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7-renal drugs final

Diuretics and Drugs Affecting Renal Function, Water,
and Electrolyte Metabolism

Subcommittee:
Strandhoy, Jack W., Chair, jstrand@wakehealth.edu Jeffries, William B. Diuretics
Recommended Curriculum Equivalent: 2 hrs 
Drug Classes and Drugs to Consider
Learning Objectives 
Physiology and Pathophysiology
Describe the location and function of major ion transporters and channels on renal
Explain how sodium transport influences the reabsorption of other ions and water in the Explain how abnormal renal function can cause hypertension or edema.
Mechanism of Action
Describe the changes that occur with electrolyte transport, water reabsorption and
hemodynamics when specific diuretics inhibit kidney function. Actions on organ systems
Describe the hemodynamic, ion transport and excretory effects of different classes of
Pharmacokinetics
Explain the importance of the organic anion transporters and protein binding to the renal
Provide examples of how other drugs or diseases can interfere with the effects of Adverse effects, drug interactions and contraindications
Explain how thiazides and loop diuretics can cause a metabolic alkalosis. Explain how diuretic therapy can lead to hyponatremia. Describe the metabolic imbalances with diuretic therapy on glucose, urate, lipids, calcium, magnesium and potassium. Explain the underlying mechanisms involved. Describe the clinical consequences of interactions between diuretics and drugs such as cardiac glycosides, oral hypoglycemics, uricosurics, aminoglycosides, amphotericin, NSAIDs and angiotensin inhibitors. Describe why reduced renal perfusion can limit the use of thiazide diuretics.
Therapeutic uses
Explain the renal and extra-renal mechanisms by which diuretics are useful in treating
Explain how osmotic drugs can reduce toxic nephropathy. Clinical Pharmacology
In salicylate overdose, failure of urine alkalinization with intravenous bicarbonate then
allows for the use of a carbonic anhydrase inhibitor to increase urine pH and allow for increased urinary clearance of salicylic acid in the absence of access to dialysis. Hydrochlorothiazide can be used in a 12.5 mg dose (1/2 tablet) to counteract the increase in circulating aldosterone secondary to use of an ACE inhibitor for the management of hypertension. Hydrochlorothiazide is indicated as the only diuretic that spares calcium in patients with osteopenia. Furosemide is the only effective oral diuretic in patients with a creatinine clearance less than 60 ml/min. Potassium-sparing diuretics are relatively contraindicated in patients receiving ACE inhibitor therapy due to the increased potential for hyperkalemia. Caution with interaction between thiazide diuretics and concurrent acute NSAIDs due to increased potential for interstitial nephritis. Relevance 
USMLE topic
Principles of therapeutics
Processes- Metabolic and Regulatory Disorders & Vascular Disorders-Principles of Therapeutics: Antihypertensive Drugs. Renal/Urinary System-Abnormal Processes 
AAMC Medical School Objectives Project Topic C:
Report X Patient Safety -
Table 1 
Drug treatment of common conditions 
Notes
Objectives for diuretics as antihypertensive drugs are covered in Cardiovascular Drugs.
Objectives for renin inhibitors, ACE inhibitors and angiotensin-receptor blockers are
Objectives for drugs used in renal transplantation and some renal diseases are covered Agents Affecting the Renal Conservation of Water
Recommended Curriculum Equivalent: 1 hr.
Drug Classes and Drugs to Consider 
Vasopressin
Vasopressin
Agonists
Antagonists
Learning Objectives
Physiology and Pathophysiology 
Explain the mechanisms by which the kidney makes a concentrated or dilute urine. Describe the roles of vasopressin, aquaporins, V1 and V2 receptors, cyclic AMP and prostaglandins in regulating renal epithelial water permeability. Mechanisms of Action
Describe how drugs can mimic or interfere with the cellular mechanisms of vasopressin.
Actions on organ systems 
Compare and contrast the renal and extrarenal effects of vasopressin and Pharmacokinetics
Explain how altering the structure of vasopressin affects its pharmacokinetics and
Adverse effects, drug interactions and contraindications 
Explain the mechanism of vasoconstriction produced by vasopressin. Explain how NSAIDs and clonidine can alter water reabsorption by the kidney. Describe the hazards of correcting hyponatremia with vasopressin antagonists too Explain how drugs such as clonidine, chlorpropamide, demeclocycline, lithium, and NSAIDs can modify the action of vasopressin. Explain how blocking the V1 receptor can alter ACTH secretion.
Therapeutic uses
Compare and contrast the therapy of central and nephrogenic diabetes insipidus.
Describe the pharmacological treatment of the syndrome of inappropriate ADH
Explain the mechanism of lithium carbonate interference with renal water reabsorption. Clinical Pharmacology   
Caution in use of conivaptan and tolvaptan concurrently with drugs inhibiting CYP3A or
P-gp due to increased risk of toxicity associated with overly rapid correction of hyponatremia. Relevance 
USMLE topic
Principles of therapeutics
AAMC Medical School Objectives Project
Report X Patient Safety - Table 1
severe medical conditions and emergencies Notes
Objectives for desmopressin-enhanced clotting factor release are covered in

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