A quantitative approach to drug dosing in chronic kidney disease

Chronic kidney disease (CKD) is increasing at an alarming rate. Medication prescribing in this growing population is especially difficult. Many pharmacological agents or their metabolites are eliminated unchanged through the kidney. Drug dosing in CKD is challenging as most patients have a number of comorbid conditions. Patients with CKD take pharmacological agents with potential for drug interactions. Most patients also have alterations to the normal functioning of a number of different organs or systems (e.g. heart, liver, gastrointestinal system) which affect pharmacokinetics of commonly used drugs in CKD. Pharmacokinetic behaviors of most drugs are highly variable in patients with CKD. In addition, pharmacological management of patients with CKD is imprecise and requires estimating renal function, applying clinical judgment and, if available, therapeutic drug monitoring to provide adequate pharmacotherapeutic concentrations to optimize pharmacodynamic response while minimizing toxicities. For drugs that are removed through the renal system unchanged, a dosing modification should be considered according to patient- and drug-specific factors. Renal replacement therapy and dialysis remove pharmacologic agents extensively, and thus a replacement dose is needed to avoid therapeutic failure. By applying a quantitative approach, health care providers can improve pharmacotherapeutic outcomes while reducing adverse drug reactions.