dose adjustment in renal failure ...practical approach for clinical pharmacists
DESCRIPTION
Dose Adjustment in Renal Failure ...Practical Approach for Clinical Pharmacists to help them perfectly adjust doses for medications according to best evidence to dateTRANSCRIPT
Dosing adjustment
in
Renal Failure
“Practical approach”
Kareem El-Fass PharmD,Bpharm
Head of Nephrology Clinical Pharmacy Department
Kidney and Urology Centre (KUC)
Estimation &/or Measurement of GFR
Exogenous Filtration Markers
Inulin, iothalamate,
DTPA, iohexol
Endogenous Filtration Markers
Creatinine Cystatin
How is Cr eliminated ?
GlomerularFiltration
Tubular Secretion
10-20 %
in Normal
40-50 %
in diseased
states
How is S.Cr performing for Kidney
function assessment ??
Is a patient with s.cr =1.2 mg/dl is
essentially free of renal insult ???
How is Cr performing for Kidney
function ??
1. Nephrotic syndrome
2. Sickle cell anemia Tubular secretion of
Cr
Decrease Cr secretion
Lupus Nephritis
3. Lupus Nephritis
How is Cr performing ??
How is Cr performing ??
How is Cr performing for Kidney
function ??
Is a patient with s.cr =1.2 mg/dl is
essentially free of renal insult ???
S.Cr =1.1 mg/dlGFR =120
ml/min
S.Cr = 1.2 mg/dl GFR =60
ml/min
How is Cr performing for Kidney
function ??
How is Cr measured ?
1. Jaffe Method (Alkaline Picrate)
2. Isotope Dilution Mass Spectroscopy (IDMS)
(SCr [IDMS] = 0.95 x SCr [Jaffe]).
Crcl Vs GFR e
e-GFR for CKD Classification
eGFR GFR estimated by equations incorporating tubular secretion
such as
1.MDRD
eGFR GFR estimated by equations incorporating tubular secretion
such as 2. CKD-
EPIKDIG
O 2012
eGFR
1. When measured GFRs >60 where they
underestimate
2. When measured GFR <60 as they overestimate.
Now ……
what equation shall we use
for dosing ???
Cockcroft-Gault
ml/min
Actual
BW Jaffe
only
FDA
Stable
only
NKF Recommendations
1. Use of either CG or MDRD for dose adjustments
yields little difference .
2. When MDRD is used it should be normalized
ASHP 2010 Recommendations
1. Calculate CrCl using Cockcroft-Gault equation
2. Identify suggested dosage adjustment
3. Determine if the dosage adjustment is logical and
appropriate for your patient
What to do for ??
1. Unstable creatinine (AKI)
What to do for ??
2. Different weights
Pharmacotherapy 2012
What to do for ??
2. Different weights
Weight category Equation to use
Underweight BMI of 18.5 kg/m2 Actual Body weight
Normal weight BMI of 18.5–24.9
kg/m2
IBW
Obese and Overweight BMI of 25 -
40 kg/m2
Adjusted Body weight 0.4
Morbidly obese MBI 40 kg/m2 or
higher
Lean body weight
What to do for ??
2. Different weights
What to do for ??
2. Different weights
http://www.pharmacologyweekly.com/app/medical-calculators/body-mass-index-bmi-weight-bsa-calculator
Where to go for CrCl and e-GFR Calculation ?
• http://www.globalrph.com/multiple_crcl_2012.cgi
How to get recommendations for dosing
• Check Many references
Allopurinol
How to get recommendations for dosing
• Check Many references
Allopurinol
How to get recommendations for dosing
• Check Many references
Allopurinol
Take-Home Messages
1. Keep Cr limitations in your sight
2. Take care of equation you use and its limitation
3. Use appropriate body weight and s.cr
4. Check different resources
5. Clinical consequences follow-up