A case study on essential dosage adjustment in chronic renal insufficiency

Shivashankar V et al / Int. J. of Pharmacology and Clin. Res. Vol-1(1) 2017 [04-07]
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IJPCR |Volume 1 | Issue 1 | Jan – Jun- 2017
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Case Study Clinical Research
A case study on essential dosage adjustment in chronic renal insufficiency
V. Shivashankar, R. Srisha
College of Pharmacy, Sri Ramakrishna Institute of Paramedical Sciences, Sri Ramakrishna Hospital
Campus, No.395, Sarojini Naidu Road, Coimbatore-641044, Tamil Nadu, India
*Corresponding author: V. Shivashankar
E-mail id: v.shivshan@gmail.com
ABSTRACT
Renal disease alters the effects of many drugs. Drug doses of certain drugs have to be appropriately adjusted depending upon
the degree of renal impairment. Drug dosing errors in patients with renal impairment are common and can lead to
accumulation and toxicity leading to adverse effects and poor outcomes. A case of a 72 years old male patient with chronic
renal failure with other co morbid disease states like systemic hypertension, diabetes mellitus, osteoporosis and peripheral
artery disease has been discussed. Laboratory data revealed both elevated serum creatinine and urea levels. On the day of
admission the patient was in end stage renal disease as his calculated GFR was 12ml/min. Modified Diet for Renal Disease
equation was used to calculate the GFR and dose adjustments were made accordingly. Drugs prescribed to the patients
included ceftriaxone 1 g, Pentoxifylline 400 mg, Tapendadol 50 mg, Levocarnitine 500 mg, Alprazolam 0.5 mg, Alpha
calcidiol 0.25 mg, Atorvastatin 20 mg, Cilostazol 50 mg, Tramadol 50 mg, Esomeprazole 40mg, Calcium 250 mg, A
systematic medication chart review revealed that pentoxyfylline is the drug of choice with altered dosing recommendations in
this patient. Therapeutic duplication in the form of using pentoxyfylline and cilostazole to treat peripheral vascular disease
was also noted. Alprazolam was started at a higher dose for the geriatric patient.
Keywords: Chronic Renal Failure, E GFR, MDRD, Pentoxyfylline
INTRODUCTION
Kidney disease is a serious health care issue that
needs to be taken care of in practice settings. This
problem is quite common among geriatrics. Renal
disease often leads to alteration of pharmacokinetics of
most drugs especially those which are actively excreted
by the kidneys. Dosage adjustment in patients based on
individuals kidney function is essential to avoid any
adverse effects of the drug in the patient.
OBJECTIVES
To improve the quality of life of hospitalized
patients with chronic kidney disease by appropriately
altering the dosage regimen based on individual patient’s
renal profile. To minimize the incidence of adverse drug
effects and drug related issues in such patients.
ISSN:2521-2206
International Journal of Pharmacology and
Clinical Research (IJPCR)

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METHODS
Demographic data, past medical history, laboratory
data and prescribed drugs were recorded in a
customized data entry form. The severity of renal
insufficiency was determined by calculating the
patient’s GFR using MDRD equation as follows:
Whenever follow up serum creatinine was measured
for the patient, Glomerular filtration rate was estimated
and dose requirements were calculated once again. A
systematic medication chart review was also performed
in order to understand the incidence of various Drug
related problems such as drug duplication, under
dosing, overdosing, drug interactions, adverse drug
reactions and other medication errors.
RESULTS
A male patient of age 72 years was admitted in the
general department for 12 days with chief complaints
of bilateral legs swelling, pain while walking, inability
to walk properly, inability to lift right arm because of
sustained injury in the right arm due to slip and fall at
home. He was a known case of Type 2 Diabetes
Mellitus, Systemic Hypertension and Chronic Renal
Failure. Patients laboratory results showed that mean
blood pressure was 140/80 mm Hg and pulse was 80
beats/ minute. Renal function test showed elevated
serum urea and creatinine levels of 91mg/dl and
3.47mg/dl respectively on the day of admission. With
the above subjective and objective data the patient was
diagnosed to have Type2 Diabetes Mellitus, Systemic
Hypertension, Chronic Renal failure, Peripheral
vascular disease and osteoporosis. The patient also
sustained right humeral shaft fracture and so had to
undergo IMIL Nailing. The drugs prescribed to the
patient given in table no: 1
Table No 1 Drug prescribed
Drug prescribed Dose Frequency D1 D2 D3 D4 D5 D6 D7 D8 D9 D
10
D
11
D
12
Inj. Ceftriaxone 1 g BD            
Tab. Pentoxyfy-lline 400 mg TID            
Tab. Levocarnitine 500 mg OD            
Tab. Alprazolam 0.5 mg HS            
Tab. Alpha calcidiol 0.25mg OD            
Tab. Cilostazol 50 mg BD            
Tab. Atorvastatin 20 mg BD - - -         
Cap. Omega 3 fatty acid 10 mg BD - -          
Inj. Tramadol 50 mg OD  - - - -     - - -
Tab. Esomeprazole 40 mg BD            
Tab. Clopidogrel + Aspirin 75mg OD - - - -        
Tab. Tapentadol 50 mg BD            
DISCUSSION
The kidneys play a vital role in the excretion of
many drugs. CKD is defined as the presence of kidney
damage or a reduction in the glomerular filtration rate
(GFR) for three months or longer [1, 2]. The degree of
renal
insufficiency and the severity of kidney disease are
generally reflected in the reduction of GFR. The Kidney
Disease Outcomes Quality Initiative (K/DOQI) of the
National Kidney Foundation (NKF) established
classification of CKD which has been accepted and used
worldwide [3].

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Table No 2 Chronic Kidney Disease Staging
Chronic Kidney Disease Staging
Stage Description GFR (ml per minute per 1.73 m2
)
1 Kidney damage with normal or increased GFR ≥ 90
2 Kidney damage with a mild decrease in GFR 60 to 89
3 Moderate decrease in GFR 30 to 59
4 Severe decrease in GFR 15 to 29
5 End Stage Renal Disease < 15 (or dialysis)
The patient had high levels of urea and creatinine in
blood. The accumulation of creatinine in blood
indicates abnormal or diminished renal function. [5]
Most of the time serum creatinine is used to evaluate
renal function and equations using serum creatinine
concentrations are the bases of most estimates of GFR.
[6] The K/DOQI clinical practice guideline advocates
using the traditional Cockcroft- Gault equation or the
Modification of Diet in Renal Disease (MDRD) study
equation for routine estimation of GFR. [7] In patients
with GFR less lower than 60 ml per minute per 1.73
m2, the MDRD equation has shown to be superior. [8]
More over MDRD equation has been shown to be the
best method for detecting GFR lower than 60 mL per
minute per 1.73m2 in older patients. [9] In this case
GFR was calculated by using Modification of Diet in
Renal Disease (MDRD) formula. [10]
The patients GFR was calculated and found to be
12 ml/min. Dosing consideration is essential in this
case because of high blood levels of urea, creatinine
and reduced glomerular filteration rate which can lead
to decreased renal drug excretion which may result in
prolonged elimination half life of the administered
drug. Patient is 72 years old and considered to be a
geriatric. As age progresses the normal kidney function
also declines due to structural and vascular changes
that occur in the kidneys due to ageing. Therefore
dosing is very essential in this patient. Drug dosing in
these cases can be subjected to interventions. [11, 12,
13] Loading doses usually do not need to be adjusted in
patients with chronic kidney disease. Published
guidelines suggest methods for maintenance dosing
adjustments: dose reduction, lengthening the dosing
interval, or both. [14] A detailed medication chart
review revealed that pentoxyfylline was used to treat
intermittent claudication in the patient at a dose of 400
mg TID. But the patient’s laboratory reports showed
that the patient had end stage renal disease with e GFR
of 12ml/min. Dosage adjustment for pentoxyfylline has
to be made. The drug has to be given at the dose of 400
mg OD. [15] Alprazolam was prescribed at a dose of
0.5mg for the patient. Use of alprazolam at higher
doses lead to adverse drug events. [17]
Benzodiazepines are associated with confusion, day
time sedation memory falls, slips and motor vehicle
accidents in elderly when prescribed at higher doses.
[16-19]
CONCLUSION
A case of a 72 years old male patient with chronic
renal failure, systemic hypertension, diabetes mellitus,
osteoporosis and peripheral artery disease has been
discussed. This article emphasizes the need to consider
important variables relevant to prescribing decisions
that are quite often not recognized in clinical care
especially in lieu with kidney disease. Renal function is
a very important physiological variable that affects the
pharmacokinetics and clinical efficacy of many drugs.
While prescribing the drugs to a patient who has renal
impairment, it is essential to consider both the patients
and the drugs characteristics. Most of the time renal
parameters are not considered before prescribing drugs.
Pharmacists play an important role in this aspect of
choosing the most empirical dosing regimen for the
patient. This can be achieved by active participation of
the pharmacists in ward rounds, regular prescription
chart review, evaluation of drug dosing based on e
GFR or creatinine clearance and altering the dose
according to individual patient demands, thereby
improving the drug safety in patients with renal
impairment.

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