Medication Management in the Critically Ill Patient with Acute Kidney Injury.

Area of Science:

• Nephrology
• Critical Care Medicine
• Clinical Pharmacology

Background:

• Acute kidney injury (AKI) is common in critically ill patients.
• AKI causes significant pharmacokinetic and pharmacodynamic changes, affecting drug efficacy and safety.
• Inaccurate medication dosing in AKI can lead to treatment failure or toxicity.

Purpose of the Study:

• To highlight the challenges in medication dosing for critically ill patients with AKI.
• To discuss limitations of traditional methods for estimating kidney function in AKI.
• To emphasize the need for tailored approaches to medication management in AKI, particularly during kidney replacement therapy (KRT).

Main Methods:

• Review of pharmacokinetic and pharmacodynamic principles in AKI.
• Discussion of limitations of conventional GFR estimation equations.
• Exploration of alternative methods for assessing kidney function (e.g., urinary creatinine clearance, kinetic eGFR, novel biomarkers).
• Consideration of factors influencing drug clearance during KRT (drug properties, KRT parameters, patient factors).

Main Results:

• Conventional GFR estimation is often inaccurate in AKI patients not requiring KRT.
• Drug concentrations can be subtherapeutic or supratherapeutic in AKI.
• Drug elimination during KRT is multifactorial and evidence-based dosing guidance is often limited.
• A foundational understanding of drug elimination during KRT is essential for clinical decision-making.

Conclusions:

• Accurate medication dosing in critically ill patients with AKI requires careful consideration of altered physiology.
• Alternative methods for assessing kidney function may improve dosing accuracy.
• Managing medications during KRT necessitates understanding drug properties, KRT specifics, and patient factors.
• Continuous reassessment of therapeutic goals is vital in dynamic AKI settings.