Pharmacotherapeutics of Chronic renal failure

1. CHRONIC RENAL FAILURE
Dr. V. S. Swathi
Assistant Professor

2. DEFINITION
• It is a chronic renal condition in which glomerular filtration rate
decreases along with structural abnormalities of renal tract

3. EPIDEMIOLOGY
• In the world, prevalence of chronic kidney disease is 23.4% and
CKD at stage 5 is 10.6%
• In India, prevalence of chronic kidney disease is 17.2%

4. TYPES
Stage Glomerular Filtration rate (ml/min)
I ≥ 90
II 60-89
III A 45-59
III B 30-44
IV 13-29
V ≤15

6. RISK FACTORS
• Older age
• Smoking
• Family history of renal diseases
• Hypertension
• Diabetes
• Cardiovascular diseases
• Obesity
• Abnormal kidney structure

7. ETIOLOGY
• Type I and II diabetes
• High blood pressure
• Glomerularnephritis
• Interstitial Nephritis
• Polycystic kidney disease
• Benign prostate hyperplasia
• Renal calculi
• Prostate cancer
• Vesicoureteral reflux
• Recurrent kidney infections

9. PATHOGENESIS

10. PATHOGENESIS CONTINUED….

11. PATHOGENESIS CONTINUED….

12. PATHOGENESIS CONTINUED….

14. CLINICAL PRESENTATION
• Polyuria
• Nocturia
• Frothy urine
• Blood in urine
• Peripheral oedema
• Shortness of breath
• Chest pain
• Weight gain/ Weight loss
• Pain in bones
• Pain in muscles
• Bleeding
• Rashes
• Nausea
• Vomiting
• Foul taste
• Paleness of skin
• Skin discoloration
• Pruritis
• Dryness of skin
• Fatigue
• Loss of libido
• Somnolence
• Confusion
• Seizures
• Coma

15. COMPLICATIONS
• Hypertension
• Cardiovascular diseases
• Anaemia
• Thrombocytopenia
• Osteodystrophy
• Gout
• Hyperkalemia
• Hyperphosphatemia
• Metabolic acidosis
• Erectile dysfunction
• Amenorrhea
• Pulmonary oedema
• Infertility
• Depression
• Sleep disorders
• Infectious Pericarditis
• End stage renal diseases

16. DIAGNOSIS
• Medical history
• Family history
• Clinical presentation
• Complete blood count
• Renal function tests
• Urine microscopy
• Urine culture
• Ultrasound
• Computed tomography
• Magnetic resonance imaging
• Intravenous urography
• Plain abdominal radiography
• Renal biopsy

19. NON PHARMACOLOGICAL TREATMENT
• Avoid risk factors
• Fluid restriction
• Sodium restriction
• Avoid potassium rich food
• Smoking cessation
• Counselling
• Renal replacement therapy
• Renal transplantation

20. TREATMENT ALGORITHM
Blood pressure control
• ACE inhibitors/ ARBs
Volume overload
• Diuretics
• Renal replacement therapy
Hyperparathyroidism
• Vitamin D supplementation

21. TREATMENT ALGORITHM CONTINUED…
Subclinical Hypothyroidism
• Levothyroxine
Anaemia
• Ferrous sulphate
• Iron sucrose
• Iron dextrose
Hypocalcaemia
• Calcium supplementation

22. TREATMENT ALGORITHM CONTINUED…
Metabolic acidosis
• Alkali supplementation
Uremic manifestation
• Renal replacement therapy
Cardiovascular complications
• Beta blockers

23. TREATMENT ALGORITHM CONTINUED…
Growth failure in children
• Growth hormone supplementation
Adults with CKD
• Stations

24. INDICATIONS FOR RENAL REPLACEMENT THERAPY
• Severe metabolic acidosis
• Hyperkalemia
• Pericarditis
• Encephalopathy
• Intractable volume overload
• Failure to thrive and malnutrition
• Peripheral neuropathy
• Intractable gastrointestinal symptoms

25. DRUGS USED IN TREATMENT OF CHRONIC KIDNEY DISEASE
Drug Category Mode of action Dose Adverse drug reactions
Ramipril Angiotensin
converting
Enzyme inhibitor
Inhibit
vasoconstriction
by inhibiting
formation of
Angiotensin II
1.25-5mg-PO-OD  Cough
 Hypotension
 Angina
 Dizziness
 Syncope
Telmisartan Angiotensin II
blocker
Inhibit
vasoconstriction
by blocking the
actions of
Angiotensin II
40-80mg-PO-OD  Upper urinary tract
infections
 Back pain
 Diarrhea
 Myalgia
 Sinusitis
Ferrous
sulphate
Iron
supplementation
Improves oxygen
supply to the cells
100-200mg-PO-OD  Vomiting
 Diarrhea
 Dark stools
 Urine discolouration
 Superficial tooth
discoloration

26. Iron Sucrose Iron supplementation Improves oxygen
supply to the cells
100mg-IV-3 doses/week for
dialysis patients
200mg-IV-Thrice weekly for
non dialysis patients
 Hypotension
 Muscle cramps
 Head ache
 Peripheral oedema
 Pruritis
Epoietin alpha Erythropoiesis
stimulating agent
Increases RBC
production 50-100 Units/kg/IV/SC-
thrice weekly
 Pyrexia
 Hypertension
 Vomiting
 Pruritis
 Arthralgia
Calcium carbonate Calcium
supplementation
Restores calcium
levels in the blood
1-1.2g-PO-OD  Anorexia
 Constipation
 Hypercalcemia
 Hypophosphatemia
 Milk alkali syndrome
Calcium acetate Phosphate scavenger Chelates phosphate in
intestine and forms
insoluble calcium
phosphate which is
excreted via faeces
1334mg-PO-TID  Arrhythmias
 Hypomagnesaemia
 Hypophosphatemia
 Hypotension
 Pruritis

27. Calcitriol Vitamin D
supplementation
Improves
calcium
absorption
0.25mcg-PO-
OD
 Abdominal pain
 Apathy
 Abnormal renal function
tests
 Arrhythmias
 Dehydration
Sodium
bicarbonate
Alkaniser Neutralises
excess acidity
2-5MEQ/kg-IF
for 4-8 hours
 Aggravation of CHF
 Cerebral Haemorrhage
 Oedema
 Hypernatremia
 Metabolic alkalosis
Atorvastatin Statins Decreases
synthesis of
cholesterol by
inhibiting the
actions of
HMG CoA
reductase
10-80mg-PO-
OD
 Diarrhea
 Nasopharyngitis
 Arthralgia
 Urinary tract infection
 Dyspepsia

28. RESOURCES
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6325814/pdf/40359_2018_A
rticle_264.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280168/pdf/0104-1169-
rlae-26-e3091.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6283671/pdf/nihms-
994044.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091174/pdf/12882_2018_A
rticle_988.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436482/pdf/CLC-42-21.pdf