therapy. alpha blocker, relaxes
the muscles in your ureter, helping you
pass the kidney stone more quickly and
with less pain.

57.  Although tamsulosin was the most
commonly studied medication,
they observed no significant
differences with other alpha blocker
medications, such
asalfuzosin, doxazosin, naftopidil, sil
odosin, orterazosin, prazosin

58. tamsulosin

59. tamsulosin

61. Cautions
 Use with caution in coronary artery disease, liver
disease, general anesthesia
 Orthostatic hypotension may occur
 Priapism rarely reported
 Discontinue if angina symptoms occur or worsen
 Patients with sulfa allergy have rarely developed
allergic reaction; avoid use if previous sulfa allergy
reactions have been life-threatening
 Not for use as antihypertensive drug
 May exacerbate heart failure

62. Infertility
 Males: Abnormal ejaculation including ejaculation
failure, ejaculation disorder, retrograde ejaculation,
and ejaculation decrease has been associated with
therapy; studies in rats revealed significantly reduced
fertility in males considered to be due to impairment
of ejaculation, which was reversible
 Females: Drug is not indicated for use in women;
female fertility in rats was significantly reduced,
considered to be due to impairment of fertilization

63. For big size stones
 Lithotripsy
 Surgical removal
 Life style changes
 Supportive care
 Calcium stones. thiazide diuretic or a phosphate-
containing preparation.
 Uric acid stones. Your doctor may prescribe
allopurinol (Zyloprim, Aloprim) to reduce uric acid
levels

64. BPH

65. Diagnosis
 Digital rectal exam
 Urine test. Analyzing a sample of your urine can help rule out
an infection or other conditions that can cause similar
symptoms.
 Blood test. The results can indicate kidney problems.
 Prostate-specific antigen (PSA) blood test. PSA is a
substance produced in your prostate. PSA levels increase when
you have an enlarged prostate. However, elevated PSA levels
can also be due to recent procedures, infection, surgery or
prostate cancer.

66. PSA Levels

67. Common Symptoms

68. Treatment option in the case
of BPH
 Alpha Blockers
 5-Alpha-Reductase Inhibitors
 Phosphodiesterase-5 Enzyme Inhibitors
 Others treatment

69. Complications
 Utis
 Prostatitis

70. Symptoms of Prostatitis
 Difficulty, frequency (nocturia), Pain or burning
sensation when urinating (dysuria)
 Cloudy urine
 Blood in the urine
 Pain in the abdomen, groin or lower back
 Pain in the area between the scrotum and rectum
(perineum)
 Pain or discomfort of the penis or testicles
 Painful ejaculation
 Flu-like signs and symptoms (with bacterial
prostatitis)

71. Treatment of Prostatitis
 Antibiotics.
 Alpha blockers.
 Anti-inflammatory gents. Nonsteroidal
anti-inflammatory drugs (NSAIDs) might
make you more comfortable.

72. Treatment of Prostatitis

73. Tamsulosin

74. Serious Side effects and
patients counselling
 Allergic reaction - (affects less than 1 in 1,000
people). The signs may include finding it
difficult to breathe, having an itchy rash,
having a swollen face, throat, or tongue
 Long-lasting and painful erection (usually not
during sexual activity) - affects less than 1 in
10,000 people

75. Serious Side effects and
patients counselling
 A severe skin reaction with symptoms that
could include skin blistering and exfoliation
(known as Stevens-Johnson syndrome,
erythema multiforme, or exfoliative
dermatitis). It is very rare, affecting less than
1 in 10,000 people (or of unknown frequency)
 Drowsiness, Swollen hands or feet,
Shortness of breath, Heart rhythm disorders
 Orthostatic hypotension

76. Prazosin
 Benign Prostate Hypertrophy (Off-label)
 Initial: 0.5 mg PO q12hr
 Maintenance: 2 mg PO q12hr

77. 5-Alpha-Reductase Inhibitors
 Finasteride is indicated for the treatment
of symptomatic BPH in men with an
enlarged prostate.
 It is beneficial in men with prostates
larger than 40 g and can improve
symptoms and reduce prostatic size by
20-30%.
Dihydrotestosterone blockers

78. 5-Alpha-Reductase Inhibitors
 Finasteride is indicated for the treatment
of symptomatic BPH in men with an
enlarged prostate.
 Finasteride improves urinary flow rate
by 2 mL/s.

79. 5-Alpha-Reductase Inhibitors
 Benign Prostatic Hyperplasia
 Proscar: 5 mg PO qDay; assess response
after 12 weeks to 6 months
 Androgenic Alopecia (Men Only)
 Propecia: 1 mg PO qDay for at least 3
months
 Female Hirsutism (Off-label)
 5 mg PO qDay

80. Side effect
 Hypo Gonadeism
 Erectile dysfunction
Dosage Modifications
Renal impairment: Dose adjustment not
necessary
Hepatic impairment: Caution in liver
dysfunction; monitor

81. Phosphodiesterase-5 Enzyme
Inhibitors
 Tadalafil- Callis
 Cialis or generic equivalent only
 BPH: 5 mg PO once daily
 Recommended to those with low sexual
potency

82. Other measures
 Kegel Exercise
 Pomegranate Juice

83. Surgical Removal

84. Post Surgical Complications
 Calcification
 Malignancy / Cancer prostate

85. Calcification is mainly
 Chemical analysis of prostatic
calcification revealed mixture of calcium
phosphate (75%) and calcium
carbonate (25%) while bladder calculus
was mixed phosphate
 Bacterial Ecoli has main role as well

86. Cancerous Prostate
 Upon removal of prostate sometimes
the cells they are cancerous which is
confirmed from the biopsy
 9 of 10 cases of the prostate residue
which contain cancer cells is intact or
not completely removed during the
TURP

87. Cancerous Prostate
In this case aggressive treatment
measure are taken in consideration to
stop the proliferation of the cells. Often
two approaches are used
1- Radiation therapy
2- Chemotherapy
3- Supportive therapy

88. Radiations
 Gamma radiations are used using
Iridium-192 or Gamma radiations, X-
ray and proton beam therapy
The 2 main types of radiation therapy
used for prostate cancer are:
 External beam radiation
 Brachytherapy (internal radiation)

89. External beam radiations
 5 days a week
 Then reduce
Over the time

90. Side effects of Radiations
 Bowel problems: Radiation can irritate
the rectum and cause a condition
called radiation proctitis. This can lead
to diarrhea, sometimes with blood in the
stool, and rectal leakage.

91. Side effects of Radiations
 Urinary problems: Radiation can
irritate the bladder and lead to a
condition called radiation cystitis. You
might need to urinate more often, have
a burning sensation while you urinate,
and/or find blood in your urine

92. Side effects of direct
Radiations
 Tiredness
 Fatigue
 Impotence/ lack of sexual desire
 Lymphadenopathy

93. Brachytherapy (internal radiation)
 Localized therapy via seeding or implant
 Brachytherapy (also called seed
implantation or interstitial radiation
therapy) uses small radioactive pellets,
or “seeds,” each about the size of a
grain of rice. These pellets are placed
directly into your prostate.

94. Brachytherapy

95. Recommendations
 Radiotherapy seeds are a treatment for early
stage prostate cancer. The cancer must be
contained completely within the prostate.
 If your prostate gland is large you might need
hormone therapy for 3 months before the
radiotherapy treatment. The hormone therapy
shrinks the prostate and makes it easier to
put the seeds into the right place

96. Types of BT and isotopes used
 Permanent BT: such as iodine-125 or
palladium-103
 Temporary BT: Radioactive iridium-192
or cesium-137 is then placed in the
catheters, usually for 5 to 15 minutes

97. Others
 Cryotherapy (also
called cryosurgery or cryoablation) is the
use of very cold temperatures to freeze and
kill prostate cancer cells.
 Two gases are commonly used, nitrous
oxide and carbon dioxide

98. Cryoptherapy Side effect
 Impotence
 Poor bowl and urine control
 Urine fistula which led to the leaking of
urine in bladder, can be repaired
surgically

99. Hormonal therapy
 Medications that stop your body from
producing testosterone. Certain
medications — known as luteinizing
hormone-releasing hormone (LHRH) or
gonadotropin-releasing hormone (GnRH)
agonists and antagonists — prevent your
body's cells from receiving messages to
make testosterone. As a result, your testicles
stop producing testosterone.

100. Hormonal therapy
 Medications that block testosterone
from reaching cancer cells. These
medications, known as anti-androgens,
usually are given in conjunction
with LHRH agonists.
 Surgery to remove the testicles
(orchiectomy)

101. Degarelix
 Degarelix is a GnRH receptor
antagonist indicated for patients with
advanced prostate cancer.

 A single dose of degarelix 240 mg
causes a decrease in the plasma
concentrations of LH and FSH and
subsequently of testosterone.

102. Degarelix
 The initial dose is 240 mg subcutaneous
injection (given as 2 injections of 120
mg at a concentration of 40 mg/mL).
 The maintenance dose is 80 mg
subcutaneous injection (at a
concentration of 20 mg/mL) every 28
days. The first maintenance dose
should be given 28 days after the
starting dose.

103. Possible side effects
 Reduced or absent sexual desire
 Erectile dysfunction (impotence)
 Shrinkage of testicles and penis
 Hot flashes, which may get better or go away with time
 Breast tenderness and growth of breast tissue
 Osteoporosis (bone thinning), which can lead to broken bones
 Anemia (low red blood cell counts)
 Decreased mental sharpness
 Loss of muscle mass
 Weight gain
 Fatigue
 Increased cholesterol levels
 Depression

104. Chemotherapy
 Chemo is sometimes used if prostate
cancer has spread outside the prostate
gland and hormone therapy isn’t
working. Recent research has also
shown that chemo might be helpful if
given along with hormone therapy.

105. Chemotherapy
 For prostate cancer, chemo drugs are
typically used one at a time. Some of
the chemo drugs used to treat prostate
cancer include:
 Docetaxel (Taxotere)
 Cabazitaxel (Jevtana)
 Mitoxantrone (Novantrone)
 Estramustine (Emcyt)

106. Docetaxel (Taxotere)
Indicated for hormone-refractory metastatic prostate
cancer in combination with prednisone
 75 mg/m² IV over 1 hr q3Weeks with daily prednisone
5 mg PO q12hr
Dose modifications
 Febrile neutropenia, ANC <500/mm³ for >1 week, or
severe/cumulative cutaneous reactions, moderate
neurosensory S/S
 Reduce to 60 mg/m²
 If AEs persist: Discontinue

107. Side effects
 Hair loss
 Mouth sores
 Loss of appetite
 Nausea and vomiting
 Diarrhea
 Increased chance of infections (from having too few
white blood cells)
 Easy bruising or bleeding (from having too few blood
platelets)
 Fatigue (from having too few red blood cells)