In cases where uric acid levels are significantly elevated (>750 mmol/l) the use of allopurinol (20 mg/kg . q 24 hr) may reduce hepatic uric acid production, while the administration of anabolic steroids may reduce protein catabolism. In cases of pre-renal ARF, rehydration, restoration of circulatory volume and supportive therapy may be all that is necessary. In cases of post renal obstruction, renal stones and ureteral obstructions will often have to be surgically removed before urine flow can be reestablished. In cases of toxin induced nephropathy, identification and removal of the toxin from the environment and gastric lavage may be useful. In cases of suspected aminoglycoside toxicity all drug medication should stop and osmotic diuresis instigated to maintain renal perfusion once normal hydration status has been achieved. Acute hypercalcemia (from acute vitamin D3 overdose but not breeding females) can cause ischemic acute tubular necrosis through the development of nephrocalcinosis, and in such cases prednisolone, calcitonin and diuresis should be considered. Chronic renal damage can also lead to calcium salt deposition in soft tissues including the kidney due to an elevation in the solubility index. Acute renal disease due to infectious agents should be empirically treated with broad spectrum anti microbials until culture and sensitivity results are obtained. It is important to use drugs with a large safety margin as drug metabolism and excretion may be significantly affected.
Use the combination of metformin; sitagliptin with caution in geriatric patients. Metformin is substantially excreted by the kidney and the risk of adverse reactions (including lactic acidosis) is greater in patients with reduced renal function. Because aging is associated with renal function decline, care should be taken with dose selection and titration. Sitagliptin dosing is recommended to be decreased in patients with a CrCl less than 50 mL/min. Obtain an estimated glomerular filtration rate (eGFR) at least annually in all patients taking metformin; sitagliptin. In patients at increased risk for the development of renal impairment such as geriatric patients, renal function should be assessed more frequently. Unless estimated renal function via the eGFR is determined to not be reduced, do not use metformin in geriatric patients 80 years of age and older. Generally, geriatric or debilitated patients should not be titrated up to maximum metformin dosages. Older, debilitated, or malnourished patients are also particularly susceptible to hypoglycemic effects of antidiabetic agents; monitor blood glucose frequently. The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs). According to OBRA, the use of antidiabetic medications should include monitoring (., periodic blood glucose) for effectiveness based on desired goals for that individual and to identify complications of treatment such as hypoglycemia or impaired renal function. Metformin has been associated with lactic acidosis, which is more likely to occur under the following conditions: serum creatinine of mg/dL or higher in males or mg/dL or higher in females, abnormal creatinine clearance from any cause, age of 80 years or older unless measurement of creatinine clearance verifies normal renal function, radiologic studies in which intravascular iodinated contrast materials are given, congestive heart failure requiring pharmacologic management, or acute/chronic metabolic acidosis with or without coma (including diabetic ketoacidosis).