CASE PRESENTATION ON ACUTE KIDNEY

INJURY

Presentation by:Krithi Shettigar

PROBLEM LIST
 Acute kidney injury - Nephrotic syndrome under evaluation
SOAP Analysis
SUBJECTIVE EVIDENCE
 C/O Bilateral lower limb swelling x 1 month
OBJECTIVE EVIDENCE
 Medical history: K/C/O Hypothyroidism
 Laboratory examination:
 TLC - 12000 (4000-10000 c/cumm)
 Platelet - 549000 (150000-410000 c/cumm)
 Urea - 120.4 (16.6-48.5 mg/dl)
 S.Cr -0.42 (0.7-1.4 mg/dl)
 Sodium - 128 (136-145 mmol/L)
 Potassium - 3.19 (3.5-5.1 mmol/L)
 Neutrophils - 92 (40-80%)
 Lymphocytes - 08 (20-40%)
 Protein - Present(+) (Negative)
 Others: Renal biopsy
ASSESSMENT
 Final diagnosis: Based on subjective and objective evidence, the present case is
found to Acute Kidney Injury - Nephrotic Syndrome under evaluation
 Risk factor: Age, decline in urine output, duration of illness
 Assessment if therapy is indicated?
Yes, therapy is needed in this patient to prevent complications of Hyperkelamia,
Metabolic acidosis, Hyponatremia, Permanent kidney damage.
STANDARD THERAPY TREATMENT ALGORITHM
CURRENT THERAPY
SI.NO BRAND NAME GENERIC NAME DOSE FREQUENCY DURATION

1 TAB. LASIX FUROSEMIDE 40mg 1-1-0 D1 - D4

2 TAB. WYSOLONE PREDNISOLONE 20mg 2-0-0 D1 - D4
3 TAB. SHELCAL CALCIUM + 500mg 1-0-1 D1 - D4
VITAMIN D3
4 TAB. PANTOP PANTOPRAZOLE 40mg 1-0-1 (B/F) D1 - D4
5 SYP. POTKLOR POTASSIUM 15ml 1-1-1 D2 - D4
CHLORIDE
ASSESSEMENT OF CURRENT THERAPY
1) TAB. LASIX 40mg, 1-1-0, D1-D4
 Generic Name: Furosemide
 Category: Loop diuretic
 Indication: To treat Acute Kideny Injury
 MOA: Primarily inhibits reabsorption of sodium and chloride in the ascending
limb of the Henle’s loop and proximal and distal renal tubules, interfering with the
chloride-binding cotransport system, thus causing its natriuretic effect.
 Std.Dose: 40-80 mg
 ADR: Interstitial nephritis, muscle spasm, dizziness, headache
 Justification:
A total of 14,154 AKI patients were included in the data analysis. After Propensity
score matching, 4427 pairs of patients were matched between the patients who
received furosemide and those without diuretics treatment. Furosemide was
associated with reduced in-hospital mortality and it was also associated with the
recovery of renal function in over-all AKI patients. Nevertheless, results illustrated
that furosemide was not associated with reduced in-hospital mortality in patients
with AKI stage 0–1 defined by UO criteria, AKI stage 2–3 according to SCr
criteria, and in those with acute-on-chronic renal injury. The study concluded that
the use of furosemide was associated with reduced short-term mortality and
improved recovery of renal function in critically ill patients with AKI.
2) WYSOLONE 20mg, 2-2-0, D1-D4
 Generic Name: Prednisolone
 Category: Corticosteroid
 Indication: Helps to lower proteinuria
 MOA: Decreases inflammation by suppression of migration of
polymorphonuclear leukocytes and reversal of increased capillary permeability;
 Std.Dose: 10 to 60 mg/day
 ADR: Nausea, Hypetension, Hyperglycemia
 Justificatiion:
Azathioprine and steroids (prednisone or prednisolone) form the basis of
conventional immunosuppression after renal transplantation. Most of the
morbidity in the early months after transplantation. Most of the attributed to
steroids, which are normally give in high doses.For this reason a randomised
controlled trial was carried out to compare the efficacy of high dose (39 patients)
and low dose (33 patients) oral prednisolone, both in combination with
azathioprine, in patients given cadaveric renal allografts. Patients were followed
up for at least two years after the transplantation. Patient and graft survival were
identical in the two groups and the morbidity associated with steroids was
impressively lower in patients receiving a low steroid dose. Although the optimal
dose of steroids is still unknown, there seems little justification for continued use
of high doses of oral steroids with azathioprine after cadaveric renal
transplantation.
3) SHELCAL 500mg, 1-0-1, D1-D4
 Generic Name: Calcium and Vitamin D3
 Category: Calcium supplements and Vitamin derivatives
 Indication: It is used as dietary supplements
 MOA:
Calcium - Cholecalciferol (vitamin D3) is a provitamin .the active
metabolite,1,25-dihydroxyvitamin D (calcitriol) stimulates calcium and phosphate
absorption from the small intestine
Vitamin D3 - To provide supplemental calcium to the body to prevent and
treat calcium deficiency, which helps to maintain normal physiological processes
in the body.
 Std.Dose:
 Calcium - 1000-1200 mg/day, divided into two or three doses per day
 Vitamin D3 - 600-800 IU/day
 ADR: headache, hypercalcemia, hypercalciuria, gastrointestinal distress
 Justification:
The maintenance of calcium homeostasis is impaired in CKD. Thus, the oral
intake of calcium in the form of diet and binders should be less than 800 to 1000
mg per day in order to achieve neutral calcium balance in patients with CKD
stages 3b/4.Two formal calcium balance studies have found that an oral intake of
800 to 1000 mg of calcium in adults with CKD leads to neutral calcium balance,
whereas amounts greater than that lead to positive calcium balance. In patients
with CKD, the main determinant of positive calcium balance is the intake and the
lack of urinary calcium excretion.
4) TAB.PANTOP 40mg, 1-0-1 (B/F), D1-D4
Generic Name: Pantoprazole
Category: Proton Pump Inhibitor
Indication: Prophylaxis for gastric irritation
MOA: Proton Pump Inhibitor supresses gastric acid secretion by inhibiting the
parietal cell H+/K+ ATP pump
Std.Dose: 20-40mg/day
ADR: Headache(12%), Edema(≤2%)
 Justification:
36 subjects received pantoprazole in a three-way crossover design study.
Ambulatory 24-h intragastric pH and distal esophageal pH were monitored at
baseline and on the last day of each treatment period. Safety was evaluated by
incidence and severity of adverse events. Pantoprazole demonstrated a linear
dose- dependent suppression of gastric acidity over the dose range 10-40 mg. All
pantoprazole doses were well tolerated. Pantoprazole demonstrates a dose-related
effect in the range 10-40 mg once daily. The once-daily dose of 40 mg provides
the highest and most consistent control of gastric pH.
5) SYP. POTKLOR 15ml, 1-1-1, D2-D4
 Generic Name: Potassium Chloride
 Category: Electrolyte Supplement
 Indication: Treatment of hypokalemia.
 MOA: Potassium is the major cation of intracellular fluid and is essential for the
conduction of nerve impulses in heart, brain, and skeletal muscle; contraction of
cardiac, skeletal and smooth muscles; maintenance of normal renal function,
acid-base balance, carbohydrate metabolism, and gastric secretion
 Std.Dose: 15ml
 ADR: Hyperkalemia, Abdominal distress
PLANNING
General treatment goals:
 To reduce extrarenal complications
 Expediting recovery of renal function
 To reduce morbidity and mortality

Patient specific goals:

 To improve quality of life.
POINTS TO PATIENT:

About the disease:

 Acute Kidney Injury occurs when there is sudden reduction in the kidney
function.

About drugs:
 Tab. LASIX 40mg 1-1-0 x 10 days
 Tab. WYSOLONE 20mg 2-0-0 x 10 days
 Tab. SHELCAL 500mg 1-0-1 x 10 days
 Tab. PANTOP 40mg 1-0-1 (B/F) x 10 days
Therapeutic monitoring parameters:
 Renal funtion test
 TLC
 Renal biopsy

Toxicity monitoring parameters:

 Furosemide - Serum electrolyte, fluid intake and output
 Potassium chloride - Electrolytes
DISCHARGE MEDICATION

BRAND NAME GENERIC NAME DOSE FREQUENCY

TAB. LASIX FUROSEMIDE 40mg 1-1-0

TAB. WYSOLONE PREDNISOLONE 20mg 2-0-0
TAB. SHELCAL CALCIUM + VITAMIN D3 500mg 1-0-1
TAB. PANTOP PANTOPRAZOLE 40mg 1-0-1 (B/F)
LIFESTYLE MODIFICATIONS:
 Supportive care should be given
 Discontinue medicines that decreases renal blood flow
 Avoid use of Nephrotoxins
 Initiate appropriate fluid and electroyte management
 Avoid foods such as salted snacks
 Take medicines as prescribed by the physician.
FOLLOW UP
 To review after 10 days in nephrology OPD with HB, RFT and Renal
biopsy report.
REFERENCES
1) Maker JH, Roller L, Dager W. Acute Kidney Injury. In: DiPiro JT, Yee GC,
Posey LM, Haines ST, Nolin TD, Ellingrod V. editors. Pharmacotherapy A
Pathophysiologic Approach. 11th ed . McGraw Hill: New York; 2017: 1840-
1893..
2) Zhao GJ, Xu C, Ying JC, Lü WB, Hong GL, Li MF, et al.,. Association between
furosemide administration and outcomes in critically ill patients with acute
kidney injury. Critical care. 2020; 24(75): 1-9.
3) Morris PJ, French ME, Chan L, Ting A. Low dose oral prednisolone in renal
transplantation. The Lancet. 1982 Mar 6;319(8271):525-527.
4) Moe SM. Rationale to reduce calcium intake in patients with CKD. Current
opinion in nephrology and hypertension. 2018 Jul;27(4):251
5) Tutuian R, Katz P O, Bochenek W, Castel D O. Dose-dependent control of
intragastric pH by pantoprazole, 10, 20 or 40 mg, in healthy volunteers. Aliment
Pharmacology Therapy. 2002; 16(4):829-836.
THANK YOU!