DRUGS ACTING ON

RENAL SYSTEM
The Renal System
 The KIDNEY are the major organs of urine formation

Fucntions
o Excreation – removing nitrogenous wastes, certain salts
and excess water from blood.
o Maintain acid-base balace
o Secreate waste production in the form of urine
o Eliminate urine from bladder.
Diuretics

DIURETICS are medicines which increase the

amount of fluid from the body when we pass urine
or substance that help the body rise the sodium and
water.
 Decrease the Blood Pressure
 Drain Fluid (urinate)
 Dehydrate (dried body)
 General indication for use of the
diuretics
 Treatment of edema
-Urine output will increase and excess fluid is flushed out of the body

 Treatment of CHF
- The sodium loss in the kidney is associated with water loss

 Treatment of Hypertension
- Diuretics will decrease the blood volume and serum sodium
Main parts of NEPHRON and its function
Different Classes of Diuretics

Osmotic Diuretics
Loop Diuretics
Thiazide Diuretics
Potassium Sparing Diuretics
Carbonic Anhydrase Inhibitors
 Osmotic Diuretics
 Osmotic diuretics are low-molecular-weight substances that are filtered out of the blood
and into the tubules where they are present in high concentrations. They work by
preventing the reabsorption of water, sodium and chloride.
 Used to prevent kidney failure and to decrease intracranial and intraocular pressure
 Side effects include fluid and electrolyte imbalance and vomiting

ABSORPTION & ELIMINATION

A- Monitol and Urea – IV
Glycerin (Glycerol) and Isosorbide – Orally
E- Quickly metabolize and eliminated and excreted through the track
Osmotic Diuretics Drugs
 Glycerin (Glycerol)
 Isosorbide
 Mannitol IV
 Urea

Works in PROXIMAL TUBULE

& LOOP OF HENLY
Mannitol
 Elevate Intracranial Pressure
 1.25 g/kg of IV mannitol over 30-60 minutes and may repeat q6-8 hr.
 Elevated Intraocular Pressure
 1.5-2 g/kg of mannitol IV over 30-60 minutes
 When used preoperatively
- Administer 1-1.5 hr. before surgery for maximal reduction of IP before operation
 Loop Diuretics
 Prevent the sodium reabsorption in the kidney
 Loop Diuretics prevent chloride for being reabsorption also prevent reabsorption of
calcium and magnesium Ions.
 Increased the urine flow
 Increased the sodium, chloride, water, calcium, magnesium excretion in the nephron.
 Decreased the plasma volume
 Induce the renin released due to the plasma volume depletion
 Side effects include electrolyte imbalances, especially hypokalemia
Absorption & Excreation
A – 60-90% absorb when given orally
E – Secretion via Proximal Tubule

Loop Diuretics Drugs

 bumetanide (Bumex)
 furosemide [(Lasix) (oral or injection)]
 ethacrynate (Edecrin)
 torsemide [(Demadex) (oral or injection)]

Loop Diuretics works at the LOOP OF HENLE

Furosemide
 Adult
-600 mg/day PO or 6 g/day IV infusion
-Up to 4 g/day PO has been given to treat chronic renal failure
 Geriatric
-600 mg/day PO or 6 g/day Iv infusion
-Up to 4 g/day PO has been given to treat chronic renal failiure
 Adolescents
-6 mg/kg/dose PO/IV
 Children
-6 mg/kgdose PO/IV
Caution
 Thiazide Diuretics
 These drugs block the chloride pump and will keep the chloride and sodium in the distal tubule to be
excreted into the urine.
 Potassium is also flushed out.
 Side effect include hypokalemia and cardiac dysfunction

Thiazide Diuretics Drugs

 chlorothiazide [(Diuril) (oral or sodium injection)]
 chlorthalidone (Hygroton)
 indapamide (Lozol)
 hydrochlorothiazide (Hydrodiuril)
 methyclothiazide (Enduron)
 metolazone (Zaroxolyn, Diulo, Mykrox)
 Works on the distal convulate tubule

Chlorthalidone
 For High Blood Pressure
-Recommended dose range is 25 to 100
Mg daily. Most patient receive 12.2 to
25 mg daily
 For Edema
-Treated with 50 to 100 mg daily or 100 mg
Every other day and the maximum dose
Is 200 mg daily.
 For Heart Failure
-Treated with 12.5 to 100 mg daily
Hydrochlorothiazide
 Hydrochlorothiazide may be taken with or without food.
 The usual adult dose for Hypertension is 12.5 to 50 mg once
daily.
 The usual adult dose for treating Edema is 25-100 mg once daily
or in divided doses
 Potassium-sparing Diuretics
Major Goal
 Decreased the reabsorption of sodium and prevent the excretion of potassium.
 Used with others diuretics in conjunction to prevent the excretion of potassium.
 Main side effect is hyperkalemia

2 Types of potassium sparing diuretics

 Amiloride and Triamterene
-They work on the principle cells of collecting duct and the tubules, essentially inhibits sodium
reabsorption and also inhibit potassium excretion, which is they work by making the kidneys pass out
more fluid. They do this by interfering with the transport of salt and water across certain cells in the
kidneys. As more fluid is passed out by the kidneys, less fluid remains in the bloodstream. So any fluid
which has built up in the tissues of the lungs or body is drawn back into the bloodstream to replace the
fluid passed out by the kidneys. This eases symptoms such as fluid retention in the legs (oedema) and
breathlessness caused by excess fluid on the lungs
 Aldosterone Inhibitor such as Eplerenone and Spironolactone
-Works in the collecting ducts which is they inhibits the binding of aldosterone receptors to prevent
the potassium excretion.

Absorption & Elimination

A-Spironolactone metabolized by liver and it highly protein bound
E-Excretion via proximal tubule

Potassium sparing diuretics drugs

 Amiloride hydrochloride
 spironolactone (Aldactone)
 triamterene (Dyrenium)
Spironolactone (Aldactone)

 For Edema In Adults (congestive heart failure, hepatic cirrhosis, or nephrotic

syndrome)
-An initial daily dosage of 100 mg of ALDACTONE administered in either single or
divided doses is recommended, but may range from 25 to 200 mg daily. 
 Essential For Hypertension
-For adults, an initial daily dosage of 50 to 100 mg of ALDACTONE administered in
either single or divided doses is recommended.
 For Hypokalemia
-ALDACTONE in a dosage ranging from 25 mg to 100 mg daily is useful in treating a
diuretic-induced hypokalemia.
Carbonic Anhydrase Inhibitors

 Carbonic Anhydrase forms sodium bicarbonate

 Block of the enzyme results to slow movement of hydrogen and bicarbonate into tubules and also work
by increasing the excretion of sodium, potassium, bicarbonate and water from the renal tubules.
 Used to decrease intraocular pressure with open-angle glaucoma
 Main side effect is metabolic acidosis

CARBONIC ANHYDRASE INHIBITORS DRUGS

 Acetazolamide Injection
 Acetazolamide Tablets
 Methazolamide
 For acetazolamide
(for oral dose form (tablet)For Glucoma
-Adult -250 mg one to four times a day.
-Children – Dose is based on body weight and must be determined by the
doctor. The usual dose is 10 to 15 mg per kg (4.5 to 6.8 mg per pound) of
body weight a day in divided doses

 For methazolamide
(for oral dosage form) For Glucoma
-Adults – 50 to 100 mg two or three times a day
-Children – Used and dose must be determine by the doctor
 FOR WHAT CONDITIONS ARE DIURETICS
USED?
 Diuretics are used with other types of medications (adjunctive therapy) in edema associated
with congestive heart failure (CHF), cirrhosis of the liver, and corticosteroid and estrogen
therapy.
 Diuretics also are useful in edema caused by renal dysfunction (for example,
nephrotic syndrome, acute glomerulonephritis, and chronic renal failure). Diuretics are used to
lower urinary calcium excretion, making them useful in preventing calcium-
containing kidney stones.
 Diuretics are used as the sole therapeutic agents to treat hypertension. Diuretics can also be
used in combination with other antihypertensive drugs to treat more severe forms of
hypertension.
 Diuretics (specifically the carbonic anhydrase inhibitors) are used as adjunctive treatment
of chronic simple (open-angle) glaucoma and secondary glaucoma
 WHAT ARE SIDE EFFECTS OF
DIURETICS?
When individuals present with fluid imbalance (depletion) due to diuretics, adverse events such
as:
> dry mouth > thirst
> Weakness > lethargy
> Drowsiness > restlessness
> muscle pains or cramps > confusion
> seizures, > muscular fatigue
> Hypotension > oliguria (decreased or absent production of urine),
> tachycardia and > gastrointestinal (GI) disturbances may occur.
Nursing consideration
 Important to remember!
 Administer in the morning not at night
 Administer with food
 Monitor daily weight – to evaluate the effectiveness of the therapy
 Low potassium Diet (sodium swells)
 Slow position changes (any BP med)
 Monitor urine output, cardiac rhythm, serum electrolytes
Avoid OTC (Over The Counter) Meds

 C - Cough and Flu

 A – Antacids like tums
 A – Acetaminophen
 N – Nsaids (Naproxen and ibuprofen)
Parenteral Fluids

What is IV therapy?
 It is an effective and efficient method of supplying fluid directly
into intravenous fluid compartment producing rapid effect with
availability of injecting large volume of fluid more than other
method of administration.
Indication of IV Therapy

Purpose
 To provide water, electrolytes, and nutrients to meet daily
requirements.
 To replace water and correct electrolyte deficits.
 To administer medications and blood productions
 What do IV solutions consist of?
IV solution contain
>Dextrose or electrolytes mixes in various proportion with water

Can electrolytes-free water can be administer by IV?

>No because it rapidly enters red blood cells and cause them to rupture

IV solutions
>There are several types of IV fluids
>Type of fluid used selected according to the client and the reason for its use
>IV solution are clearly labeled with the exact components and amount of solution
>IV solutions orders – often written with abbreviations
Remember the Abbreviations!

 “D” is for Dextrose

 “W” is for Water
 “S” is for Saline
 “NS” is for Normal Saline
 Ringer Lactate (Lactated Ringer)- Commonly used Electrolyte
Solution
-Abbreviated “RL or “LR”
 Solution Strength
 IV often identified with abbreviation letters
-These Indicate the components in the IV solution
 The numbers indicate the solution strength or concentration of components in the IV fluid
 Numbers written as subscripts
For example;
D5W - Dextrose 5% in water
NS – Sodium Chloride 0.9%
RL – Lactated Ringer Solution (Electrolytes)
D5 and ½ NS (0.45%) – Dextrose 5% in 0.4% Sodium Chloride
 IV Solution Additive - Potassium

Potassium Chloride (KCL)

 Common additive to IV fluids
 Potassium Chloride – measured in miliequivalents (MEQ)
 Order usually written to indicate the amount of milliequivalents per liter
 IV solution are often available with potassium premixed in them
 Safety Alert!
Remember the following when adding Potassium to
an IV:
 It should be compatible with the solution and well diluted.
 Monitor client during infusion. Rapid infusion of potassium can cause death due to cardiac
depression, arrhythmias and arrest.
 Check IV site frequently, medication is extremely irritating.
 Administer IV using an infusion control device.
 Never administer potassium concentrate IV push.
 Do Not add potassium to an IV bag that is already infusing.
-This would cause the medication to concentrate in the lower portion of IV bag
-Result in client receiving a concentrated medication solution – can be harmful.
IV Fluid

3 Main types
 Isotonic Fluids
Iso - means equal
Tonic – concentration of solution
 Isotonic Fluid is close to same osmolality as serum
 Isotonic fluids expand the EFC volume
 Expand the intravascular space

What implications does this have for a patient with hypertension or heart failure if they
receive isotonic IV’s?
 Risk of fluid overload
 Isotonic Solutions
Provides benefits of:
 Hydration
 Maintain Electrolytes
 Used during and after surgery

Isotonic Fluids Types

 0.9% Sodium Chloride (Normal Saline)
 Lactated Ringer’s (LR)
 D5W
D5/W – Helpful for:

 Provide free water necessary for renal excretion of solutes

 Used to replace water losses and treat hypernatremia

 Provides 170 calories

 Hypotonic Fluids
What is Hypotonic fluid
 Solution containing a
lower concentration
of Salt and Solute than
ICF (fluid inside the cell)
 Have Lower Osmolality
(less concentration)
Purpose of hypotonic fluids
 Replace cellular fluid
 Provides free water for excretion of wastes
 Often use o.45% NS – RX Hypernatremia or other hyperosmolar conditions
 Less Osmolarity than serum
-Dilutes the serum

Excessive use of Hypotonic Solutions

 Leads to intravascular fluid depletion
 Decreased blood pressure
 Cellular Edema
Hypotonic Fluid solution
 ½ NS – 0.45% NaCl (Sodium Chloride)

 1/3 NS – 0.33 % NaCl (Sodium Chloride)

 ¼ NS – 0.225% NaCl (Sodium Chloride)

 2.5% Dextrose in water aslong D5W (5% dextrose in water)

0.45% NS - Hypotonic
 Provide free water in addition to NA + and CL
 Used to replace hypotonic fluid losses
 Used as maintenance solution
-Does not replace daily losses of other electrolytes
 Provides no calories
 A hypotonic solution that provides NA +, CL-, and free water
-Used as a basic fluid for maintenance needs
Helpful For:
 Cellular Dehydration:
-Fluid shifts out of blood vessels (less concentrated) to the tissue cells (more concentrated)
 Ex: Dry mucous membrane
 Hypergylcemia condition:
-Diabetic Ketoacidosis

Can Be Harmful:
 Sudden shift of fluid blood vessel to the cells
-Cardiovascular Collapse
 Hypotonic solutions – Potential to cause cellular swelling
 Monitor for changes in mentation ---> Indicate cerebral edema
Example - Hypotonic IV Solution
 D5NS . 45 (5% Dextrose in ½ Normal Saline)
 5% Dextrose and Water (D5W) – Provide

Nursing Consideration and Intervention

 Not for ICP Patient ( Intracranial Pressure)
 Give slowly (prevent cellular edema)
 Hypovolemia (risk)
Caution: Liver Disease, Trauma and Burns
 Hypertonic Fluids
What is Hypertonic Fluid?
 A Solution containing a Higher Concentration of Salt or Solute that ICF ( fluid Inside
The Cell)
 Have a higher osmolality that serum
 Pull Fluids and Electrolytes from the Intracellular and Interstitial compartment into
the intravascular compartment
Examples
 D5/0.9 NS and D5/0.45 NS
-use postop when some sodium is needed
 D5LR
Hypertonic Fluids Type

 3% NS
 5% NS
 D10W
 D5 ½ NS
 D5LR
 D50W
 Helps to:
 Edema
 Urine output
 Stabilize BP
 Used to maintain fluid intake
 Can temporarily be used to treat Hypovolemia if plasma expander is not available
 Solutions with concentrations greater that 10% must be administered through a central
line
-Allows adequate dilution to prevent shrinkage of RBCS
Used for:
 Hypovolemia
(low fluid Patient)
 Heat Related
(Heat exhaustion)
 Peritonitis
(Low fluid patient)
 Peritoneal Dialysis
Nursing Consideration
 Infuse slowly not rapidly
-if infused rapidly or large quantity hypertonic solutions may cause big massive fluid
shift and overwhelm extracellular fluid and it can lead to
 Risk for: cellular dehydration and fluid overload

Sign and symptoms of having a Fluid overload

 Bounding Pulses
 High Blood pressure
 JVD (Jugular Vein Distention)
 Crackles in lungs (fluid in the lungs)
 Edema
Electrolytes
What is electrolytes?
 Electrolytes are minerals found in body fluids that carry an electrical charge and are
essential to keeping the heart, nerves and muscles functioning
 As such, it is important to maintain a precise and constant balance of electrolytes.
 Cation – positively charge electrolyte
 Anion – Negatively charge electrolyte
 Cation – is anions for homeostasis to exist in each fluid compartment
 Commonly measured in mEq/L
What do electrolytes Do?
 Regulates the fluid levels in your body plasma fluid levels in your blood plasma and
your body.
 Keep the pH (acid/alkaline) of your blood on the normal range (7.35 - 7.45, slightly
alkaline).
 Enable muscle contractions, including the beating of your heart.
 Transmit nerve signals from heart, muscle and nerve cells to other cells.
 Help blood to clot.
 Help build new tissue.
What can cause an Electrolyte Imbalance?

 Losing fluids as a result of persistent vomiting or diarrhea, sweating

or fever.
 Not drinking or eating enough.
 Chronic respiratory problems, such as emphysema.
 Higher – than - normal blood pH (a condition called metabolic
alkalosis).
 Medications such as steroids, diuretics and laxatives,
Different Electrolytes
Electrolyte Imbalances
>Hyponatremia/ >Hypocalcemia/
Hypernatremia Hypercalcemia

>Hypokalemia/ >Hypophosphatemia
Hyperkalemia Hyperphosphatemia

>Hypomagnesemia/ >Hypochloremia
Hypermagnesemia Hyperchloremia
Sodium (Na+)

 It is the most prevalent cation in the ECF

 Total body Sodium is about 5000 mEq in an adult
 Daily required of sodium is about 100 mEq
 In normal individuals, the kidney strives to achieve Na+ balance – that is, to have Na+ excretion
equal to Na+ ingestion
 Normal range of Sodium is 135 - 145

Function
 Maintain balance of extracellular fluid, thereby it controls the movements of the water between
fluid compartments,
 Transmission of nerve impulses
 Neuro muscular and myocardial impulse transmission
Electrolytes Imbalance
Hyponatremia
 Low sodium at the level of < 135 mEq/L that causes water to move into cells.
 Deficiency in Na+ related to amount of body fluid
Several Types
 Dilutianal
 Depletion
 Hypovolemic
 Hypervolemic
 Isovolemic
Surgical Causes – Hyponatremia
 Intestinal Obstruction
 Intestinal Fistulas – Biliary / duodenal / gastric / pancreatic
 GOO – serve vomiting
 Ryle’s tube aspiration
 Severe diarrhea – Colitis / colorectal polyps
 After surgery & trauma – occurs

What do you see

 Sunken eyes, Dry coated tongue, poor skin turgon
 Headache, N/V, muscle twitching, altered mental status
 Irritability, neurological symptoms, convulsions coma
What do we Do?
>Mild / Chronic >Severe / Acute
Case Case
-Na <115 mEq/ L -Na <100 mEq/L
-Restrict flui intake for -Infuse hypertonic NaCl
Hyper/isovolemic, solution (3% or 5% NaCl)
Hyponatremia -Frusemide to remove
-IV fluids and/ or excess fluid
Increased Na+ -Monitor client in ICU
Intake for hypovolemic
hyponatremia
Hypernatremia
 Excess Na+ relative to body water
 Occurs less often than hyponatremia
 Na >150 mEq/ L
 When hypernatremia occurs, fluid shifts outside the cells
 May be caused by water deficit or over- ingestion of Na+ - Renal dysfunction
 Also may result from diabetes insipidus, Cardiac failure, Drugs – NSAID / Steriods

What do you see?

 Think S-A-L-T
Skin flushed
Agitation
Low grade fever
Thirst
 Neurological symtoms
 Sign of hypovolemia
What do we do?
 Correct underlying disorder
 Restrict saline and Sodium
 Gradual / slow fluid replacement
 Monitor for s/s of cerebral edema
 Monitor serum Na+ level
 Seizure precaution
 Potassium (K+)
 Major intracellular cation
 Untreated changes in K+ levels can lead to serious neuromuscular and cardiac problems
 Normal K+ levels = 3.5 – 5.5 mEq/L

Balancing Potassium
 Most K+ ingested is excreted by the kidneys
 Three other influential factors in K+ balance:
 Na+/K+ pump
 Renal regulation
 pH level
 Electrolytes Imbalance
Hypokalemia
Low potassium which is serum K+ <3.5 mEq/l
May effect how the body store glucogen (your muscle’ source of energy) or cause abnormal heart rhythms

What do you see?

Skeletal muscle weakness
Irritability
Confusion, Drowsiness
Weakness, Fatigue
Arrhythmias – Irregular rate, tachycardia
Lethargy
Thready Pulse
Intestinal Motility
Nausea
Vomiting
Ileus
What do we do?
 Increase dietary K+
 Oral KCl supplement
 IV K+ replacement
 Change to K+ sparing diuretics
 Monitor EGC changes

IV K+ Replacement
 Mix well when adding to an IV solution bag
 Concentrations should not exceed 40-60 mEq/L
 Rates usually 10-20 mEq/hr
 Never give push potassium
Hyperkalemia
 Serum K+ >6 mEq/L
 Less common than hypokalemia
 Cause by altered kidney function, increased intake (salt substitutes), blood
transfusions, meds (K+ sparing diuretics), cell death (trauma)
What do you see?
 Irritability
 Paresthesia
 Muscle weakness (especially legs)
 EGC changes (tented/ peak T wave)
 Irregular pulse
 Hypotension
 Nausea, abdominal cramps, diarrhea
What do we do?
>Mild >Emergency
-Loop diuretic (Lasix) -10% calcium gluconate
-Dietary retriction for cardiac effects
-Sodium bicarbonate for
>Moderate acidosis
-Cation – exchange resin
Such as kayexalate (act by
exchanging the cations in
the resin for the potassium
In the intestine) potassium
Is then excreted in the stool
Calcium

 99% in bone, 1% in serum and soft tissue (measured by serum Ca++)

 Works with phosphorus to form bones and teeth
 Role in cell membrane permeability affects cardiac muscle contraction
 Participates in blood clotting
 Normal Value 8.5 – 10.5 mg/dl
Electrolytes Imbalance
Hypocalcemia
 Serum Calcium <8.9 mg/dl
 Caused by inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid
surgery, loop diuretics, low magnesium levels

What do we see?
 Neuromuscular
-Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers toes),
tetany, carpropedal spasms
 Fracture
 Diarrhea
 Diminished response to digoxin
 EKG changes
What do we do?
 Calcium gluconate for postop thyroid or parathyroid client
 Cardiac monitoring
 Oral or IV calcium replacement

Hypercalcemia
 Serum calcium > 10.1 mg/dl
-Cancer
-Hyperparathyroidism

What do you see/

 Fatigue, confusion, lethargy, coma
 Muscle weakness, hyporeflexia
 Bradycardia cardiac arrest
 Anorexia, nausea/vomiting, decreased bowel sound, constipation
 Polyuria, renal calculi, renal failure
What do we do?
 If asymptomatic, treat underlying cause
 Hydrated the patient to encourage diuresis
-Loop diuretics
-Corticosteroids
Magnesium

 Cofactor for many enzyme – ATP utilization in muscle fiber

 Role in protein synthesis and carbohydrate metabolism
 Helps cardiovascular system function (vasodilation)
 Regulates muscle contractions
 Electrolytes Imbalance
Hypomagnesemia
 Serum Mg++ level <1.5 mEq/L
 Cause by poor dietary intake, poor GI absorption, excessive GI/urinary losses

High risk client

 Chronic alcoholism
 Malabsorption
 GI/urinary system disorders
 Sepsis
 Wounds needing debridement
What do you see? What do we do?
 Cofusion >Mild
 Hallucination -Dietary replacement
 Muscle weakness >Severe
 Leg/foot cramps -IV or MI magnesium sulfate
 Tetany >Monitor
 ECG changes -Neuro status
 Tachycardia -Cardiac status
 Hypertension -Safety
 Anorexia
 Vomiting
Mag Sulfate Infusion

 Use infusion pump – no faster than 150 mg/min

 Monitor vital sign for hypotension and respiratory distress
 Monitor serum Mg++ level q6h
 Cardiac monitoring
 Calcium gluconate as an antidote for overdose
Hypermagnesemia
 Serum Mg++ level >2.5 mEq/L
 Not common
 Renal dysfunction is most common cause
-Renal failure
-Addison’s disease
-Adrenocortical insuffiency
-Untreated DKA

What do you see?

 Decreased neuromuscular activity
 Generalized weakness
 Occasionally nausea/vomiting
What do we do?
 Increased fluids if renal function normal
 Loop Diuretic if no response to fluid
 Calcium gluconate for toxicity
 Mechanical ventilation for respiratory depression
 Hemodialysis