RENAL REGULATION  Some substances pass from blood through

walls of nephron and become part of filtrate

 Kidneys regulate
 Potassium, phosphate, hydrogen, ammonium
◦ Fluid volume, electrolytes, acid-base ion, and some acid drugs are secreted into
balance filtrate
 Kidneys secrete  Reabsorption and secretion are critical to
pharmacokinetics of many drugs
◦ Renin- for blood-pressure regulation

◦ Erythropoietin – to stimulate blood-

cell production

◦ Calcitrol –active form of vitamin D

for bone hemeostasis

KIDNEY STRUCTURE

 Urinary system consists of

◦ Two kidneys

◦ Two ureters

◦ One bladder

◦ One urethra
RENAL FAILURE
 Objective 2: List the four processes carried out
by the nephron.  Decrease in kidney’s ability to function

 Objective 3: Name the part of the nephron ◦ Drugs can accumulate to high levels
responsible for each process.
◦ Medication dosages need to be
NEPHRON adjusted

 Nephron is functional unit of kidney ◦ Administering average dose to person

in renal failure can be fatal
 Blood enters nephron and is filtered through
Bowman’s capsule DIAGNOSIS OF RENAL FAILURE

 Fluid is called filtrate  Urinalysis

 Water and small molecules pass into proximal  Serum creatinine

tubule
 Diagnostic imaging
 Filtrate passes through loop of Henle, then
distal tubule  Renal biopsy

 Filtrate empties into collecting ducts and  Glomerular filtration rate (GFR)
leaves nephron as urine
 Best marker for estimating renal
REABSOPTION function

 Filtrate in Bowman’s capsule is same  Measure volume of water filtered per

composition as plasma minus large proteins minute

 Some substances in filtrate cross wall of ACUTE RENAL FAILURE

nephron and reenter blood
 Requires immediate treatment
 Most of water in filtrate is reabsorbed
 Accumulation of waste products can be fatal
 Glucose, amino acids, sodium, chloride,
calcium, and bicarbonate are reabsorbed  Most common cause is hypoperfusion
  Cause must be rapidly identified - Dietary management: Restriction of protein,
reduction of sodium, potassium, phosphorus,
 Heart failure magnesium
 Dysrhythmias

 Hemorrhage  Objective 4: pituitary hormone that influences

urine volume:
 Dehydration
◦ ADH (Posterior pituitary)
CHRONIC RENAL FAILURE
◦ Objective 5: adrenocortical hormone
 Occurs over months or years
that influences urine volume:
 Usually history of diabetes mellitus or
hypertension ◦ Aldosterone (increases Na+
reabsorption in the distal tubule)
 May be undiagnosed for a long time
◦ Objective 6: four ways fluid is lost
 Nephrotoxic drugs can cause acute or chronic from the body
renal failure
◦ Urine, perspiration, lungs, stool
◦ See Table 30-1

 Objective 7: describe the actions of diuretics

Diuretics act to
Deplete blood volume
Excrete sodium
Vasodilate peripheral arterioles
(how is unknown)

DIURETICS
1

 Increase rate of urine flow

 Excretion of excess fluid used to treat

- Hypertension, heart failure, kidney failure

- Liver failure or cirrhosis, pulmonary edema

PHARMACOTHERAPY SIDE EFFECTS OF DIURETICS THERAPY

 Attempts to cure cause of dysfunction  Fluid and electrolytes disturbances

- Diuretics to increase urine output ◦ Dehydration

- Cardiovascular drugs to treat hypertension or
heart failure ◦ Orthostatic hypotension
 ◦ Potassium and sodium imbalances
 Diuretics work in the kidney at various sites of
the nephron
 Can interfere with the action of aldosterone
causing loss of sodium
◦ Where goes sodium, so goes water
 What happens with diuretics
◦ Decrease excess water
◦ Loop diuretics + 0.9% NaCl = loss of
calcium
◦ Decrease excess NaCl
◦ Decrease cerebral edema (Mannitol)
◦ Decrease increased IOP (Diamox)
 Mannitol is an osmotic diuretic (a sugar);
◦ in the brain, its presence causes water
to be drawn to it
 Works the same way in the eye:
◦ the excess intraocular fluid is drawn to
the mannitol in the hyperosmotic
plasma
CARBONIC ANHYDRASE INHIBITOR
- Diamox very weak diuretic
- Useful in treating glaucoma
METHYLXANTHINES
- Aminophylline
- Theophylline
- Caffeine
- Theobromine
- Diuretic effect from improved blood flow to
kidney
- Generally not used for diuretic effect
Objective 8: describe the uses, actions, and adverse
effects of the thiazide and thiazide-like diuretics
 Drugs that affect the loop of Henle
◦ Bumetanide (Bumex)
◦ Ethacrynic acid (Edecrin)
◦ Furosemide (Lasix)
◦ Torsemide (Demadex)
LOOP DIURETICS
 Act in the loop of Henle in the kidney
◦ Inhibits Na and Cl reabsorption
 Some increase blood flow to glomeruli
 Inhibits electrolyte absorption in proximal
tubule
◦ Lose sodium, chloride, potassium,
magnesium, sodium bicarbonate
 Onset of diuretic effect varies, but is within 1-
2 hours. IV, drugs work within 5-10 minutes
 Peak effect within 1-2 hours
 Duration approximately 6 hours
 Maximum mg/day
◦ Bumex 10 mg per 24 hours
◦ Edecrin 400 mg per 24 hours
◦ Lasix 1000 mg/24 hours
 Cross sensitivities
◦ Sulfonamides and Lasix, Demadex
 SE to expect
◦ Oral irritation
◦ Dry mouth
◦ Orthostatic hypotension
 SE to report with loop diuretics
◦ GI irritation, abdominal pain
◦ Electrolyte imbalance, dehydration
◦ Hives, pruritus, rash
◦ Some can cause loss of hearing and
hyperglycemia (interfere with
hypoglycemic agents)
 Drug interactions
◦ Alcohol, barbiturates, narcotics
◦ Aminoglycosides
◦ Cisplatin
◦ NSAIDs
◦ Corticosteroids
◦ Probenecid
 ◦ Digoxin  Block reabsorption of sodium
and chloride ions from the
 Loop diuretics include tubule
◦ Bumetanide (Bumex)  The unreabsorbed Na and Cl
ions pass into the collecting
◦ Ethacrynic acid (Edecrin) ducts, taking water with them
◦ Furosemide (Lasix)  Thiazides have antihypertensive properties
because of direct vasodilation effect on
◦ Torsemide (Demadex) peripheral arterioles
 Loop or high-ceiling are most effective ◦ Expected outcomes from treatment
diuretics
 Decreased edema and
 Mechanism of action: to block reabsorption of improvement of symptoms RT
sodium and chloride in loop of Henle excess fluid accumulation
 Primary use: to reduce edema associated with  Reduction in BP
heart, hepatic, or renal failure
 Assessments
 Furosemide and torsemide also approved for
hypertension ◦ Mental status
LOOP HEIGH CELING DIURETICS ◦ Diabetics require baseline blood
glucose
 Obtain baseline and monitor periodically lab
values, weight, current level of urine output ◦ Assess hearing
 Monitor electrolytes, especially potassium, ◦ Assess for symptoms of acute gout
sodium, and chloride
 SE to expect: orthostatic hypotension
 Monitor blood urea nitrogen (BUN), serum
creatinine, uric acid, and blood-glucose levels ◦ Usually in initial stages of treatment
 Assess for circulatory collapse, dysrhythmias, ◦ Teach client safety measures
hearing loss, renal failure, and anemia
 SE to report
 Monitor for side effects orthostatic
hypotension, hypokalemia, hyponatremia, ◦ GI irritation, N/V, constipation
polyuria
◦ Electrolyte imbalance, dehydration
 Observe for rash or pruritis
◦ Hyperuricemia
 Teach clients to take diuretics in the morning,
change position slowly, monitor weight ◦ Hyperglycemia
 Clients should take potassium supplements, if ◦ Hives, rash
ordered, and consume potassium–rich foods
 Thiazides can interact with

◦ Digoxin, corticosteroids

◦ Lithium, NSAIDs

◦ Oral hypoglycemic agents

 Thiazides can interact with

THIAZIDES
◦ Digoxin, corticosteroids
 Action of the thiazides
◦ Lithium, NSAIDs
◦ Act on the distal tubules of the kidney
◦ Oral hypoglycemic agents
THIAZIDE AND THIAZIDE LIKE DIURETICS
 Thiazide diuretics include
◦ Bendroflumethiazide (Naturetin)
◦ Chlorothiazide (Diuril)
◦ Hydrochlorothiazide (HCTZ)
{Esidrix, HydroDiuril}
◦ Polythiazide (Renese)
◦ Trichlomethiazide (Naqua,
Metahydrin, Diurese)
POTASSIUM SPARRING DIURETIC
 Thiazide-like drugs include
◦ Chlorthalidone (Hygroton)
◦ Indapamide (Lozol)
◦ Metolazone (Zaroxolyn)
 Largest, most commonly prescribed class of
diuretics
 Mechanism of action: to block Na+
reabsorption and increase potassium and water
excretion
 Primary use: to treat mild to moderate
hypertension
◦ Also indicated to reduce edema
associated with heart, hepatic, and
renal failure
 Less efficacious than loop diuretics
◦ Not effective in clients with severe
renal failure

Objective 11: list the electrolyte imbalance
that most commonly occurs as a result of
diuretic therapy
- Why is there concern about the electrolyte
balance?
Obj. 12 Potassium-Sparing Diuretics
 Weak antihypertensives
 Mechanism of action unknown
 Do work in distal renal tubule
◦ Retains potassium
◦ Excretes sodium
◦ Some have anti-aldosterone activity
 Maximum dosing per 24 hrs
- drug dependent
 SE to expect with Midamor:
- anorexia, N/V, flatulence and HA
 SE to report:
- electrolyte imbalance, dehydration,
- SE to expect and report with Aldactone and
Dyrenium:
o mental confusion, HA, diarrhea,
electrolyte imbalance, dehydration,
gynecomastia, reduced libido, breast
tenderness
- Dyrenium can also cause allergic reaction
(hives, pruritus, rash)
- Generally, drug interactions for the K+ sparing
agents
o Lithium, ACE inhibitors, salt
substitutes, K+ replacement
o NSAIDs,
o Potassium-sparing drugs include
o Amiloride (Midamor)
o Spironolactone (Aldactone)
o Triamterene (Dyrenium)
- Potassium-sparing drugs include
o Amiloride (Midamor)
o Spironolactone (Aldactone)
 o Triamterene (Dyrenium)
- Advantage: diuresis without affecting blood
potassium levels
- Mechanism of action: either by blocking
sodium or by blocking aldosterone
THIAZIDE AND THIAZIDE LIKE DIURETICS
- Potassium-sparing diuretics shown in Table
30.5
 Obtaining medical, drug, dietary, and lifestyle
history
 Assessment of client’s weight, intake/output,
skin turgor/moisture, vital signs, breath
sounds, and presence of edema
 Obtain baseline and monitor periodically lab
values, weight, current level of urine output

 Measure electrolytes, especially potassium,

Objective 13: explain how increased fluid intake sodium, and chloride, prior to loop-diuretic
enhances the action of diuretics therapy

 Why is an adequate fluid intake important with  Monitor blood urea nitrogen (BUN), serum
diuretic therapy? creatinine, uric acid, blood-glucose levels

 If the client has to get up during the night to  Increased potassium loss may occur when
void, what will they probably do? used with digoxin

 Increased risk of lithium toxicity when taking

thiazide diuretics

 Allergies to sulfa-based medications can


Cannot be classified as loop, thiazide, or indicate hypersensitivity
potassium-sparing agents
 Use with caution in pregnant women
 Three of these drugs inhibit carbonic
 DO not administer to lactating women
anhydrase
 Teach client to
 Primary use: to maintain urine flow in times of
hypoperfusion  Use sunscreen to decrease
photosensitivity
◦ For clients with acute renal failure or
during prolonged surgery  Take potassium supplements, if
ordered

 Consume potassium-rich foods

 Report any tenderness or pain in joints

 Advantage: client will not experience

hypokalemia
ROLE OF THE NURSE
 Critical to assess electrolytes (potassium and
 Pharmacological management of renal failure sodium), blood urea nitrogen (BUN), serum
and diuretic therapy creatinine

◦ Careful monitoring of client’s  Adverse effects : hyperkalemia, and GI

condition bleeding, confusion, dizziness, muscle
weakness, blurred vision, impotence,
◦ Providing education relating to amenorrhea, gynecomastia
prescribed drug management
 Spironolactone may decrease effectiveness of
anticoagulants
  Clients taking lithium or digoxin may be at
increased risk for toxicity

 Triamterene contraindicated for lactating

women

 Report signs and symptoms of hyperkalemia

 Avoid use of potassium-based salt substitutes

 When in direct sunlight use sunscreen

 Avoid performing tasks that require mental

alertness

 Do not eat excess amount of foods high in

potassium
LOOP DIURETICS
 Prototype drug: furesomide (Lasix); increases
urine output even when blood flow to kidney
is diminished
 Mechanism of action : to block reabsorption of
sodium in Loop of Henle
 Primary use: to treat hypertension and reduce
edema associated with heart failure, hepatic
cirrhosis, and renal failure
• Adverse effects: rapid excretion of large
amounts of water, dehydration and electrolyte
imbalances ototoxicity
 Primary use: to treat mild to moderate
hypertension
◦ To treat severe hypertension, in
combination with other drugs
◦ To treat fluid retention from heart
failure, liver disease, corticosteroid or
estrogen therapy
 Adverse effects: dehydration, orthostatic
hypotension, hypokalemia
 Less effective than loop diuretics but help
prevent hypokalemia
 Prototype drug : spironolactone (Aldactone)
 Mechanism of action: to block action of
aldosterone

 Other examples  Primary use: to significantly reduce mortality

in heart failure
◦ Torsemide: longer half life than
 Adverse effects: hyperkalemia
furosemide; once- a- day dosing

◦ Bumetanide (Bumex): 40 times

potency of furosemide; shorter
duration of action

THIAZIDE DIURETICS

 Prototype drug: chlorothiazide (Diuril)

 Mechanism of action: to block sodium

absorption in distal tubule of nephron