GUIDELINES FOR PRESCRIBING IN RENAL FAILURE

GUIDELINES FOR PRESCRIBING IN RENAL FAILURE

37.1 GENERAL PRINCIPLES

Renal impairment constitutes a major source of morbidity and mortality in patients with malignancy. 1, 2

Acute renal failure is defined as a sudden decrease in the glomerular filtration rate (GFR) associated with a rise in serum urea and/or creatinine. There is usually, but not always, a reduction in urine output. 3, 4

Acute renal failure is often reversible if diagnosed and treated promptly. 3

The causes of acute renal failure in cancer patients may be multifactorial (see Table 37.1).

Table 37.1 Causes of acute renal failure in cancer patients 1, 2

Causes Drugs

Extracellular fluid depletion Hypercalcaemia Hyperuricaemia Sepsis Tumour infiltration Tumour lysis syndrome Urinary tract obstruction

Comments NSAIDs, mitomycin-C, platinum compounds, methotrexate, ifosfamide, ACE inhibitors, diuretics Poor oral intake, vomiting or diarrhoea

Following chemotherapy

Renal vein or ureter Following chemotherapy

Chronic renal failure is a long-term condition in which there is reduction in glomerular function. It is often progressive and irreversible. 5

Drugs or drug metabolites may accumulate in renal failure, leading to toxicity. Prescribing in renal failure should be approached with caution and should be in accordance with the estimated GFR. 6

Evidence suggests that some opioids are safer to use than others. However all patients with renal impairment are at risk of drug toxicity and therefore should be monitored on a regular basis. Signs of opioid toxicity may include visual hallucinations, myoclonus, drowsiness or confusion.7

Long acting opioid preparations should be avoided (e.g. MST?/MXL?) as the metabolites accumulate in renal failure. An exception to this rule is transdermal fentanyl as renal failure does not affect the pharmacokinetics of the drug. 6, 7, 8

37.2 GUIDELINES

37.2.1 Assessment of acute renal failure If acute renal failure is diagnosed, an assessment of the cause should be carried out where

appropriate (see Table 37.2).

Table 37.2 Assessment of acute renal failure 3 [Level 2]

Assessment of fluid status Review of medication. Discontinue nephrotoxic drugs Baseline bloods e.g. FBC, urea and electrolytes, urate, Ca2+(corr) Septic screen: including MSSU and blood cultures

Dipstick urine/ measure urine output Urinary catheterisation

Renal ultrasound

37.2.2 Calculating the degree of renal impairment 5, 9, 10 [Level 1] When diagnosing renal failure the serum creatinine may be misleading as it is significantly

influenced by muscle mass, age and sex. 5 The estimated Glomerular Filtration Rate (eGFR) should be calculated using one of the

formulae in Table 37.3. The result may then be used to estimate the degree of renal impairment and the stage of chronic kidney disease (see Table 37.4). Alternatively, on line calculations may be done at eGFRcalc/GFR.pl Clinical biochemistry laboratories can report the eGFR if requested. An estimated GFR should not be used for acute renal failure or in patients on dialysis.

Table 37.3 Formulae for calculations of eGFR 5, 9, 10 [Level 1]

Modification of Diet in Renal Diseaseabbreviated (MDRD) 11 Cockcroft and Gault Equation 12 (males)

Cockcroft and Gault Equation 12 (females)

eGFR (ml/min) = 186 x (Creat/88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black) eGFR(ml/min) = (140 - age) x weight (kg) x 1.23 divided by Serum creatinine (micromols/l)

eGFR(ml/min) = (140 - age) x weight (kg) x 1.04 divided by Serum creatinine (micromols/l)

Table 37.4 Stages of chronic kidney disease (CKD) 5, 13

Stage

1 2

GFR (mls/min) >90

60-89

3a 45-60 3b 30-45 4 15-29

5 ................
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