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PHARMACOLOGICAL RENAL CARE OF THE GERIATIC PATIENT

PHARMACOLOGICAL RENAL CARE OF THE GERIATIC PATIENT. Ruth Ann Fritz RN CNS-BC CCRN CNN April 16, 2011. Objectives. Identify normal changes in GU system Identify causes and care of End Stage Renal Disease in the older adult population Calculate GFR

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PHARMACOLOGICAL RENAL CARE OF THE GERIATIC PATIENT

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  1. PHARMACOLOGICAL RENAL CARE OF THE GERIATIC PATIENT Ruth Ann Fritz RN CNS-BC CCRN CNN April 16, 2011

  2. Objectives • Identify normal changes in GU system • Identify causes and care of End Stage Renal Disease in the older adult population • Calculate GFR • Discuss pharmacological management of Diabetes, Hyperlipidemia, and Hypertension in the geriatric renal patient • Identify proper renal doses for classes of medications • Name two interventions to protect patient’s kidneys

  3. AGE RELATED CHANGES • Decreased body mass and malnutrition • Genitourinary • Male- Enlarged prostate - difficulties emptying bladder • Females - Urgency, frequency, nocturia - Thin mucosa, loss of muscle tone • BPH, incontinence, and UTI complications • Renal changes • Decreased renal blood flow • Decreased tubular function • Decreased glomerular filtration rate (GFR)

  4. AGE RELATED CHANGES • Renal changes – cont. • Decreased ability to regulate H+ ion and concentrate urine • Nephron degeneration - Decrease GFR (by age 70 - 33-50% less) • More difficulty maintaining homeostasis and fluid balance • Glomerular filtration rates decrease 6.5ml/ 10 years • Creatinine level alone not reflect renal function as decreased body mass and less creatinine production

  5. ANATOMY • Kidney • Renal artery • Cortex • Medulla • 1 million nephrons each • Renal pelvis • Ureter

  6. ANATOMY • Nephron • Glomerulus • Tubules • Loop of Henle • Arterioles • Afferent • Efferent • Capillaries • Veins

  7. Benign Prostatic Hypertrophy • Anatomy and physiology

  8. PHYSIOLOGY • Endocrine function • Renin, Prostaglandins, • Erythropoietin • Metabolic function • Activation Vitamin D • Gluconeogenesis - 10% • Metabolism of endogenous compounds-insulin / steroids- Enzymes (Cytochrome P450) • Excretory function – (fluid, toxins, acid/base) • Glomerular Filtration • Passive • Most proteins to large • Tubular Secretion • Active transport • Proximal tubule • Tubular reabsorption • Water - fluid • Solutes/drugs

  9. CHRONIC KIDNEY DISEASE • Incidence in elderly • Older adults increased risk - CV system • Due to age-related changes & BPH - renal pathology • Hypertension results in 50-60 % deaths due to CRF • Acute Renal Injury vs. CKD • Elderly on dialysis increased by >50% in last decade • Risk factors/ Causes • Diabetes Mellitus and Hypertension • Chronic illnesses, infections, nephrotoxic factors -examples - X ray dye, NSAIDS, antibiotics

  10. GLOMERULAR FILTRATION RATE • GFR – equal to the total of the filtration rates of all the functioning nephrons in the kidney • All functions associated with GFR • Calculations based on BSA calculations • GFR indicator of ability of kidney to eliminate drugs from the body • Calculation • 24hr Creatinine Clearance • Estimates calculated from creatinine level, gender, age, weight, and race

  11. GLOMERULAR FILTRATION RATE • Calculation ---(NKF web site) • Estimates • Cockcroft-Gault Equation (CG) • Modification of Diet in Renal Disease – (MDRD) – more accurate when GFR<60 • 2009 Chronic Kidney Disease epidemiology collaboration (CKD-Epi)- more accurate when GFR > or < 60 • Decreased GFR in elderly • Predictor of adverse outcomes such as death and cardiovascular disease • Requires adjustment in drug doses

  12. GLOMERULAR FILTRATION RATE • Example -(NKF web site) • 22 year old black male • Creatinine – 1.2 • GFR – 98ml – normal or stage 1 CKD if damage • 58 year old white male • Creatinine – 1.2 • GFR – 66 ml – stage 2 CKD if damage • 80 year old white female • Creatinine 1.2 • GFR – 46 ml – stage 3 CKD

  13. DEFINITION OF CKD • Kidney damage for >/=3months, as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either: • Pathological abnormalities; or • Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests • GFR<60 mL/min for >/= 3 months, with or without kidney damage

  14. MARKERS OF CKD • Proteinuria – main marker • Spot total protein/creatinine ratio >200 mg/g • False positives or negatives / two or more positive tests • Associated with complications - early detection • Prognostic finding – decrease in proteinuria correlated with slower loss of kidney function • Hematuria • Other urine sediment abnormalities – casts, crystals • Abnormal blood tests

  15. STAGES OF CKD

  16. INTERVENTIONS • Increased risk for CKD GFR>90 • Screen for risk factors • Stage 1 GFR >/= 90 – markers of damage • Diagnose cause of CKD and treat • Screen and treat risk factors • Treat co-morbid conditions • Screen and treat cardiovascular risk factors • Stage 2 GFR60-89 mild complications • Adjust medication doses • Minimum yearly assess rate of GFR decline

  17. INTERVENTIONS • Stage 3 GFR 30-59 – moderate complications • Minimum bi-yearly GFR assessment • Screen for complications every 3 months and treat if present • Stage 4 GFR15-29 – severe complications • Refer for preparation for renal replacement therapy • Management of complications • Stage 5 GFR<15 – uremia, cardiovascular disease • Begin replacement therapy if uremic and patient desirable • Stage 6 – on replacement therapy

  18. RENAL DOSES OF MEDS • Check references and calculate doses of medications based on GFR • Age, sex, lab • Race - AA, non AA • Loading doses – no renal dose adjustments • Maintenance doses – adjust two ways • Reduce dose at regular intervals • Lengthen dosing intervals • If on hemodialysis may need to time meds after treatment

  19. PROTEINURIA MANAGEMENT • Monitor spot protein/creatinine ratio goal 500-1000mg/g • ACE Inhibitors/ARBs -renal/cardio protective • Slow progression of diabetic kidney disease and nondiabetic kidney disease with proteinuria • Reduce proteinuria • May have 15% drop in GFR in week 1 - usually returns to baseline in 4-6 weeks • Stop ACE Inhibitor / ARB • Potassium 5.6 or higher despite treatment • GFR decline > 30% in 4 months without explanation

  20. MALNUTRITION • Protein-energy malnutrition develops with CKD or with age and associated with adverse out comes • Low protein • Low calorie intake • Anorexia • Other causes – proteinuria, GI issues, metabolic acidosis, chronic inflammatory state in CKD • Nutrition – Dietary consult – complex patients • Megace, protein supplements – caution K level

  21. DIABETES • #1 cause of CKD • Intensive management of diabetes goal Hgb A1C 6 or less • Metformin (Glucophage)- risk of Lactic acid • Avoid creatinine >1.5 men/>1.4 women • GFR<50 -50% dose, GFR 10-50- 25% dose • Avoid over age 80 or chronic heart failure • Sulfonylureas – risk of hypoglycemia, long ½ life drugs • Glipizide (Glucotol)/ glimepride (Amaryl) safe • Avoid Glyburide (DiaBeta) and Chlorpropamide (Diabinese) • Insulin management

  22. HYPERTENSION • #2 cause of CKD - complication of CKD- risk ESRD and Cardiovascular disease - JNC 7 and KDOQI Guidelines • Target BP less than 130/80 or lower • Lifestyle changes (CKD diet) • Preferred agents • Diabetic or Proteinuria – ACE inhibitor or ARB • Caution : If patient hypotensive and on ACE - reduced GFR • Potential hyperkalemia with ACE/ARB, or with Potassium supplements with diuretics • Compelling indications, - Heart failure, DM, post MI • Beers list –avoid Alpha blockers (Cardura), Clonidine

  23. HYPERTENSION /FLUID MANAGEMENT • Education -low sodium diet, BS control, and daily weights • Monitor lab, GFR, BP, Dehydration • Thiazide diuretics • HCTZ, Metolazone • Avoid <30GFR – creatinine >2.5, or has gout • Loop diuretics • Lasix, Demadex, Bumex • All CKD stages • Potassium sparing • Spirolactone, Triamterene, Amiloride • Caution/avoid renal disease, ACE, potassium supplements • Dialysis - ESRD

  24. ELECTROLYTES/ACIDOSIS • Potassium supplementation/restriction • Diuretic use • CKD – monitor lab, diet instructions • Hemodialysis - great caution • Peritoneal – may need supplementation • Bicarbonate – metabolic acidosis • Calcium • Magnesium - caution • Aluminum – avoid (caution Sucrafate)

  25. CARDIOVASCULAR DISEASE • Risk for CVD – CAD, Cerebral vascular, and or peripheral vascular disease • Perfusion – atherosclerosis/calcification • Cardiac function – CHF, LVH • Most patients die of CVD not CKD • Hyperlipidemia management, stop smoking, cardiac evaluations , modification of medications • Potential for Digoxin Toxicity with decreasing GFR – adjust dose and schedule • Anticoagulation –Caution Lovenox/Aggrenox

  26. HYPERLIPIDEMIA • Statin doses GFR >/=30 <30/dialysis • Simvastatin (Zocor) 20-80 5-40 • Atovastatin (Lipitor) 10-80 10-80 • Pravastatin (Pravachol) 20-40 10-40 • Fluvastatin (Lescol) 20-80 10-40 • Lovastatin (Mevacor) – avoid <30 GFR • Dose adjustments for pt on Cyclosporine or Tacrolimus • Nicotinic acid – Niacin / Fish oil • Bile acid sequestrant – Cholestid • Zetia

  27. INFECTION MANAGEMENT • CKD patient at increased risk for infections, elderly prone to develop UTI/sepsis • Antibiotics – long ½ life and some are nephrotoxic and need drug levels – Check dosages • Penicillin • Avoid Penicillin G • Amoxicillin – 500mg TID or BID • Avoid • Imipenum/cilastatin – seizures • Tetracyclines except doxycycline – exacerbates uremia

  28. INFECTION MANAGEMENT • Avoid • Nitrofurantoin (Macrobid)– metabolite cause peripheral neuritis/ nephrotoxic • Aminoaglycosides – if possible • Examples of dosages • Cipro 250-500 daily • Levaquin 250 QOD** • Vancomycin – 1gm load/ 500mg- 750mg dose-ESRD – end of treatment-Drug levels • Z pack no change – lasts longer • Bactrim – decrease 50% GFR 15-30, avoid < 15 GFR

  29. NEUROPATHY • Common complication – level of CKD • Encephalopathy • Peripheral polyneuropathy • Autonomic dysfunction • Sleep disorders – restless legs • Peripheral mononeuropathy • Dialysis, - PD/HD, transplant, Epogen, vitamins • Tricylic antidepressants – avoid Elavil (Amtriptiline)– Beers list • Anticonvulsants -Neurontin (Gabapentin) adjust dose on CKD level • Lidocaine patch, Lyrica, Requib

  30. PAIN MANAGEMENT • Avoid • All NSAIDS and Cox inhibitors – Toradol • Darvocet, Demerol, and Codeine, Benadryl (Beers list), Cymbalta – avoid <30 GFR • Caution • Tylenol (max 3 gm/day)( in Lortab) • Reduce dose –Neurotin, Allopurinol, Morphine • Tramadol (Ultram/Ultracet) check seizure 200mg/day • Topical Lidocaine, capsaicin • Treat depression, insomnia- (Rozerem/Trazadone)

  31. GASTOINTESTIONAL CARE • Antacids • Laxatives – avoid MOM, Mag citrate • GERD treatment • H2 – avoid Tagament • PPIs • Nausea – constipation, gastroparesis • GI preps – caution with phosphate preparations - GoLytely • Enema – Avoid fleets phos soda - Phos

  32. ANEMIA MANAGEMENT • Early complication of CKD – increased Cardiovascular risk – Target 11-12 hemoglobin • Lab for anemia workup • Supplemental Iron IV/Oral – caution constipation • Erythropoietin Therapy • Procrit -predialysis/Epogen – dialysis • Aranesp • Renal Vitamin with Folic Acid • Malnutrition plays role -Albumin level

  33. BONE AND MINERAL • Abnormal mineral metabolism of CKD leads to secondary hyperparathyroidism and bone disease and other related complications (fractures) • Early complication due to abnormal mineral metabolism and treatments in CKD. Can result in calcification of arterial system and cardiovascular disease

  34. BONE AND MINERAL • Lab–Ca, phos, PTH, Vitamin D 25/ 1,25 • Dietary Phosphorous Management/oral Vitamin D • Phosphate Binders • Ca based – Tums, Phoslo • Non Ca based – Renagel, Fosrenal • Activated Vitamin D Therapy oral/IV • Calcijex /Rocaltrol • Zemplar • Hectoral • Sensipar

  35. HERBAL MEDICATION • St John's wort and ginkgo – increase metabolism of other meds • Ginkgo bleeding risk if on ASA, warfarin, or ibuprofen • Alfalfa, dandelion, and noni juice contain potassium • If contain heavy metals and Chinese products with aristolochic acid are nephrotoxic • Vasoconstrictive additives can cause hypertension

  36. PROTECTION OF KIDNEY • NSAID use risk – Arthritis in elderly • Contrast Protections • Monitor lab prior to procedures – Calculate GFR • Mucomyst • Sodium Bicarbonate/NS Infusion • Non Ionic contrast – minimal amt • Avoid hypotension • Avoid nephrotoxic meds/ proper dosages of meds • Avoid dehydration, control co-morbids, and Educate !!

  37. GERIATRIC MEDICATION ISSUES • Polypharmacy • Different providers • Name brand or generic • Simple dosing schedule as possible • Be sure can afford – try to make meds last • Encourage use of aids- pillboxes, calendars • Instruct relatives and caregivers - use Home health, pharmacy that delivers • Caution when prescribe – review meds – check side effects, and interactions

  38. QUESTIONS

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