【摘要】 本文报道1例临床药师参与肾移植术后肾功能不全的罕见膀胱腺癌腹膜转移患者接受腹腔灌注治疗的个体化方案制订与药学监护过程。患者合并肾移植术后慢性肾脏病G5期，抗肿瘤治疗方案需要在疗效、肾毒性风险与合并用药安全性之间寻求平衡。临床药师全程参与，结合指南推荐与患者的病理生理特点，协助确定药物剂量，并实施用药前评估、用药过程中不良反应监护及治疗药物监测，确保患者用药安全及有效。更多还原

【Abstract】 This article reports a case in which clinical pharmacists participated in formulating an individualized treatment plan and providing pharmaceutical care for a patient with renal insufficiency following kidney transplantation who had a rare bladder adenocarcinoma with peritoneal metastasis and received intraperitoneal perfusion therapy. The patient was complicated by stage G5 chronic kidney disease post-kidney transplantation, the anti-tumor treatment plan needed to balance efficacy, renal toxicity risk, and the safety of concurrent medications. Clinical pharmacists participated in the pharmaceutical care by integrating guideline recommendations with the patient′s pathophysiological characteristics, assisting in determining drug dosage, and implementing pre-medication evaluation, adverse reaction monitoring during medication administration, and therapeutic drug monitoring to ensure the safety and effectiveness of the patient′s medication.更多还原