Is It Safe to Use Dexamethasone 40mg in End-Stage Kidney Disease?

Q: Is It Safe to Use Dexamethasone 40mg in End-Stage Kidney Disease?

Regarding your inquiry： 1. <br>First, medications like benzodiazepines can still be used in patients with chronic kidney disease unless there is a contraindication such as hyperkalemia. <br>2. <br>Controlling blood pressure is always the primary goal in the treatment of chronic k

Is it appropriate to use Dapagliflozin 40mg in patients with end-stage renal disease (eGFR < 5)?

Hello Dr.
Wu,
Initially, I was only receiving treatment for kidney disease at Hospital A (where the doctors are relatively younger) and had stabilized for about two years.
However, my kidney function indicators, BUN and creatinine, have been gradually rising, so I sought a second opinion from a more experienced attending physician at Hospital B.
After assessing my condition, the doctor at Hospital B adjusted my antihypertensive medication by adding 40 mg of Datanwen, stating it would help protect the renal afferent arterioles.
Following the advice of the physician at Hospital B, my antihypertensive regimen is as follows: in the morning: 25 mg of Amlodipine + 40 mg of Datanwen + 30 mg of Huanmaixun, and at bedtime: 30 mg of Huanmaixun + 50 mg of Apresoline.
My blood pressure has been relatively well controlled, but my kidney function continues to decline slowly.
Recently, due to a rapid increase in creatinine levels, the doctor at Hospital A suggested that I stop taking Datanwen and switch to the following regimen: in the morning: 50 mg of Amlodipine + 30 mg of Huanmaixun + 50 mg of Apresoline, and at bedtime: 30 mg of Huanmaixun + 50 mg of Apresoline (and if my blood pressure becomes too high, I can take one 5 mg tablet of Captopril).
It has been about 10 days since I stopped taking Datanwen, but my blood pressure remains quite variable.
In the morning, I can barely maintain it around 145/90, but by the afternoon and evening, it rises to 155/100, which increases my anxiety about monitoring my blood pressure.
Therefore, I would like to ask you:
1.
Given my current kidney condition (eGFR < 5, BUN approximately 80), do you still recommend using 40 mg of Datanwen?
2.
During this period of medication adjustment, could the fluctuations in my blood pressure be more detrimental to my kidneys than when I was taking Datanwen (when my blood pressure was stable around 135/85)?
3.
Literature suggests that Captopril can rapidly lower blood pressure but also carries the risk of inadequate renal perfusion, making it unsuitable for blood pressure reduction.
Why then did the doctor at Hospital A suggest that I could take one tablet if my blood pressure is excessively high?
I would greatly appreciate any insights you could provide.
Thank you!

Niming, 20~29 year old female. Ask Date: 2020/10/10

Dr. Wu Jiyu reply Internal Medicine

Regarding your inquiry: 1.
First, medications like benzodiazepines can still be used in patients with chronic kidney disease unless there is a contraindication such as hyperkalemia.
2.
Controlling blood pressure is always the primary goal in the treatment of chronic kidney disease.
3.
Based on your mention of eGFR < 5, you should discuss renal replacement therapy with your physician to prepare in advance.
Thank you for your inquiry; the Nephrology Department at Changhua Hospital is here to support you.

Reply Date: 2020/10/10

More Info

When considering the use of Dexamethasone (often referred to as "得安穩" in Chinese) in patients with end-stage kidney disease (ESKD), it is crucial to understand both the pharmacological properties of the medication and the implications of renal impairment on its metabolism and effects.

1. Safety of Dexamethasone in ESKD: Dexamethasone is a corticosteroid that is primarily used for its anti-inflammatory and immunosuppressive properties. In patients with ESKD, the use of corticosteroids can be complex. While Dexamethasone itself is not primarily eliminated through the kidneys, its use can still have systemic effects that may complicate the management of kidney disease. In patients with severely reduced kidney function (eGFR < 5), the risk of side effects, such as fluid retention, hypertension, and electrolyte imbalances, is heightened. Therefore, while Dexamethasone can be used in ESKD, it should be done with caution and under close medical supervision.

2. Blood Pressure Management: Your concern regarding blood pressure fluctuations during the adjustment of your medication regimen is valid. Blood pressure control is critical in patients with chronic kidney disease (CKD) and ESKD, as uncontrolled hypertension can lead to further renal damage. If Dexamethasone was previously helping to stabilize your blood pressure, discontinuing it may lead to increased variability in your readings. It is essential to communicate these fluctuations to your healthcare provider, as they may need to adjust your antihypertensive medications accordingly.

3. Risks of Rapid Blood Pressure Reduction: The literature does indicate that rapid reductions in blood pressure can lead to decreased renal perfusion, particularly in patients with existing renal impairment. This is a significant concern, as it can exacerbate kidney function decline. The recommendation to use medications like "壓達能" (likely referring to a specific antihypertensive) in acute situations should be approached with caution. While it may be necessary to manage dangerously high blood pressure, the potential risks to kidney perfusion must be weighed against the benefits of immediate blood pressure control.

4. Consultation with Healthcare Providers: Given your complex medical history and current medications, it is crucial to maintain open lines of communication with your healthcare providers. They can help you navigate the risks and benefits of continuing or discontinuing Dexamethasone, as well as adjusting your antihypertensive regimen to achieve optimal blood pressure control without compromising kidney function.

In summary, while Dexamethasone can be used in patients with end-stage kidney disease, it requires careful consideration of the potential risks and benefits. Blood pressure management is paramount, and any changes in medication should be closely monitored by your healthcare team. Always consult with your physician before making any changes to your medication regimen, especially in the context of advanced kidney disease.

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