Clinical Pharmacy in

Pediatric Nephrology

Clinical Pharmacy
Is the branch of pharmacy in which
pharmacists provide patient care that
optimizes medication therapy and promotes
health, wellness, and disease prevention. Its
practice is centered inside the hospitals and
clinics in company with physicians for the
purpose of ensuring optimal medications
prescription. A clinical pharmacist should
have a foundational understanding of the
biomedical,
pharmaceutical,
sociobehavioral, and clinical sciences (American
College of Clinical Pharmacy, www.accp.com).

Pediatric Nephrology
Functional anatomy of the kidney
Physiological roles of the kidney and UT
Drug handling by the kidney
Clinical conditions (presentations, investigations, therapy)
Glomerular: AGN, MLNS
Tubular: deToni-Debr-Fanconi syndrome
Hypertension
UTI
Chronic renal failure, drugs in CRF
Dialysis, drugs and dialysis
Transplantation

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the kidney

Functional anatomy of the UT

Physiology
1.3 million nephrons in each kidney
The total area of the glomerular capillary
endothelium across which filtration occurs is
about 0.8 m2.
The filtration slits are approximately 25 nm
wide and each is closed by a thin membrane.
They permit passage of neutral substances
up to 4 nm diameter and almost totally
exclude substances with 8 nm or greater
diameter. Also charges on the molecules
affect their passage.

Physiology
Glomerular function FILTRATION
Renal blood flow (RBF) about 25% of cardiac
output. More in cortex than medulla.
Glomerular capillary pressure 40% of
systemic arterial pressure.
Various substances affect the afferent or
efferent arterioles differently hence the net
effect on glomerular filtration pressure varies.
Clearance of a substance: is the volume of
plasma cleared from that substance per
minute. Most commonly used is creatinine.
Clearance = (Ucrx V)/(Pcr)
(mg/ml x ml/min)/(mg/ml)

Physiology
Tubular functions REABSORPTION and
SECRETION

Physiology

Physiology
Bladder function STORAGE and
MICTURITION

Drug handling by the kidney

Kidneys are involved in the process of
elimination of drugs.
Drugs may be filtered, reabsorbed or
secreted by glomeruli and tubules in an
active or inactive form.
Filtrtation is passive and nonsaturable.
Protein-bound drugs are poorly filtered.
Weak acid drugs are secreted in PCT.
Lipid soluble drugs are rapidly reabsorbed.
Some drugs may be metabolized in the
kidney.

Some Clinical Conditions

Glomerular diseases
Acute glomerulonephritis
Commonest cause is post streptococcal
Triad of oliguria, gross hematuria and hypertension.
In some cases there may be proteinuria or renal
impairment.
Investigations: urine analysis, renal functions, ASOT,
serum electrolytes, serum C3.
Therapy includes fluid and salt restriction,
antihypertensive drugs, antistreptococcal antibiotics.
In rare conditions dialysis may be required.

Some Clinical Conditions

Glomerular diseases
Minimal lesion nephrotic syndrome
Age 2-8 years
Albuminuria, hypoalbuminemia,
hypercholoesterolemia, generalized edema.
In some cases there may be hematuria,
hypertension or renal impairment.
Investigations: urine analysis, renal functions, serum
lipids and proteins, CBC.
Therapy includes ample fluid intake, high protein
diet, diuretics and albumin transfusion are
controversial, corticosteroids in max dose except in
presence of hypertension or infection

Some Clinical Conditions

Tubular diseases
De Toni-Debr-Fanconi syndrome
Generalized proximal renal tubular dysfunction with
impaired reabsorption of aa, bicarbonate, glucose, P,
urate, Na, K, Mg, Ca and low molecualr weight
proteins
Either priamary or secondary.
Polyuria, dehydration, metabolic acidosis and
glucosuria. Growth retardation and rickets
Investigations: urine analysis, serum electrolytes,
ABG.
Therapy includes replacement of all substances lost
in urine to keep their serum levels within normal.

Some Clinical Conditions

Systemic hypertension

Some Clinical Conditions

Systemic hypertension
Non-pharmacological treatment
Pharmacological treatment
Investigations, prevention and treatment of
complications

Some Clinical Conditions

Urinary tract infection
May be lower or upper UTI
Symptoms of lower UTI include dysuria,
frequency, hematuria, suprapubic pain.
Upper UTI presents with fever, loin pain.
Investigations: urine analysis, culture and
antibiotic sensitivity, CBC.
Recurrence warrants investigation for
predisposing factors.

Chronic Renal Failure

Progressive and usually irreversible loss of renal
function. GFR <= 60 ml/min/1.73m2
End stage renal disease (ESRD) ehen life cannot be
maintained without renal replacement therapy
(dialysis or transplantation). GFR<10-15
ml/min/1.73m2
Clinical symptoms:

Oligo-polyhydramnios
Failure to thrive
Anorexia, nausea, vomiting, fatigue
Pruritis
Oliguria, polyuria
Delayed puberty
Pallor
Bone deformities
Hypertension
Edema

Chronic Renal Failure

Metabolic abnormalities

Hyponatremia
Hyperkalemia
Metabolic acidosis
Hyperuricemia
Hypocalcemia
Hyperphosphatemia

Renal osteodystrophy

Hypovitaminosis D
Hyperparathyroidism

Anemia
Growth failure
Delayed puberty
Cardiovascular disease
GI bleeding
Platelet dysfunction

Treat hypertension
Reduce proteinuria
Correct anemia
Reduce salt and fluid intake
Control hyperlipidemia
Control hyperphosphatemia
Control hyperkalemia
Treat renal osteodystrophy
Revise drugs and their doses

Dialysis
Principle
Indications
Clinical manifestations (encephalopathy,
pericarditis)
Metabolic problems not responding to medical
treatment
Fluid overload
Rapid rise in parameters of renal function.

Modalities
Peritoneal dialysis (PD)
Hemodialysis (HD)

Dialysis

Dialysis

PD

HD

Drugs in Chronic Renal Failure

and Dialysis

Drugs in Chronic Renal Failure

and Dialysis

Renal Transplantation

Team
Donor
Recipient
Preparation
Procedure
Protocol
Follow up
Complications
Rejection