Introduction. Heart failure (HF) is highly prevalent in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) and is strongly associated with mortality in these patients. However, the treatment of HF in this population is largely unclear. Study Design. We conducted a systematic integrative review of the literature to assess the current evidence of HF treatment in CKD Autosomal Dominant Polycystic Kidney Disease (ADPKD) formal systematic literature review. Another aim is to propose research recommendations for areas in which there are gaps in knowledge. The development of the ADPKD guideline is being led by the Work Group Co-Chairs, Dr. Olivier Devuyst of Switzerland and Dr. Vicente Torres of the US He received 5 g of liposomal amphotericin B and was discharged after 54 days from the hospital. We also performed a systematic review of the literature and identified seven additional cases of COVID associated mucormycosis (CAM). Of the eight cases included in our review, diabetes mellitus was the most common risk factor
Autosomal Dominant Polycystic Kidney Disease (ADPKD) – KDIGO
Pain management in patients with chronic liver disease poses unique challenges for clinicians. Many of the commonly used over-the-counter and prescription pain relievers like acetaminophen, non-steroidal anti-inflammatory drugs NSAIDsand opiates are metabolized through the liver.
Adverse events from analgesics are all too common, potentially fatal, and often avoidable in patients with chronic liver disease, especially in those with cirrhosis or hepatitis. Unfortunately there currently are no definitive practice guidelines about treating the pain patient with chronic liver disease. This article examines some of the most commonly used analgesics, and the misconceptions as well as false impressions clinicians have regarding their usage in the chronic liver disease population.
According to the Centers for Disease Control and Prevention CDC, Americans were discharged from hospitals with chronic liver disease as their primary diagnosis in Chronic liver disease and cirrhosis alter the metabolism and effect of drugs by different mechanisms that could potentially have hazardous side effects.
There are three main pathways of drug metabolism by the liver:. Acetaminophen Tylenol, generic is the most commonly prescribed over-the-counter analgesic and antipyretic medication in the US, literature review kidney disease. Acetaminophen overdose is the most common cause of fulminant liver failure. Acetaminophen can cause hepatic toxicity through two mechanisms. When ingested, literature review kidney disease, the large majority of acetaminophen is metabolized in the liver by glucuronidation and sulfonation to nontoxic metabolites, which are then excreted with bile and urine.
Once formed, it is primarily glutathione that is responsible for the detoxification of NAPQI and protection against oxidative damage. Glutathione is produced primarily in the liver. Several studies have literature review kidney disease that CYP enzymatic action is either normal or reduced in patients with liver disease. However, there have been mixed results concerning levels of glutathione in patients with liver disease. It was discovered in several studies that patients with chronic liver disease had reduced plasma and hepatic glut-athione levels.
It is at this level that binding of hepatic NAPQI is seen. The half-life of acetaminophen is prolonged in patients with chronic liver disease. However, a study by Benson showed that repeated maximal dosing did not lead to accumulation in patients with chronic stable liver disease CSLD. When compared to normal patients, Forrest et al demonstrated similar levels of cysteine and mercapturic acid conjugates, literature review kidney disease, suggesting intact detoxification of NAPQI, literature review kidney disease.
Inthe American Liver Foundation ALF issued recommendations that patients not exceed 3 grams a day of acetaminophen for any "prolonged period of time. Burns et al recommended that for patients with chronic active alcohol ingestion and cirrhosis, acetaminophen may be used at a maximum of 2 grams per day, which is one-half the recommended daily dose well below toxicity levels. Some healthcare professionals encourage patients to stay well below the 4 grams per day cutoff, literature review kidney disease, even in patients without chronic liver disease or other concerns.
In Januarythe FDA released recommendations that manufacturers of prescription products that contain acetaminophen limit the per tablet capsule dose to mg to reduce the risk of liver toxicity. The FDA additionally made it a requirement that manufacturers of prescription combination products include boxed label warnings of potential liver injury, literature review kidney disease.
These changes were literature review kidney disease to make accidental overdoses by patients less likely. In consideration of these findings, normal recommended doses of acetaminophen can be safely given for short-term use to literature review kidney disease who suffer from CSLD, provided they do not drink alcohol or take medications that could increase CYP activity. For long-term treatment, it is prudent to literature review kidney disease total daily dosing in CSLD patients to 2 to 3 grams per day, until additional studies can demonstrate safety.
While it is true that these patients may metabolize acetaminophen more slowly than their healthy counterparts, no evidence of toxic accumulation has been seen to date. Since salicin was first extracted from the bark of the willow tree, to its first documented use in treating fever inNSAIDs have been one of the most popular drug classes—with 30 million people worldwide using NSAIDs daily.
However, it was not until that it was discovered that aspirin acts as an inhibitor of cyclooxygenase COXliterature review kidney disease, preventing the transformation of arachidonic acid to various prostaglandins. Two COX isoforms have since been identified—COX-1 and COX COX-1 forms prostaglandins that are important in protecting the gastric mucosa, in ensuring proper platelet function, and in maintaining renal function, literature review kidney disease.
In contrast, COX-2 is almost undetectable under normal physiologic conditions, literature review kidney disease. However during periods of inflammation, COX-2 expression can increase by up to a factor of The older NSAIDs are non-selective, inhibiting both COX-1 and COX-2, while newer agents were designed to selectively inhibit COX The metabolism of NSAIDs is governed largely by the hepatic CPY enzymes.
As discussed previously, patients with CSLD have been shown to have either normal or reduced levels of CYP Patients with chronic liver disease have a reduced ability to metabolize many drugs, and an impaired ability to synthesize hepatic albumin, which would increase serum levels of the NSAID—putting the patient at increased risk for complications.
This is troubling when one considers that these patients are at increased risk for esophageal varices as well as the gastrointestinal GI ulcers already inherent with NSAID use. One study showed that patients were 2.
The effect of NSAIDs on renal function is well documented. NSAIDs reduce prostaglandins responsible for maintaining renal perfusion, literature review kidney disease.
Cirrhotic patients with portal hypertension are dependent on prostaglandins to counteract the renin-angiotensin-aldosterone system, maintain glomerular filtration rate GFRand prevent sodium retention, literature review kidney disease. All non-selective NSAIDs reduce the effectiveness of diuretics in patients with ascites, impairing free water clearance and worsening ascites and edema. However, in a study comparing the selective COX-2 inhibitor celecoxib Celebrex and naproxen Alevea significant reduction in natriuretic response to furosemide was seen with naproxen but not with celecoxib.
Selective COX-2 inhibitors have been shown to be effective pain relievers. When compared to non-selective NSAIDs, selective COX-2 inhibitors have shown less renal and GI adverse events. They have been shown to cause a decrease in GFR, but to a lesser extent than non-selective NSAIDs, 26 as well as potential cardiac complications.
At this time there are no long-term studies examining the effects of COX-2 inhibitors in cirrhotic patients. The bottom line: NSAIDs have been shown to increase the risk of variceal and other upper GI bleeding, renal failure, and diuretic resistant ascites. They should therefore be avoided in all patients with cirrhosis.
While selective COX-2 NSAIDs are associated with less side effects, they reduce GFR and further long-term prospective studies are needed to better assess their safety.
Therefore, while they may be a safe analgesic option in the future, it is currently recommended that they be avoided in these patients. Opiates are the mainstay of pain management in most patients with severe pain. Unfortunately, they could also be the worst agent to use in patients with liver disease. Most opioids are metabolized by one or more of the CYP isozymes, and this typically results in multiple metabolites.
However, there are a few opioids that are only minimally metabolized by CYP and, thus, may be safer options for patients with chronic liver disease.
These include hydromorphone, oxymorphone, and tapentadol. Morphine, an opiate that has been in use sincecan be detrimental in patients with chronic liver disease. The clearance of morphine is highly impaired in cirrhotic patients and could cause deleterious side effects, including encephalopathy. There literature review kidney disease two systems that metabolize morphine that are both equally affected in patients with end-stage liver disease: CYP pathway and glucuronidation.
In one study, patients with a history of hepatic encephalopathy were given morphine. They found that after oral intake, the plasma concentrations of its metabolites M3G and M6G were much lower than the control group and hence morphine had about two times more bioavailability.
Morphine metabolites, M3G and M6G, are cleared by the kidney, literature review kidney disease, which in most cirrhotic patients is also poorly functioning. However, codeine is transformed to its active form, morphine, and has variable concentrations in the plasma. Two opiates that have less toxicity in chronic liver disease patients are fentanyl and hydromorphone based on two reasons:. Hepatitis C virus HCV infection is the most common chronic bloodborne infection in the United States; approximately 3.
Many of these patients are also on long-term methadone maintenance for literature review kidney disease of opioid addiction, 31 but methadone is also commonly used as a low-cost pain medication. Its mechanism of action is by binding to the µ-opioid receptor, and is metabolized by the isoenzymes CYP3A4, CYP2B6 and CYP2D6. One study at a methadone maintenance program observed patients who had HCV and were former injection drug users.
Many of the patients had persistent elevated liver enzymes. Compared to the general population with HCV, there was no significant elevation of liver enzymes in methadone patients. Methadone intake should be restricted in patients with concomitant alcoholism because it decreases the metabolism of methadone, which inevitably increases plasma levels.
Acetaminophen and NSAIDs are often added to opioid medications. Effects of combination medications have been well published in chronic pain and acute literature review kidney disease post-operatively. Many different organizations and societies are proponents of prescribing combination medications. For instance, The American Geriatrics Society recommends using combination analgesics in patients with chronic problems like hypertension and coronary artery disease.
With regards to liver toxicity, a retrospective analysis based upon insurance claims of hospitalization related to hepatotoxicity found no significant increase in hepatotoxicity-related hospitalizations in patients who were taking combination drugs as compared to opioids alone. In there was a committee meeting by the FDA advisory team that wanted to eliminate any prescription acetaminophen combination drugs. The committee voted to recommend removal of acetaminophen-containing drugs.
In a review article by Michna et al inpublications provided to the committee were not randomized controlled trials and, thus, absolute risk and rate could not be estimated from the studies. There were no concrete studies that eliminated confounding variables like baseline liver functions, other medications that could have potentiated acetaminophen toxicity, and reference groups. Patients with CSLD frequently suffer from painful neuropathic pain as a result of concomitant conditions such as diabetes and long-standing alcoholism.
The anticonvulsant medications, such as gabapentin and pregabalin Lyrica are not hepatically metabolized literature review kidney disease frequently used to treat neuropathic pain.
Practitioners should be mindful of unwanted side effects of dizziness, literature review kidney disease, sedation, and nausea. Additionally, as these agents are excreted by the kidneys, lower dosing adjustments will be required in patients with concomitant renal insufficiency.
Carbamazepine is hepatically metabolized and known to cause hepatic toxicity, 38 and therefore should be avoided in CSLD patients. Tricyclic antidepressants nortriptyline, amitriptyline and imipramine are also frequently used off-label in the treatment of neuropathic pain.
These agents rely heavily on hepatic first-pass metabolism. CSLD patients should be started on a low dose nightly and gradually titrated as tolerated. CSLD patients will require a lower maintenance dose compared to the healthy population. Practitioners should watch for sedation as well as anticholinergic side effects. Treating chronic pain patients with chronic liver disease presents a clinical challenge to the medical professional.
Unfortunately there are no concrete guidelines regarding the usage of OTC or prescription pain medications in patients with chronic liver disease. This literature review revealed that the preferred opiates in liver disease are hydromorphone and fentanyl, since they have a shorter half-life and have less harmful side effects on the renal system.
Neuropathic pain may be safely treated with anticonvulsants and tricyclic antidepressants, with dose adjustments and monitoring for side effects. With regards to OTC medications, normal recommended doses of acetaminophen can be safely given to patients who suffer from CSLD in the short term.
Natural treatment and diet for kidney failure
, time: 31:50Safe Usage of Analgesics in Patients with Chronic Liver Disease: A Review of the Literature
May 18, · Data were evaluated on the efficacy and safety of gout flare prophylaxis and therapy in patients with chronic kidney disease (CKD), in a literature review published in Arthritis Research & Therapy.. Researchers of the current analysis searched PubMed, Cochrane Library, and EMBASE to identify studies that included patients with gout and renal impairment, and with exposure to colchicine Feb 21, · KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl ; Nesrallah GE, Mustafa RA, Clark WF, et al. Canadian Society of Nephrology clinical practice guideline for timing the initiation of chronic dialysis. CMAJ ; Tattersall J, Dekker F, Heimbürger O, et al He received 5 g of liposomal amphotericin B and was discharged after 54 days from the hospital. We also performed a systematic review of the literature and identified seven additional cases of COVID associated mucormycosis (CAM). Of the eight cases included in our review, diabetes mellitus was the most common risk factor
No comments:
Post a Comment