Kidneys

o Bean-shape organs embedded in dorsal

part of the abdomen retroperitoneally
o Consist of three regions
1. Outer region (renal cortex),
containing foods – filtering
mechanism
2. Middle region (renal medulla)
3. Inner region (renal pelvis)

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Nephron
o It is the structural and functional unit of the kidney
o Over 1 million in each kidney
o Contains
1. Glomerular capsule – filters small solutes from the
blood
2. Bowman’s capsule – funnel like structure; beginning of
the nephron
o Appear as a long tubule with a closed end
o Divided into three portions
1. Proximal convoluted tubule – reabsorbs ions, water,
and nutrients; removes toxins and adjusts filtrate pH
2. Loop of Henle (ascending) – reabsorbs sodium and
chloride from the filtrate into the interstitial fluid
3. Loop of Henle (descending) – aquaporins allow water
to pass from the filtrate into the interstitial fluid
4. Distal convoluted tubule – selectively secretes and
absorbs different ions to maintain blood pH and
electrolyte balance
Collecting duct – reabsorbs solutes and water from the
filtrate
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Physiology
1. Kidney
o Receive and filter a large volume of blood from the renal artery
o Use tubular absorption and secretion to convert glomerular filtrate into urine
2. Nephrons
o Use glomeruli to filter blood
o Flow filtrate through the renal tubules
3. Tubules
o Reabsorb and secrete various substance from the filtrate
o Change filtrate composition and concentration, ultimately producing urine

Glomerular filtration rate (GFR) – depends on the glomerular capillary permeability, blood pressure and
effective filtration rate

Kidney cells – secrete renin in response to decreased blood pressure, blood volume or plasma sodium
concentration

Urinary Tract Disorders

Urinary Tract Infections

➢ Microbial infections of any part of the urinary tract.
➢ Upper UTI – pyelonephritis
➢ Lower UTI – cystitis, urethritis, prostatitis
➢ Common management: nitrofurantoin and trimethoprim- sulfamethoxazole
➢ Uncomplicated UTIs – fluoroquinolones (levofloxacin)

Acute Cystitis
➢ Frequently occurs in female patients (shorter urethra); common in women of childbearing age, older
women and younger girls.
➢ Common caused: E.coli
➢ Symptoms: pain, burning on urination and urinary frequency and urgency
➢ Need for urine culture before antibiotic is given

Prostatitis
➢ Lower UTI in male

Acute Pyelonephritis
➢ Upper UTI, commonly seen in women of childbearing age, older women, young girls
➢ Common cause: E.coli
➢ Symptoms: chills, high fever, flank pain, pain during urination, urinary frequency and urgency, pyuria
➢ Management: IV antibiotics (aminoglycosides or piperacillin-tazobactam)

Urinary Antiseptics / anti-infectives

➢ Prevents bacterial growth in the kidneys and bladder, not effective for systemic infections
➢ Lower dosages – bacteriostatic effect
➢ Higher dosages – bactericidal effect

B. Drugs affecting Urinary System

1. Urinary Antiseptics / Anti-infectives and Antibiotics

✧ Urinary antiseptics / anti-infectives are limited to the treatment of UTIs.
✧ Drug action occurs in the renal tubule and bladder, where it is effective in reducing bacterial
growth.
✧ A urinalysis, as well as a culture and sensitivity test, is usually performed before the initiation
of drug therapy.
✧ As bactericidal agents, these drugs have the potential to cause superinfections. ✧
The urinary antiseptics/antiinfectives are fosfomycin tromethamine, nitrofurantoin,
methenamine hippurate, trimethoprim, ertapenem, and the fluoroquinolones.

Nitrofurantoin
• First prescribed to treat UTIs in 1953.
• Bacteriostatic or bactericidal, depending on the drug dosage, and it is effective against many gram
positive and gram-negative organisms, especially E. coli.
• Given in prophylaxis as prophylactic use (bacteriostatic)
• High dose – bactericidal effect – gram-positive and gram-negative organisms such as E. coli,
Staphylococcus aureus, streptococci, and Neisseria and Klebsiella species.
 • Indication: used to treat cystitis and UTIs.
• Pharmacokinetics: well absorbed from the gastrointestinal (GI) tract; moderately protein bound,
excreted in the urine; short half-life 20 minutes; accumulate in the serum with urinary dysfunction. •
Usually taken with food to decrease GI distress (anorexia, nausea, vomiting, abdominal pain, and
diarrhea)
• 🡻 Absorption occurs when the drug is taken with antacids.
• Onset and duration of action are unknown; peak action occurs 30 minutes after absorption. • Contact
health care provider if sudden onset of dyspnea, chest pain, cough, fever, and chills develops • Side
effects: Side effects of nitrofurantoin include GI disturbances such as anorexia, nausea, vomiting,
diarrhea, and abdominal pain and pulmonary reactions such as dyspnea, chest pain, and
cough. • Drug interactions: antacids decrease nitrofurantoin absorption

Methanamine
• Bactericidal effect when the urine pH is less than 5.5.
• Effective against gram-positive and gram-negative organisms, especially E. coli, Enterococcus and
Proteus species, and Pseudomonas aeruginosa.
• Indication: chronic UTIs.
• Absorbed readily from the GI tract, and approximately 90% of the drug is excreted in the urine
unchanged.
• Methenamine forms ammonia and formaldehyde in acid urine – need to acidify the urine to exert a
bactericidal action.
• To decrease the urine pH: Cranberry juice (several 8-ounce glasses per day), ascorbic acid, and
ammonium chloride
• Side effects: nausea, dysuria, hematuria, and crystalluria
• Drug interactions: NaHCO3 inhibits the action of methenamine; Methenamine + sulfonamides =
crystalluria

Trimethoprim and Trimethoprim – Sulfamethoxazole

• Used alone for the treatment of UTIs, but usually used in combination with a sulfonamide,
sulfamethoxazole (the combined generic preparation is called TMP-SMZ), to prevent the occurrence
of trimethoprim-resistant organisms.
• This drug combination produces slow acting bactericidal effects against most gram-positive and
gram-negative organisms, especially strains of S. aureus, including methicillin-resistant S. aureus
(MRSA), and also Shigella and Proteus species.
• Indication: treatment and prevention of acute and chronic UTIs
• Half-life is 6 to 12 hours and longer in patients with renal dysfunction
• Side effects: GI symptoms (anorexia, nausea, and vomiting and skin problems such as rash and
pruritus)

Flouroquinolones (Quinolones)
• Fluoroquinolones are one of the groups of urinary antibacterials that are effective against strains of
Acinetobacter, Chlamydia, Clostridium, Klebsiella, Staphylococcus, and Streptococcus species that
cause lower UTIs
• E.g.: ciprofloxacin, ofloxacin, and levofloxacin
• Reserved for patients who have no alternative treatment related to its harsh adverse reactions of
tendon rupture, peripheral neuropathy, central nervous system effects, and exacerbation of
myasthenia gravis
• Need to decrease the dosage if there is renal dysfunction
• Half-lives is 2 to 8 hours, but prolonged in patients with renal dysfunction
• Used for caution for complicated UTIs and acute pylonephritis and levofloxacin is only used for
uncomplicated UTIs when no other options are available.
 • Side effects of ciprofloxacin and ofloxacin: headaches, photosensitivity, dizziness, nausea, vomiting,
diarrhea, visual impairment, rash, and pruritus
• Serious adverse reactions: peripheral neuropathy, tendinitis, and tendon rupture • Fluoroquinolones
may exacerbate muscle weakness in patients with myasthenia gravis • Direct patients to stop taking
fluoroquinolones immediately if experiencing serious adverse reactions and notify health care provider.

2. Urinary Analgesics

Phenazopyridine
• Phenazopyridine hydrochloride, an azo dye, and dimethyl sulfoxide (also called DMSO) are urinary
analgesics that are used to relieve the urinary pain, burning sensation, frequency, and urgency of
urination that are symptomatic of cystitis.
• Phenazopyridine (Pyridium) can cause GI disturbances such as abdominal cramps, hemolytic
anemia, and renal and hepatic dysfunction.
• The urine becomes a harmless reddish orange because of the phenazopyridine dye.
• Phenazopyridine can alter the glucose urine test (Clinitest), therefore a blood test should be used to
monitor glucose levels.
• Dimethyl sulfoxide may cause a garlic-like taste and skin hyperpigmentation.
• Maybe used with antibiotics and should discontinue after 2 days of antibiotic use
• Side effect: headache, vertigo, nausea, GI distress
• Adverse effects: anaphylaxis, methemoglobinemia, renal and hepatic failure

Nursing Consideration
1. Ensure renal function before administering
2. Use only as analgesic
3. Take with food
4. Do not double the dose if dose is missed
5. Report to physician if notices yellowing of the eyes

3. Urinary Stimulants
✧ When bladder function is decreased or lost as a result of
a.) Neurogenic bladder (a dysfunction caused by a lesion of the nervous system)
b.) Spinal cord injury (paraplegia, hemiplegia)
c.) Severe head injury, a parasympathomimetic may be used to stimulate micturition
(urination).
✧ Drug of choice – bethanechol chloride – urinary stimulant
✧ It is a direct-acting parasympathomimetic
✧ Mechanism of action: increase bladder tone by increasing tone of the detrusor urinal muscle,
which produces a contraction strong enough to stimulate urination.

4. Urinary Antispasmodics / Antimuscarinics / Anticholinergics

✧ Urinary tract spasms resulting from infection or injury can be relieved with antispasmodics
that have a direct action on the smooth muscles of the urinary tract.
✧ Antispasmodics/antimuscarinics/anticholinergics frequently have side effects including
blurred vision, headache, dizziness, dry mouth, constipation, and tachycardia.
✧ The patient taking these drugs should be taught to report urinary retention, severe dizziness,
blurred vision, palpitations, and confusion.

Urinary Antispasmodics
 Hyoscyamine, mirabegron,
oxybutynin Cl, and flavoxate HCl
✧ Mechanism of action: relaxes smooth muscles of the urinary tract → 🡻 bladder muscle spasm
✧ Used to manage the disorders of the lower urinary tract associated with hypermotility;
(dysuria, urgency, nocturia, suprapubic pain, frequency and incontinence
✧ Side effects: headache, insomnia, drowsiness, dizziness, confusion, excitement, blurred vision,
dry mouth, GI distress, urinary retention, urinary hesitancy
✧ Contraindication: urinary or GI obstruction, glaucoma, obstructive breathing, severe
ulcerative colitis, myasthenia gravis, hypersensitivity to anticholinergics, paralytic ileus,
unstable CV status
✧ Administration consideration: administer 1 hour before antacids or antidiarrheals ✧ Drug
interaction: amantadine increases adverse anticholinergic effects; phenothiazines or
haloperidol will result in decreased antipsychotic effect; antacids and antidiarrheals result in
decreased absorption of hyoscyamine; additive effect with other anticholinergic drug

✧ Antispasmodics have the same effects as antimuscarinics, agents that block parasympathetic
nerve impulses; parasympatholytics; and anticholinergics

Antimuscarinic / Anticholinergic
✧ E.g.: Tolterodine tartrate, trospium chloride, solifenacin succinate, darifenacin hydrobromide
✧ Used to control an overactive bladder, which causes frequency in urination
✧ Effect: decrease urgency and urinary incontinence

5. Drugs used to treat Benign Prostatic Hyperplasia (BPH)

Doxazosin, Tamsulosin,
Terazosin, Finasteride (Proscar)
✧ Mechanism of action: block alpha 1 receptors in the prostate leading to relaxation of smooth
muscles, improving urine flow and decreasing BPH symptoms
✧ Used to increase urine flow and decrease symptoms of BPH
✧ Administration Consideration:
a.) Do not handle crushed tablets if pregnant
b.) Not indicated for females or pediatric use
c.) Postural effects may occur 2 to 6 hours after dose
d.) If treatment is interrupted for several days restart medication at initial dose
✧ Side effects: impotence, decrease volume of ejaculate, decreased libido, asthenia, dizziness,
postural hypotension, nasal congestion, peripheral edema, diarrhea
✧ Contraindication: hypersensitivity and caution in clients with impaired hepatic function ✧
Drug Interaction: Use cautiously with warfarin; cimetidine may decrease clearance; do not
use with alpha adrenergic blockers

Nursing Consideration
1. Change position slowly
2. Avoid activities requiring alertness
3. Take medications same time each day
 4. Advise women who are or may become pregnant not to handle crushed tablets of
finasteride related to risk to male fetus
5. Male with sexual partners should not be pregnant to avoid exposing his partner to
his semen 6. Volume of ejaculation decreased but does not impair fertility

6. Drugs Used to Treat Renal Failure

✧ Mechanism of action: the primary focus of pharmacologic management of renal failure is to
restore and maintain renal perfusion and to eliminate drugs that are directly nephrotoxic ✧
Diuretics to improve urinary outflow and antihypertensive
✧ Dopaminergic receptors cause vasodilation in the renal, mesenteric, coronary and
itnracerebral vascular beds
✧ Used to increase urine flow

Dopamine
• Increase renal perfusion – 2 to 5mcg/kg/min
• Raise blood pressure – 50mcg/kg/min

7. Hematopoietic Growth Factor

✧ Mechanism of action: used to stimulate RBC production
✧ Reverse anemia associated with chronic renal failure
✧ Common medication: epoetin alfa (Epogen, Procrit) SQ / IV 300 to 500 IU/kg/dose 3
times/week
✧ Administration consideration:
a.) Initial effects can be seen within 1 to 2 weeks
Faculty: Cherry B. Lazatin, RN,RPh,MAN Page 7 of 13
COLLEGE OF NURSING AND PHARMACY
C-NCM 106 – PHARMACOLOGY
First Semester | AY 2021-2022

b.) Hematocrit reaches normal levels (20 to 33%) in 2 to 3 weeks

c.) Do not shake solution
d.) IV administration: epoetin alfa may be given undiluted by direct IV as a bolus dose
✧ Side effects: hypertension, headache, seizure, iron deficiency, sweating
✧ Adverse effects: thrombocytosis, clotting of AV fistula, bone pain, arthralgias, headache

Nursing Considerations
1. Blood pressure may rise during early therapy as haematocrit increases; notify
physician of a rapid rise in haematocrit greater than 4 points in 2 weeks
2. Do not give with any other drug solution
3. Use only one dose per vial, do not re-enter vial
4. Client may require additional heparin during dialysis to prevent clotting of the vascular access

8. Drugs to Prevent Organ Rejection

Cyclosporine (Neoral)
• It is an immunosuppressant
• Acts on T-lymphocytes to suppress production of interleukin-2
• Used to prevent rejection of allogenic kidney transplant
• Oral administration is preferred
• Blood levels should be monitored frequently
 • Administer prednisone concurrently
• Client should be instructed to monitor signs of infections
• Grapefruit juice can raise cyclosporine levels, thus increasing risk of toxicity
• Mix the concentrated medication solution with milk, chocolate milk, or orange juice before
administration
• Side effects: nausea, vomiting, hypertension, tremor, hirsutism, depression, anaphylactic shock •
Given 4 to 12 hours before transplant and continued for 1 to 2 weeks after surgery

Azathioprine (Imuran)
• Cytotoxic drug
• Suppresses cell mediated and humoral immunity
• Used with cyclosporine to help suppress transplant rejection
• Can cause neutropenia
• Side effects: nausea, vomiting, bone marrow depression, agranulocytosis, secondary infection

Muromonab – CD3 (Orthoclone OKT3)

• Antibody
• Used to prevent acute allograft rejection of kidney transplants
• Side effect: nausea, vomiting, chest pain, dyspnea
• Dose: 5mg/day administered in less than 1 minute for 10 to 14 days