Clinical Pharmacy in Pediatric Nephrology

Clinical PharmacyIs 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, socio-behavioral, and clinical sciences (American College of Clinical Pharmacy, www.accp.com).

Pediatric NephrologyFunctional anatomy of the kidneyPhysiological roles of the kidney and UTDrug handling by the kidneyClinical conditions (presentations, investigations, therapy)Glomerular: AGN, MLNSTubular: deToni-Debr-Fanconi syndromeHypertensionUTIChronic renal failure, drugs in CRFDialysis, drugs and dialysisTransplantation

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

Physiology1.3 million nephrons in each kidneyThe 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.

PhysiologyGlomerular function FILTRATIONRenal 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)

PhysiologyTubular functions REABSORPTION and SECRETION

Physiology

PhysiologyBladder function STORAGE and MICTURITION

Drug handling by the kidneyKidneys 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 ConditionsCommonest cause is post streptococcalTriad 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.Glomerular diseasesAcute glomerulonephritis

Some Clinical ConditionsAge 2-8 yearsAlbuminuria, 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 infectionGlomerular diseasesMinimal lesion nephrotic syndrome

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

Some Clinical ConditionsSystemic hypertension

Some Clinical ConditionsSystemic hypertensionNon-pharmacological treatmentPharmacological treatmentInvestigations, prevention and treatment of complications

Some Clinical ConditionsUrinary tract infectionMay be lower or upper UTISymptoms 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 FailureProgressive and usually irreversible loss of renal function. GFR

Chronic Renal FailureMetabolic abnormalitiesHyponatremiaHyperkalemiaMetabolic acidosisHyperuricemiaHypocalcemiaHyperphosphatemiaRenal osteodystrophyHypovitaminosis DHyperparathyroidismAnemiaGrowth failureDelayed pubertyCardiovascular diseaseGI bleedingPlatelet dysfunctionTreat hypertensionReduce proteinuriaCorrect anemiaReduce salt and fluid intakeControl hyperlipidemiaControl hyperphosphatemiaControl hyperkalemiaTreat renal osteodystrophyRevise drugs and their doses

DialysisPrincipleIndicationsClinical manifestations (encephalopathy, pericarditis)Metabolic problems not responding to medical treatmentFluid overloadRapid rise in parameters of renal function.ModalitiesPeritoneal dialysis (PD)Hemodialysis (HD)

Dialysis

Dialysis

PDHD

Drugs in Chronic Renal Failure and Dialysis

Drugs in Chronic Renal Failure and Dialysis

Renal TransplantationTeam DonorRecipientPreparationProcedureProtocolFollow upComplicationsRejection