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Patients on hemodialysis (HD) have a high burden of chronic inflammation induced associated with multiple comorbidities including poor nutritional status. Endotoxin (ET) is a Gram-negative bacterial cell wall component and a potent stimulus for innate immune system activation leading to the transcription of proinflammatory cytokines (e.g., IL-1, IL-6, and TNF-α) that adversely affect proteinmetabolism and nutrition. Several cross-sectional observational studies have found that elevated serum ET concentrations in hemodialysis patients are associated with lower serumalbumin, higher proinflammatory cytokine, and C-reactive protein concentrations. Possible sources of ET in the systemic circulation are bacterial translocation from the gastrointestinal tract and iron supplementation, potentially leading to intestinal bacterial overgrowth. Sevelamer is a nonabsorbable hydrogel approved for use as a phosphate binder in HD patients. Reductions in serum ET concentrations in hemodialysis patients have been observed with sevelamer therapy in observational studies and the few published interventional studies. Reduction of ET concentrations was associated with concomitant reductions in TNF-α, IL-6, and CRP and improvement in serum albumin in the majority of these small studies. Additional studies are needed to evaluate the potential effects of sevelamer treatment on nutritional status in chronic kidney disease (CKD) patients with elevated ET. [ABSTRACT FROM AUTHOR]

Objective: To provide information on the role of pharmacists in non-steroidal anti-inflammatory drug (NSAID) avoidance in high-risk patients. Summary: Nonprescription analgesics such as ibuprofen and naprox-en are widely used by Americans. These nonsteroidal anti-inflammatory drugs (NSAIDs) are available in large quantities in pharmacies and also in wholesale stores, gas stations, and convenience stores. In addition, more than 111 million people use prescription NSAIDs each year, including many older Americans. NSAIDs may seem innocuous, but they carry a significant risk of disrupting blood flow to the kidneys and thus precipitating acute kidney injury (AKI). Episodes of AKI can lead to costly hospitalizations and long-term consequences such as new-onset chronic kidney disease (CKD) or more rapid progression of existing CKD. Most cases of NS AID-induced AKI can be avoided by recognizing high-risk patients and counseling them on appropriate use of these medications. Community pharmacy-based NSAID counseling and education at the point of prescription dispensing or nonprescription purchase could complement and augment NSAID-induced AKI education provided by other members of the health care team to high-risk patients. Conclusion: NSAID use is widespread and severely compromises effective renal perfusion in high-risk patients. The community pharmacist can play a pivotal role in NSAID avoidance education to prevent potential episodes of AKI that have long-term consequences for patients. [ABSTRACT FROM AUTHOR]

After consideration of risks and benefits, some patients with kidney failure choose conservative management. Conservative management of kidney failure (CM-KF) does not include dialysis or transplant and utilizes primarily pharmacologic strategies for symptom management, which can be challenging due to the number and complexity of symptoms. Additionally, there are safety concerns regarding altered pharmacokinetics and the adverse effects induced by some of the therapies that may be selected to treat symptoms. This review describes common kidney failure symptoms and provides recommendations for pharmacologic management in CM-KF. Selection of medication should be individualized to the patient and comorbidities, drug interactions, cost, and adverse effects should be carefully considered. Additional studies specifically focused on CM-KF are needed. [ABSTRACT FROM AUTHOR]

Purpose. The case of a patient who developed clinically relevant increases in serum creatinine (SCr) levels while receiving fenofibrate therapy is reported. Summary. Fenofibrate therapy was initiated for a 60-year old Hispanic man with stage 4 chronic kidney disease (CKD) for the treatment of hypertriglyceridemia. Two weeks after taking 48 mg of fenofibrate daily, the patient's SCr and blood urea nitrogen concentrations increased from 3.0 and 25 mg/dL, respectively, to 3.5 and 30 mg/dL, respectively. His estimated glomerular filtration rate (eGFR) had decreased from 24.8 to 17.9 mL/min/1.73 m2. One month after initiating fenofibrate, his SCr concentration had increased to 3.7 mg/dL, a 32% increase from baseline. Because of persistently high triglyceride concentrations (e.g., 402 mg/dL), the fenofibrate dosage was increased to 145 mg daily. The patient's SCr concentration rose to 4.7 mg/dL (a 62% increase from baseline), and his eGFR was calculated as 13 mL/min/1.73 m2. The patient was referred by the nephrology service for vascular-access placement in preparation for hemodialysis. Four days after discontinuation of fenofibrate, the patient's SCr concentration dropped to 3.3 mg/dL and returned to baseline approximately six weeks later, with an eGFR of 20.5 mL/min/1.73 m2. Preparation for hemodialysis was terminated, and the patient's eGFR remained stable at 20.2 mL/min/ 1.73 m2 for the 12 months after fenofibrate discontinuation. A score of 4 on the Naranjo et al. probability scale indicated that there was a possible association between fenofibrate and renal dysfunction in this patient. Conclusion. A 60-year-old patient developed renal impairment after receiving fenofibrate for the treatment of hypertriglyceridemia. [ABSTRACT FROM AUTHOR]