Clinical Application of Pharmacokinetics: Basis for Rational Dose Selection in a Critically Ill Patient on Renal Replacement Therapy

2018 ◽  
Vol 44 (3) ◽  
pp. 433-436
Author(s):  
Slobodan M. Janković
2021 ◽  
Vol 10 (15) ◽  
pp. 3379
Author(s):  
Matthias Klingele ◽  
Lea Baerens

Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.


2018 ◽  
Vol 33 (3) ◽  
pp. 395-398 ◽  
Author(s):  
Patrick M. Wieruszewski ◽  
Arnaldo Lopez-Ruiz ◽  
Robert C. Albright ◽  
Jennifer E. Fugate ◽  
Erin Frazee Barreto

The objective of this study is to describe the pharmacokinetics of lacosamide in a critically ill adult during continuous venovenous hemofiltration (CVVH). A 78-year-old male developed sepsis and acute kidney injury following cardiac surgery. He was initially treated with intermittent hemodialysis but developed nonconvulsive status epilepticus at the end of the first session and was subsequently initiated on CVVH. In addition to lorazepam boluses, levetiracetam, and midazolam infusion, he was loaded with lacosamide 400 mg intravenously and started on 200 mg intravenously twice daily as maintenance therapy. Noncompartmental modeling of lacosamide pharmacokinetics revealed significant extracorporeal removal, a volume of distribution of 0.69 L/kg, elimination half-life of 13.6 hours, and peak and trough concentrations of 7.4 and 3.7 mg/L, respectively (goal trough, 5-10 mg/L). We found significant extracorporeal removal of serum lacosamide during CVVH, which was higher than previously reported. This led to subtherapeutic concentrations and decreased overall antiepileptic drug exposure. The relationship between serum lacosamide concentrations and clinical efficacy is not well understood; thus, therapeutic drug monitoring is not routinely recommended. Yet, we demonstrated that measuring serum lacosamide concentrations in the critically ill population during continuous renal replacement therapy may be useful to individualize dosing programs. Further pharmacokinetic studies of lacosamide may be necessary to generate widespread dosing recommendations.


2018 ◽  
Author(s):  
Nathan A. Vaughan ◽  
Faisal G. Qureshi

Acute kidney injury (AKI) is common in the critically ill patient, including the traumatically injured and postsurgical setting. Renal replacement therapy (RRT) provides an efficacious therapy in the management of AKI. The expanding knowledge of the technique and its challenges have propagated its application to the treatment of critically ill children. RRT utilizes diffusion and convection to manage electrolytes and toxic metabolites to maintain homeostasis. The various components of the dialysis circuit can be arranged to best address the patient’s physiologic derangements during continuous RRT. A knowledge of the anticoagulation management, circuit priming, and dosing in children is required by the intensivist to provide efficacious care. Understanding the technique for venous and peritoneal access facilitates the surgeon to safely provide a means of therapy. Peritoneal dialysis provides a means of therapy when continuous RRT is not available. As with any therapy, the complication profile determines the role of therapy. Comprehension of the associated outcomes with different pediatric pathologies will allow the surgical team to improve patient care. This review contains 5 figures, 7 tables, and 66 references. Key Words: acute renal failure, critical care, hemodialysis, pediatric, renal replacement therapy


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