Toxic Nephropathy

Published on 27/03/2015 by admin

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Chapter 527 Toxic Nephropathy

Aberrant renal function often results from purposeful or accidental exposure to any number of agents that are potential or actual nephrotoxins. Iodinated radiocontrast agents are generally well tolerated by most patients without significant adverse consequences. In volume-depleted patients or patients with underlying chronic kidney disease, their use poses a serious risk for the development of acute kidney injury with significant attendant morbidity and mortality. Biologic nephrotoxins include venomous exposures from insects, reptiles, amphibians, and a wide variety of sea-dwelling animals. The most common forms of toxic nephropathy unfortunately relate to the purposeful exposure of children to pharmacologic agents, accounting for close to 20% of episodes of acute kidney injury occurring in children and adolescents. Age, underlying medical condition including surgical exposure, genetics, exposure dose, and the concomitant use of other drugs all influence the likelihood of developing acute kidney injury.

Agents that commonly cause acute kidney injury and some of their clinical manifestations are summarized in Table 527-1. Mechanisms of injury often help to explain the presentation; multiple toxic exposures in patients with complicated clinical histories often limit the ability to clearly establish clinical cause and effect. For example, diminished urine output may be the clinical hallmark of tubular obstruction cause by agents such as methotrexate or agents that cause acute tubular necrosis such as amphotericin B or pentamidine. Alternatively, nephrogenic diabetes insipidus may be the critical clinical manifestation of agents that cause interstitial nephritis such as lithium or cisplatin. Nephrotoxicity is often reversible if the noxious agent is promptly removed.

Table 527-1 RENAL SYNDROMES PRODUCED BY NEPHROTOXINS

NEPHROTIC SYNDROME

Angiotensin-converting enzyme inhibitors

Gold salts

Interferon

Mercury compounds

Nonsteroidal anti-inflammatory drugs

Penicillamine

NEPHROGENIC DIABETES INSIPIDUS

Amphotericin B

Cisplatin

Colchicine