Renal Failure - (Commonly used agents)

Intro	Aluminum Hydroxide - AlternaGel ®, Alu-Cap ®
Calcium acetate - PhosLo ®	Calcitriol - Calcijex ®; Rocaltrol ®
Doxercalciferol - Hectorol ®	Ferric Sodium Gluconate - Ferrlecit ®
paricalcitol - Zemplar ®	sevelamer - Renagel ®

Intro

Renal failure/Oliguria (General guidelines)
(1) Avoid magnesium containing products (Maalox etc), NSAID’s, and nephrotoxins.

(2) Consider fluid challenge to rule out pre-renal azotemia if not fluid overloaded.

(3) Lasix: IV bolus 10-200 mg (usually every 2 hours). Doses > 200mg should be infused at 4 to 10 mg/min (usually 4 mg/min) to minimize ototoxicity. IV infusion of 0.25 to 0.4 mg/kg/hour titrated to urine output.

(4) Metolazone (Zaroxylyn ® ) 5-10 mg po qd (max 20 mg/day)

(5) Bumetanide (Bumex ®): IV bolus 0.5 to 4mg over 1-2min prn (usually q2-3 hr). IV infusion: usually 0.5 to 1 mg/hr. T1/2= 1 to 1.5hr Duration of action: 2-4hrs.

(6) Torsemide (Demadex ®): IV bolus: 5 to 100 mg over 1-2 minutes. IV infusion: 5 to 20 mg/hr. [1 mg Bumex] = [10-20 mg Demadex] = [40 mg Lasix]

(7) Mannitol: When instituting treatment with mannitol in patients with marked oliguria, a test dose should be used. Infusion of 0.2 grams/kg over 3 to 5 min should produce a diuresis of at least 30 to 50 ml/hr. A second test dose may be given if no response is seen—if no response with second dose—do not use. To treat oliguria: 12.5 to 25 grams IV every 2 to 4 hours. A 15 to 20% solution may be used. Rate should be adjusted to maintain urinary output at 30-50 ml/hr. (Usual test dose= 12.5 grams over 3 to 5 minutes. )

Ca x PO4 RATIO
When the Ca x PO4 product exceeds 70, there is a possibility of dangerous precipitation of Ca in non-osseous tissues. Use of Ca based PO4 binders may transiently exacerbate the problem. Use of aluminum hydroxide (300 to 600 mg p.o. tid with meals) for periods not to exceed 7-10 days (to avoid Al3+ toxicity) may be necessary. When the Ca x PO4 product falls below this dangerous level, calcium-carbonate or calcium-acetate may be started. RenaGel®, a new polymeric resin that does not contain Ca++ may be used.

Aluminum Hydroxide - AlternaGel ®, Alu-Cap ®

Hyperphosphatemia: Oral: Initial: 300-600 mg 3 times/day with meals. (Not to exceed 7-10 days (to avoid Al3+ toxicity).

Hyperacidity: Oral: 600-1200 mg between meals and at bedtime.

Aluminum antacids may cause constipation, phosphate depletion, and bezoar or fecalith formation. In patients with renal failure, aluminum may accumulate to toxic levels.

Supplied: Suspension, oral: 320 mg/5 mL (473 mL)
AlternaGel®: 600 mg/5 mL (360 mL)

Calcium acetate - PhosLo ®

Hyperphosphatemia: Start 2 tablets (1334 mg) with each meal. Range: 2 to 4 tablets with each meal. Can be increased gradually to bring the serum phosphate value <6 mg/dl as long as hypercalcemia does not develop.

Usual dose: (3 to 4 tablets) 2001-2868 mg with each meal.

[Supplied: 667mg tablet, Gelcap]

Calcitriol - Calcijex ®; Rocaltrol ®

MECHANISM OF ACTION: Promotes absorption of calcium in the intestines and retention at the kidneys thereby increasing calcium levels in the serum; decreases excessive serum phosphatase levels, parathyroid hormone levels, and decreases bone resorption; increases renal tubule phosphate resorption.

Vitamin D Analog.

May be administered without regard to food. Give with meals to reduce GI problems. May be administered as a bolus dose I.V. through the catheter at the end of hemodialysis. Individualize dosage to maintain calcium levels of 9-10 mg/dL.
USE — Management of hypocalcemia in patients on chronic renal dialysis; management of secondary hyperparathyroidism in moderate-to-severe chronic renal failure; management of hypocalcemia in hypoparathyroidism and pseudo- hypoparathyroidism

Dosing (Adults):
Renal failure:
Oral: 0.25 mcg/day or every other day (may require 0.5-1 mcg/day).
IV: 0.5 mcg (0.01 mcg/kg) 3 times/week; most doses in the range of 0.5-3 mcg (0.01-0.05 mcg/kg) 3 times/week.

Hypoparathyroidism/pseudohypoparathyroidism: Oral: 0.5-2 mcg/day.
Vitamin D-dependent rickets: Oral: 1 mcg qd.

Kidney failure disrupts systemic calcium and phosphate homeostasis and affects the bone, gut, and parathyroid glands via limited exretion of phosphate, diminished hydroxylation of 25-hydroxyvitamin D to calcitriol (1,25-dihydroxyvitamin D) and resulting hypocalcemia. Circulating calcitriol levels begin to fall when the glomerular filtration rate is less than 40 mL/min and are typically markedly reduced in subjects with end-stage renal failure. Both the loss of functioning renal tissue and, in early renal failure, physiologic suppression by hyperphosphatemia participate in the decline in calcitriol synthesis.

Supplied: Capsule (Rocaltrol®): 0.25 mcg, 0.5 mcg.
Injection, solution: 1 mcg/mL (1 mL); 2 mcg/mL (2 mL). Calcijex®: 1 mcg/mL (1 mL). Oral soln: (Rocaltrol®): 1 mcg/mL (15 mL).

Doxercalciferol - Hectorol ®

Management of secondary hyperparathyroidism in patients undergoing chronic renal dialysis. Synthetic vitamin D analog.

Dosing (Adults):
Initial dose of doxercalciferol is 10 mcg administered three times weekly at dialysis. The maximum recommended dose of doxercalciferol is 20 mcg administered three times a week at dialysis for a total of 60 mcg/week

Ferric Sodium Gluconate - Ferrlecit ®

Indicated for the treatment of iron deficiency anemia in patients undergoing chronic hemodialysis who are receiving supplemental erythropoietin therapy.

Dosing (Adults):
The recommended dosage of ferric sodium gluconate for the repletion treatment of iron deficiency in hemodialysis patients is 10 ml of ferric sodium gluconate (125 mg of elemental iron) diluted in 100 ml of 0.9% sodium chloride solution administered intravenously over 1 hour. Most patients will require a minimum cumulative dose of 1 gram of elemental iron, administered over eight sessions at sequential dialysis treatments to achieve favorable hemoglobin or hematocrit response.

paricalcitol - Zemplar ®

Indicated for the prevention and treatment of secondary hyperparathyroidism associated with chronic renal failure.
Synthetic vitamin D analogue.

Dosing: 0.04 to 0.1 mcg/kg (2.8 to 7.0 mcg) IV 3 times/week at dialysis. Max dose 0.24 mcg/kg (16.8 mcg).

sevelamer - Renagel ®

Calcium/aluminum free phosphate binder. Decreases phosphate levels without altering calcium, aluminum, or bicarbonate concentrations.

ESRD (hyperphosphatemia): 2 to 4 (800-1600 mg) caps orally three times daily with meals.

Note: the dose may be based on serum phosphorous.
Initial phosphate level:
>6.0 mg/dl and <7.5 mg/dl: 800 mg 3 times/day
>7.5 mg/dl and <9.0 mg/dl: 1200-1600 mg 3 times/day
>9.0 mg/dl: 1600 mg 3 times/day

Adjustment: Dosage should be adjusted based on serum phosphorous concentration, with a goal of lowering to <6.0 mg/dl.

Supplied: 400 mg, 800 mg tablet

Disclaimer

Listed dosages are for - Adult patients ONLY. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. GlobalRPH does not directly or indirectly practice medicine or provide medical services and therefore assumes no liability whatsoever of any kind for the information and data accessed through the Service or for any diagnosis or treatment made in reliance thereon.

David F. McAuley, Pharm.D., R.Ph. GlobalRPh Inc.

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