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Drug removal in continuous renal replacement therapy

Authors
Bruce A Mueller, PharmD, FCCP, FASN, FNKF
Thomas A Golper, MD
Section Editors
Jeffrey S Berns, MD
Paul M Palevsky, MD
Deputy Editor
Alice M Sheridan, MD

INTRODUCTION

Continuous renal replacement therapy (CRRT) is occasionally required for critically ill patients with acute kidney injury (AKI) [1]. Some, but not all, drugs are removed by CRRT. For patients treated with CRRT, it is important to understand the factors that determine drug removal to permit optimal drug dosing [2]. This is particularly true for antibiotics since subtherapeutic levels are commonly observed in patients on CRRT [3-6] and associated with antibiotic failure [3,7].

This topic reviews drug clearance and an approach to drug dosing in patients on CRRT. The general mechanisms underlying solute clearance by RRTs are discussed elsewhere. (See "Mechanisms of solute clearance and ultrafiltration in peritoneal dialysis".)

Other issues related to CRRT, including optimal prescription, and anticoagulation are discussed elsewhere. (See "Continuous renal replacement therapy in acute kidney injury (acute renal failure)" and "Anticoagulation for continuous renal replacement therapy".)

PHARMACOKINETICS OVERVIEW

The effectiveness and potential toxicity of drugs are related to their concentration. Drug concentration is determined by absorption, volume of distribution, and clearance, all which may be altered among critically ill patients [8].

In patients on CRRT, drug clearance is the sum of metabolisms and excretion by the liver and gastrointestinal tract, removal by residual renal function that may be present, and removal by RRT. Drug clearance is difficult to estimate and may change from day to day among critically ill patients, particularly as kidney function deteriorates and CRRT is initiated, and as kidney function begins to improve and CRRT is discontinued or the patient is transitioned to other RRT modalities [9-13].

               
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Literature review current through: Nov 2017. | This topic last updated: Oct 20, 2017.
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