Advanced Clinical Pharmacy – Research, Development
and Practical Applications 1
Rhiannon Braund Editor
Renal Medicine
and Clinical
Pharmacy
,Advanced Clinical Pharmacy - Research,
Development and Practical Applications
Volume 1
Series Editor
Rhiannon Braund, University of Otago, Dunedin, New Zealand
,This exciting new book series Advanced Clinical Pharmacy incorporates new areas
of research and development with practical approaches and is designed to aid
pharmacists up-skill in various new and traditional areas of practice that are
applicable, but not limited to, hospital-based care, as well as incorporating the more
advanced aspects of community-based care.
Advanced Clinical Pharmacy will incorporate titles that help intermediate level
pharmacists see what further areas of practice need to be incorporated in to their
skill set, as well as provide guidance on areas of expertise that they may wish to
focus on for more advanced practice in the future. It will also provide more advanced
pharmacists with a tool for ensuring they are current and up-to-date in a wider range
of topics, as well as in their chosen area of expertise. Additionally, it may provide
newly registered pharmacists with guidance on what areas of practice they may
aspire to work in.
The series will provide more comprehensive information that is also more focused
than is typically found in traditional clinical pharmacy text books (which cover all
topics in a single volume and typically cover a topic in one or two chapters). It will
allow pharmacists to select topics that are more applicable to their individual areas
of work, as well as areas that in the future they may wish to work in. Each volume
will provide a summary of the main theory that underpins the topic, but will then
move on to advanced information including areas of current research, clinical
applications, case studies, practical tips, and common pitfalls. It will also look at
future directions and also, where applicable, hints for the independent practitioner –
in preparation for the advancement of pharmacists as more independent health
professionals.
Titles in the series can be monographs (up to 3 authors) or edited volumes,
ranging from 200–500 pages per volume. Each title will be published as ebook as
well as in hard bound print format.
This series will be of interest to a wide readership, ranging from intermediate
level pharmacists, with experience of 3 to 5 years post-registration (for a bachelor’s
degree) or experience of 2 to 3 years (for a PharmD), through to more advanced/
senior clinical pharmacists. It is hoped that the information would also be of interest
to pharmacists working in community-based care, who wish to increase their
knowledge and skill, as well as hospital-based pharmacists.
The series may also be useful as educational tools for the teaching of pharmacists
involved in both formal post-graduate education as well as more ad hoc workplace
based programmes – however, different titles in the series may be more suitable for
this than others.
Unique features
• Offers readers the ability to select the topics that are of interest to them and focus
on their area of work/expertise
• Provides the salient points of the background theory but then quickly moves on
to more advanced knowledge that contains both current research as well as prac-
tical information in the context of cases (but not limited to case scenarios)
More information about this series at http://www.springer.com/series/15660
,Rhiannon Braund
Editor
Renal Medicine and Clinical
Pharmacy
,Editor
Rhiannon Braund
University of Otago
Dunedin, New Zealand
ISSN 2524-5325 ISSN 2524-5333 (electronic)
Advanced Clinical Pharmacy - Research, Development and Practical Applications
ISBN 978-3-030-37654-3 ISBN 978-3-030-37655-0 (eBook)
https://doi.org/10.1007/978-3-030-37655-0
© Springer Nature Switzerland AG 2020
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,To Emily May White (2002–2017), who gave
the gift of life.
,Preface
While many young pharmacists emerge into practice with a substantive knowledge
base, the evolution of clinical practice coupled with the required additional special-
ized knowledge that comes from clinical specialties can make it difficult to evolve
as a practitioner. This knowledge can be hard to gather from senior clinicians and
from specialized medical texts and usually requires a pharmacist to have worked in
the specialty for a considerable period of time. These texts facilitate the uptake of
this knowledge, by providing the background details of key concepts, in an easy to
understand manner and in a way that is targeted specifically to pharmacists.
This series of books have been designed to allow new practitioners, or those
moving into new clinical areas, a refresher of the core pharmaceutical concepts, as
well as moving on to the rationale optimisation of pharmacotherapy, and finishing
with advanced clinical practice. Included are pearls of wisdom, from other practitio-
ners, as well as common pitfalls. This provides a solid platform to then develop
further expertise.
In these books, international experts with specialist clinical knowledge have dis-
tilled the core knowledge of each clinical area, providing real-world insights to
create a book that will help guide junior pharmacists to become the specialist phar-
macists of the future.
Dunedin, New Zealand Rhiannon Braund
vii
,Contents
1 Introduction to Renal Pharmacy�������������������������������������������������������������� 1
Carolyn Coulter
2 How Kidney Function Affects Drug Pharmacokinetics ������������������������ 5
Carolyn Coulter
3 Acute Kidney Injury: Pre-renal, Intra-renal and Post-renal���������������� 23
Christine Sluman, Pooja Mehta Gudka,
and Kathryn McCormick
4 Chronic Kidney Disease and End Stage Renal Disease�������������������������� 45
Dan Martinusen
5 Dialysis�������������������������������������������������������������������������������������������������������� 117
Timothy Nguyen, A. Mary Vilay, Neeta Bahal O’Mara,
and Rebecca Maxson
6 Drug-Induced Nephrotoxicity������������������������������������������������������������������ 131
Adriano Max Moreira Reis
Index������������������������������������������������������������������������������������������������������������������ 159
ix
,Chapter 1
Introduction to Renal Pharmacy
Carolyn Coulter
Abstract Renal dysfunction is a common reason for requiring pharmacists to
adjust their thinking when optimizing a drug dosing regimen. However, many phar-
macists find this clinical task quite daunting as there are many factors to consider,
such as whether renal clearance alone is affected, if renal metabolism is also
affected, if there renal pathology to consider, if this an acute situation or more
chronic or even both, and if renal replacement therapy indicated. But if each ques-
tion is considered in a logical stepwise manner, then often this process becomes
much easier to understand. There may still be unanswered questions at the end of
this process, but usually there is a great clarity around these and whether they are
going to impact the patient clinically.
Keywords Renal pharmacy · Renal dysfunction · Pharmacotherapy · Clinical
practice · Nephrology · Pharmacy practice · Adverse drug reactions
Renal dysfunction is a common reason for requiring pharmacists to adjust their
thinking when optimizing a drug dosing regimen. However, many pharmacists find
this clinical task quite daunting as there are many factors to consider, such as
whether renal clearance alone is affected, if renal metabolism is also affected, if
there renal pathology to consider, if this an acute situation or more chronic or even
both, and if renal replacement therapy indicated. But if each question is considered
in a logical stepwise manner, then often this process becomes much easier to under-
stand. There may still be unanswered questions at the end of this process, but usu-
ally there is a great clarity around these and whether they are going to impact the
patient clinically.
Today there is a greater focus on medicines reconciliation for all patients admit-
ted to hospital, and with this comes the perceived need to prescribe all medicines on
C. Coulter (*)
Timaru Hospital Pharmacy, Timaru, New Zealand
e-mail: ccoulter@scdhb.health.nz
© Springer Nature Switzerland AG 2020 1
R. Braund (ed.), Renal Medicine and Clinical Pharmacy, Advanced Clinical
Pharmacy - Research, Development and Practical Applications 1,
https://doi.org/10.1007/978-3-030-37655-0_1
, 2 C. Coulter
admission. However, the very key steps in treating patients with renal dysfunction
are to initially ask what may have caused, or contributed to, the renal problem and
what may further exacerbate it. Then it is appropriate to ask what medicines are
required now, and what medicines will be required in the future. Treating patients
with renal dysfunction starts by ceasing or with-holding all inappropriate medi-
cines, followed by the rational prescribing of medicines while always considering
the clinical appropriateness, the optimized dosing regimen, and also the pill burden.
For example if you have a patient with an acute kidney injury and you want to
review their medicines on admission you firstly need to consider what caused, or
contributed, the acute kidney injury. Secondly, what of the regular medicines are
currently required, and what can be safely with-held until the kidney injury has
resolved. Thirdly, are there any other therapies that should be instigated both for the
acute situation and long term for this patient. Chronic kidney disease requires the
same analysis, but with a greater focus on the long term requirements.
Initially hospital pharmacists may often consider that dose adjustment as per
standard renal dosing guidelines is appropriate, these often do not consider the clini-
cal complexity that may exist. Guidelines for dose adjustments in renal impairment
that are based on reduction in glomerular filtration rate, calculated from creatinine
clearance, are an excellent staring point, but then critical thinking must be employed.
It is very appropriate to dose adjust a medicine for a chronic condition, but if
your patient has severe sepsis then dose adjustment of antibiotics based on creati-
nine calculations during an acute kidney injury most likely will lead to treatment
failure. Instead if the pharmacist considers the pharmacokinetics, the clinical indi-
cation including the need to treat aggressively, then a more appropriate dosing regi-
men may be initiated. This dosing regimen may require frequent review with
multiple changes over time, especially if the patient improves – or deteriorates fur-
ther and requires acute renal replacement. Dose adjustments can also seem complex
but these just require consideration of what is the target concentration – is a loading
dose required, and for the maintenance dose what proportion is cleared by the kid-
neys and by how much this will be affected. Additionally, a pharmacist must watch
for therapeutic failure as well as potential toxicity.
An appreciation of renal disorders is required for pharmacists who wish to be a
valued member of a nephrology team. The kidneys are important for drug dosing as
they are one of the most important clearance systems in the body, but they can be
affected by processes occurring before the kidneys, such as blood volume and car-
diac output, or process after the kidney such as bladder and urological issues.
However, there are also many diseases that affect the kidneys – these may be dis-
eases just affecting the kidneys such as glomerular nephritis, or they may be sys-
temic diseases that also result in renal pathology such as systemic lupus
erythematosus. The kidneys can also be affected by xenobiotics in the body, which
does include other nephrotoxic medicines.
Moreover, the kidneys have a role in acid-base control, electrolyte and water
control, they perform some metabolism, as well as regulation of some hormones,
and they help control blood pressure. The kidneys can also be affected by congenital
structural abnormalities, as well infections, and dysfunction from other organs. If
