RISK FACTOR

RENAL FAILURE & TB

ACUTE RENAL FAILURE RISK FACTOR

PRE- DRUG – AGE = 60 GENDER

RENAL INDUCED y.o & = MALE >
ISCHEMIA ARF OLDER FEMALE

NSAIDs, ACE-I, etc.

[see next] 

PRE-
ACUTE EXISTING DEHYDRA
SURGERY
INFECTION CHRONIC TION
DISEASE

RENAL (CKD)
RESPIRATORY
CARDIOVASCULAR
Koda-Kimble et al, 2013
Koda-Kimble et al, 2013
ACUTE RENAL FAILURE DRUG-INDUCED
TBC RISK FACTOR FOR DISEASE
• Once infected • Children younger
with M. than 2 y.o and
tuberculosis, a adults older than
person’s lifetime 65 y.o = 2-5x
risk of active TB higher risk.
= 10% higher.
Greatest risk
INFECTED
PEOPLE AGE
for active
disease = first
2 years after
infection PATIENT
HIV- WITH
infected IMUN
PATIENT SUPRESSI
ON • Patient with renal
• HIV-infected
patients have an failure, cancer, under
immunosuppressive
annual risk of drug treatment = 4-
active TB = 10%. 16x higher risk.
TBC RISK FACTOR FOR INFECTION
Location
 TB is most prevalent in large LOCA
urban areas, such as 7 states TION
in U.S. = CA, Florida, Georgia,
Illinois, New Jersey, NY, Texas
(McCray et al, 2006). GENHealthcare workers must “thinkPLACE
OF
 Indonesia, in 2012, DERTB” when caring for patient fromBIRTH
estimated TB incidence rates other country (Mexico, Philippines,
are 125k-299k cases (WHO, 2013).
Place of birth RISK
Vietnam, India, China) who
experience symptoms such as
 Foreign-born persons = 8.7x cough,FACTOR
fever, weight loss.
higher risk.
 More than half (56%) cases
of TB patient in 2005 are AGE RACE
foreign-born, (Mexico,
Philippines, Vietnam, India,
China) (McCray et al, 2006). ETHNI
 Close contacts with CITY
pulmonary TB patient = 30%
of infection rate (risk)
TBC RISK FACTOR FOR INFECTION
Race
LOCA
 TB rates per race = Hispanic,
blacks, and Asians  7.3,
TION
8.3, and 19.6 times higher
GEN PLACE
than whites (CDC, 2005). OF
Age DER BIRTH
 TB is most common among
people 25 to 44 years old
(35%), followed by those 45
RISK
to 64 years old (28%), 65 FACTOR
years old and older (21%) (CDC,
2005).

Gender
AGE RACE
 TB rates are similar for males
and females, but after that, Co-
the male predominance infection
increases with each decade HIV
of life (CDC, 2005).
 TBC RISK FACTOR FOR INFECTION
Co-infection with HIV
LOCA
 HIV is the most important TION
risk factor for active TB, esp
people 25 – 44 years old PLACE
(6).
GEN OF
DER BIRTH
 TB & HIV act synergistically,
making each disease worse
than it might be. RISK
 HIV coinfection may not FACTOR
increase the risk of acquiring
M. tuberculosis infection, but it AGE RACE
does increase the likelihood
of progression to active (TB)
Co-
disease infection
 Risk factor for co-infection = HIV
increase.
 MANAGEMENT
THERAPY FOR
RENAL FAILURE & TB
 DESIRED OUTCOMES
Short-term goals :
 Minimizing degree of renal failure
 Reducing extra-renal complications
 Expediting patient;s recovery of renal function
Long-term goal :
 Patient’s renal function restored to their pre-ARF
baseline.
Volume
Replacement

GENERAL Hemodynamic
Support
Adjustment of
Other Therapy
APPROACH
TO General
Approach
TREATMENT
 Therapy :
Insulin 10 IU with Dextrose 40% 50 cc

BNF 61, 2011

Dipiro et al, 2008

DRP : Dextrose concentration is lower

(40%) than suggested (50%).

Recommendation : dosage adjustment 

GDS : 96 mg/dL
Dextrose 50%.
K serum : 6,4 mEq/L
METABOLIC
ACIDOSIS UGD
 Therapy :
Bicarbonate 25 mEq (infusion) in NaCl 0,9% 500 cc
DIH 17th ed., 2008

 HCO3 = 0.2 x 50 kg x 9,6 mEq/L = 96 mEq

Condition :
metabolic
acidosis
with hyper-
kalemia
DRP : Amount of HCO 3 given is lower (25 mEq) than
suggested (50 mEq).

Recommendation : dosage adjustment  i.v Bicarbonate 50

mEq over 5 minutes, and then 1,5-2,0 mEq/kg per day for
maintenance therapy (Dipiro et al, 2008).
HCO3 : 9,6 mEq/L (N : 22-26)
pCO2 : 16 mmHg (N : 35-45)
pH : 7,01 (N : ±7,35)
METABOLIC
SO2 : 92% (N : 95-99)
BE : -8 (N: -2 to +2) ACIDOSIS UGD
 Sodium bicarbonate helps
to correct the metabolic
acidosis by raising the extra-
HCO3 bolus of infusion of 50 – 100 mEq cellular pH  rapid K+ shift
in patient hyperkalemia with metabolic
acidosis.
METABOLIC
ACIDOSIS UGD
Patient therapy : O2 NRM 6 LPM
SO2 : 92%

OXYGEN THERAPY UGD

Category : Mild hypoxia Patient therapy : O2 NRM 6 LPM
Suggestion : Nasal cannula or NRM. SO2 : 92%

Recommendation  depend on condition or

level of emergency, NRM is okay. But, in need
for flow rate adjustment.
Flow rate : adjust to 10-15 LPM.

OXYGEN THERAPY UGD

(A) Blood from
an artery is
pumped into…

(B) dialyzer where

it flows through the
cellophane tubes,
which act as the
semipermeable
Koda-Kimble et al, 2013 membrane (inset).

HEMODIALYSIS UGD
HEMODIALYSIS UGD
 TBC

Dipiro et al, 2008

KeMenKes RI-BPN-TBC, 2014

Klirens Kreatinin pasien =

22,76 mL/menit  tk. 4
DOSAGE ADJUSTMENT
Therapy : Regimen for category II TB patient
Oral anti-TB drugs (W = 50 kg), undergo therapy for 1 month.
Rifampisin po 150 mg
Isoniazid (INH) po 75 mg 3 tablet KDT sehari
Pyrazinamid po 400 mg 1 kali minum sekaligus
Etambutol po 275 mg
Injection
Streptomycin iv 750 mg

(KeMenKes RI-BPN-TBC, 2014).

R/H/Z/E TBC
DRP : Dosage & usage frequent of anti-TB drugs aren’t adjusted yet with
patient’s condition.

Recommendation : dosage adjustment for anti-TB drugs (W = 50 kg)

• Rifampisin  patien W > 50 kg = 600 mg/day
• Isoniazid (INH)  300 mg/use, 3 times a week
• Pyrazinamid  1,25 g/day, 3 times a week
• Etambutol  750 mg/day, 3 times a week
Monitor : renal function, liver function, potential & actual ADR
[see next  …]
(KeMenKes RI-BPN-TBC, 2014).

R/H/Z/E TBC
Recommendation : add Vit. B6 tablet 50 mg/day to regimen.
Anti-TB drugs (W = 50 kg), 56 day intensive therapy  undergo therapy for 1
month  26 days left.
For the next 26 days  oral anti TB drug + Streptomycin inj. + vit B6
After the next 26 days  (dosage adjustment for continued therapy based on lab
test for renal & liver function)
(KeMenKes RI-BPN-TBC, 2014).

(+) VIT. B6 TBC

Patient education :
• Use the medicines as the doctor and pharmacist said, as shown below :
• Rifampicin 600 mg a day, before meal
• Isoniazid 300 mg / use, 3 times a week
• Pyrazinamide 1,25 g / use, 3 times a week
• Etambutol, 750 mg / use, 3 times a week
• Streptomycin 750 mg / use, 3 times a week  injection  go to nearest hospital
• Vit. B6 50 mg a day, after meal
• Tell doctor right away if you have feel : dizziness, less appetite, stomach upset,
nausea or vomiting, pain in your lower chest (heartburn), flu-like symptom
without fever, severe weakness or tiredness, skin rash or itching, bruises on
your skin that you can-not explain, nosebleeds, pain in your hands or legs.
• Your urine, or saliva, or even tears, color may change into orange-red color, it’s
okay as long as it’s painless (when you’re peeing). If you feel (severe) pain when
peeing (& abnormal red-blood-like color in urine), see your doctor ASAP.
• Keeping contact with doctor and check-up per 2 week., until your doctor tells
you to stop or change the check-up schedule.

PHARMACOLOGY
THERAPY
Patient education :
• Drink a lot of water (minimal 2 L/day)
• Healthy Diet  high K+, high nutrition & fiber, low sugar & cholesterol
• Use a mask daily (outside the house, inside the house if possible/desirable)
• Separate daily activity equipment (bath & body, clothes, bed-set, dinner-set)
from family & guest (healthy people)
• Light exercise

NON-PHARMACOLOGY
THERAPY