Medication Summary
Tolvaptan (Jynarque), a selective vasopressin V2-receptor antagonist, is approved by the US Food and Drug Administration (FDA) to slow kidney function decline in adults at risk of rapidly progressive autosomal dominant polycystic kidney disease (ADPKD). [43, 42, 44]
The drugs of choice for hypertension related to ADPKD are angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). Do not treat ADPKD-related abdominal pain with nonsteroidal anti-inflammatory drugs (NSAIDs) because of their potential nephrotoxic effect.
Cyst infections require antibiotics that are gyrase inhibitors (eg, ciprofloxacin, chloramphenicol, clindamycin). Trimethoprim-sulfamethoxazole is also an effective antibiotic for reaching the inner cavity of the cyst.
Kidney failure requires drugs to maintain electrolyte levels (eg, calcium carbonate, calcium acetate, sevelamer, lanthanum carbonate, calcitriol [possibly], diuretics, blood pressure medications). Approximately 62% of patients with kidney insufficiency require at least 2 antihypertensive agents for optimal blood pressure control.
Vasopressin Antagonists
Class Summary
The selective vasopressin V2-receptor antagonist, tolvaptan, causes an increase in urine water excretion that results in an increase in free water clearance (aquaresis), a decrease in urine osmolality, and a resulting increase in serum sodium concentration.
Tolvaptan (Jynarque)
Indicated to slow kidney function decline in adults at risk of rapidly progressing autosomal dominant polycystic kidney disease (ADPKD). This indication is specific for Jynarque (ie, not Samsca) as the dosing and duration differs. Because of the potential for serious liver injury, Jynarque is available only through a restricted distribution program.
Angiotensin-Converting Enzyme Inhibitors
Class Summary
ACE inhibitors suppress the renin-angiotensin-aldosterone system.
Enalapril (Vasotec)
Enalapril is a competitive inhibitor of ACE. It reduces angiotensin II levels, decreasing aldosterone secretion.
Lisinopril (Prinivil, Zestril)
This agent prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Captopril
Captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Angiotensin II Receptor Antagonists
Class Summary
ARBs interfere with the binding of formed angiotensin II to its endogenous receptor. These agents reduce blood pressure and proteinuria, protecting renal function and delaying onset of end-stage renal disease (ESRD).
Valsartan (Diovan)
Valsartan is a prodrug that produces direct antagonism of angiotensin II receptors. It displaces angiotensin II from the AT1 receptor and may lower blood pressure by antagonizing AT1-induced vasoconstriction, aldosterone release, catecholamine release, arginine vasopressin release, water intake, and hypertrophic responses.
Valsartan may induce more complete inhibition of the renin-angiotensin system than ACE inhibitors, it does not affect response to bradykinin, and it is less likely to be associated with cough and angioedema. It is for use in patients unable to tolerate ACE inhibitors.
Losartan (Cozaar)
Losartan is an ARB that blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. It may induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors, it does not affect the response to bradykinin, and it is less likely to be associated with cough and angioedema. It is used for patients unable to tolerate ACE inhibitors.
Candesartan (Atacand)
Candesartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. It may induce more complete inhibition of renin-angiotensin system than ACE inhibitors, it does not affect response to bradykinin, and it is less likely to be associated with cough and angioedema. It is used in patients unable to tolerate ACE inhibitors.
Olmesartan (Benicar)
Olmesartan blocks the vasoconstrictor effects of angiotensin II by selectively blocking binding of angiotensin II to the AT-1 receptor in vascular smooth muscle. Its action is independent of pathways for angiotensin II synthesis.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ciprofloxacin (Cipro)
Ciprofloxacin inhibits bacterial DNA synthesis and, consequently, growth. It is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-resistant Staphylococus aureus (MRSA), S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Levofloxacin (Levaquin) overcomes many of these limitations. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Levofloxacin (Levaquin)
Levofloxacin inhibits growth of susceptible organisms by inhibiting DNA gyrase and promoting breakage of DNA strands.
Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS)
This agent inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Clindamycin (Cleocin)
Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Chloramphenicol
Chloramphenicol binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. It is effective against gram-negative and gram-positive bacteria.
Phosphate Binders
Class Summary
Administer phosphate binders to maintain phosphate levels in renal failure.
Calcium Acetate ( PhosLo, Eliphos)
Calcium acetate reduces the phosphorus load.
Lanthanum carbonate (Fosrenol)
Lanthanum is a noncalcium, nonaluminum phosphate binder indicated for reduction of high phosphorus levels in patients with ESRD. It directly binds dietary phosphorus in the upper GI tract, thereby inhibiting phosphorus absorption.
Sevelamer hydrochloride (Renagel, Renvela)
This polymeric phosphate binder for oral administration does not contain aluminum. Thus, aluminum intoxication is not a concern.
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Polycystic kidney.
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Polycystic kidney disease and massive polycystic liver disease.
