Chapter 6-05: Key Medications and Interventions in Nephrology

Diuretics

Thiazide diuretics

• hydrochlorothiazide

• chlorthalidone

• chlorothiazide

• metolazone

• indapamide

Inhibits sodium reabsorption via Na⁺Cl^– transporter in the distal convoluted tubule

• Treatment of uncomplicated hypertension

• Treatment of edema in combination with loop diuretics

• Prevention of recurrent nephrolithiasis due to hypercalciuria

• Hyponatremia

• Hyperglycemia

• Hyperlipidemia

• Hyperuricemia

• Hypercalcemia

• Hypovolemia

Loop diuretics

• furosemide (Lasix)

• bumetanide (Bumex)

• torsemide

• ethacrynic acid

Inhibits sodium reabsorption via Na⁺-K⁺-2Cl^– transporter in thick ascending loop of Henle

• Treatment of hypertension in persons with decreased renal function

• Edema

• Heart failure

• Hyperkalemia

• Hypercalcemia with edema

• Ototoxicity

• Hyponatremia

• Hypokalemia

• Hypomagnesemia

Potassium-sparing diuretics

• amiloride

• triamterene

Blocks ENaC sodium channels in the principal cells of the collecting tubule

• Hypokalemia in patients on loop or thiazide diuretics

• Polyuria in lithium-induced DI (amiloride)

• Hyperkalemia

• Metabolic acidosis

• Nephrolithiasis (triamterene)

Mineralocorticoid receptor antagonists (also called “potassium-sparing”)

• spironolactone

• eplerenone

Competitively inhibits mineralocorticoid receptor of ENaC sodium channels in the collecting tubule

• Resistant hypertension

• Hypertension in primary hyperaldosteronism

• Heart failure refractory to optimal treatment

• Ascites

• Anti-androgen hormonal therapy (spironolactone)

• Hyperkalemia

• Metabolic acidosis

Carbonic anhydrase inhibitors

• acetazolamide

Inhibits carbonic anhydrase, leading to excretion of sodium bicarbonate

• Hypervolemia with metabolic alkalosis and alkalemia

• Metabolic alkalosis while weaning mechanical ventilation

• Metabolic acidosis

Osmotic diuretic

• mannitol

Promotes osmotic diuresis due to inability to be reabsorbed

• Hyponatremia

• Increased ICP

• Hyperosmolality

• Hypervolemia and hyponatremia if not filtered due to renal impairment

Medications used to treat metabolic complication of CKD

Erythropoiesis-stimulating agents (ESAs)

• epoetin alfa

• darbepoetin alfa

• methoxy polyethyline glycol-epoetin beta

Directly stimulates red blood cell production and maintenance

• Treatment of anemia due to kidney disease

• Rule out iron deficiency anemia before starting ESAs

• Hypertension

• Venous access thrombosis

• Potentially increased risk of malignancy and thrombosis if supratherapeutic levels are targeted

Phosphate binders

Calcium based:

• calcium acetate (Phoslo)

• calcium carbonate (Tums)

Non-calcium based:

• sevelamer (Renvela)

• lanthanum carbonate (Carbrenol)

Iron-based phosphate binders:

• ferric citrate (Auryxia)

• sucroferric oxyhydroxide (Velphoro)

Ionically binds phosphate in the gut to prevent dietary absorption

• Treatment of hyperphosphatemia

• Metabolic acidosis (sevelamer)

• Hypercalcemia (calcium acetate and calcium citrate)

Vitamin D analogs

• calcitriol (Rocaltrol)

• paricalcitol (Zemplar)

• doxercalciferol (Hectorol)

Replaces deficient activated 1,25-OH vitamin D

• Treatment of secondary hyperparathyroidism (usually due to CKD)

• Hypercalcemia

• Hyperphosphatemia

Alkali supplements

• sodium bicarbonate

• sodium citrate (Bicitra- rapidly metabolized to bicarb)

Exogenous supplementation of alkaline compounds or compounds with alkaline metabolites

• Treatment of metabolic acidosis due to CKD

• Bloating (sodium bicarb)

• Increased absorption of aluminum

Potassium lowering agents

• patiromer (Veltassa)

• sodium zirconium cyclosilicate (Lokelma)

Binds potassium in the GI tract and thus causes more fecal potassium secretion

• Chronic hyperkalemia

• Patiromer: Constipation, low K⁺/Mg²⁺, abdominal pain

• Sodium zirconium cyclosilicate: Edema, low potassium

Calcium-lowering medications

Hormone

• calcitonin

Inhibits osteoclast activity

• Treatment of acute hypercalcemia (Note: significant tachyphlaxis after 24-48 hours of administration)

• Hypersensitivity

• Rhinitis

• Hypocalcemia

Bisphosphonates

• zoledronic acid

• alendronate

• pamidronate

Interferes with osteoclast recruitment and function

• Osteoporosis

• Hypercalcemia

• GI irritation

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