复发肾病综合征合并他克莫司肾损害患者的药学监护

目的：探讨临床药师参与肾病综合征合并他克莫司肾损害患者的药学监护要点。方法：临床药师参与1例17岁男性复发性肾病综合征患者的治疗，从他克莫司的肾损害评估、免疫抑制剂治疗方案的制定、调脂药物的选择、药物间相互作用等方面提供药学监护。结果：医生采纳临床药师建议，相继停用他克莫司，加用环磷酰胺抑制免疫，调整阿托伐他汀为普伐他汀降低血脂。通过加用五酯胶囊，提高他克莫司血药浓度。患者水肿好转，24 h尿蛋白由10.96 g下降至7.80 g。结论：药学监护对促进合理用药和患者治疗能提供必要支持。

Pharmaceutical Care for a Case of Relaps Nephrotic Syndrome with Tacrolimusinduced Kidney Injury

Objective: To investigate the key points of participation of clinical pharmacists in pharmaceutical care for nephrotic syndrome with tacrolimus-induced kidney injury. Methods: Clinical pharmacists participated in therapy for a 17-year-old male patient with relaps nephrotic syndrome and gave advice on the evaluation of tacrolimus-induced kidney injury, the selection of immunosuppressive drugs therapy, drug choice for decreasing cholesterol, and drug interactions. Results: Physicians adopted the recommendations from clinical pharmacists, that cyclophosphamide instead of tacrolimus was used for immunosuppressive therapy; pravastatin instead of atorvastatin was used for decreasing cholesterol; the Wuzhi capsules was used for increasing the blood concentration of tacrolimus. Through teamwork, edema of the patient was relieved and 24 h uninary protein decreased from 10.96 g to 7.80 g. Conclusion: Pharmaceutical care can provide necessary support in rational drug use and patient care.