# Chapter 23: Medications in Nephrology

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## Chapter 23: Medications in Nephrology

This chapter provides a reference for common medication classes used in nephrology, highlighting their mechanisms, uses, and key considerations.

| Medication Class | Examples | Primary Mechanism & Use | Key Clinical Pearls & Cautions |
|----|----|----|----|
| **RAAS Inhibitors** (ACEi/ARB) | Lisinopril, Losartan | Block the renin-angiotensin-aldosterone system. Used for hypertension and proteinuria to slow CKD progression. | Monitor for hyperkalemia and acute rise in creatinine (acceptable up to 30%). ACEi can cause a dry cough. |
| **SGLT2 Inhibitors** | Empagliflozin, Dapagliflozin | Block glucose reabsorption in the proximal tubule. Slows CKD progression and reduces cardiovascular events. | Causes an initial, expected dip in eGFR. Risk of euglycemic DKA and genital mycotic infections. |
| **Loop Diuretics** | Furosemide, Torsemide, Bumetanide | Inhibit Na-K-2Cl cotransporter in the thick ascending limb. Used for volume overload. | Dose needs to be increased as eGFR declines. Torsemide and bumetanide have better oral bioavailability than furosemide. |
| **nsMRAs** | Finerenone | Non-steroidal mineralocorticoid receptor antagonist. Reduces albuminuria and cardiovascular risk in diabetic kidney disease. | Lower risk of hyperkalemia compared to steroidal MRAs (spironolactone). |
| **Phosphate Binders** | Calcium Acetate, Sevelamer, Ferric Citrate | Bind dietary phosphate in the GI tract to treat hyperphosphatemia in CKD. | Must be taken with meals. Choice depends on serum calcium levels and cost (non-calcium binders are more expensive). |
| **ESAs** | Epoetin alfa, Darbepoetin alfa | Erythropoiesis-Stimulating Agents used to treat anemia of CKD. | Ensure iron stores are adequate before starting. Target hemoglobin is 10-11 g/dL to avoid increased cardiovascular risk. |

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## 📚 Sources — Chapter 20 (Medications)

1.  **Lapi F, et al.** Triple-whammy AKI risk. *BMJ.* 2013;346:e8525. [PMID: 23299844](https://pubmed.ncbi.nlm.nih.gov/23299844/).
2.  **Perazella MA, Rosner MH.** Drug-Induced AKI. *Clin J Am Soc Nephrol.* 2022;17(8):1220-1233. [PMID: 35273009](https://pubmed.ncbi.nlm.nih.gov/35273009/).
3.  **Moayyedi P, et al; COMPASS.** PPI safety. *Gastroenterology.* 2019;157(3):682-691. [PMID: 31152740](https://pubmed.ncbi.nlm.nih.gov/31152740/).
4.  **Matzke GR, et al.** Drug dosing in AKI/CKD. *Kidney Int.* 2011;80(11):1122-1137. [PMID: 21918498](https://pubmed.ncbi.nlm.nih.gov/21918498/).
5.  **Rybak MJ, et al.** Vancomycin therapeutic monitoring. *Am J Health Syst Pharm.* 2020;77(11):835-864. [PMID: 32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/).
6.  **Luther MK, et al.** Vanco + pip-tazo AKI. *Crit Care Med.* 2018;46(1):12-20. [PMID: 29088001](https://pubmed.ncbi.nlm.nih.gov/29088001/).
7.  **Muriithi AK, Nasr SH, Leung N.** Urine eosinophils for AIN. *Clin J Am Soc Nephrol.* 2013;8(11):1857-1862. [PMID: 24052222](https://pubmed.ncbi.nlm.nih.gov/24052222/).


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