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Barreto J, Borges C, Rodrigues TB, Jesus DC, Campos-Staffico AM, Nadruz W, Luiz da Costa J, Bueno de Oliveira R, Sposito AC. Pharmacokinetic Properties of Dapagliflozin in Hemodialysis and Peritoneal Dialysis Patients. Clin J Am Soc Nephrol 2023; 18:1051-1058. [PMID: 37227937 PMCID: PMC10564347 DOI: 10.2215/cjn.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors attenuate incident cardiovascular outcomes, irrespective of baseline GFR, in conservatively managed CKD. As this condition inexorably progresses to demanding KRT, drug withdrawal is supported by the current lack of evidence of safety of SGLT2 inhibitors in dialysis. METHODS This study was a prospective, single-center, open-label trial ( ClinicalTrials.gov identifier: NCT05343078 ) aimed at assessing the pharmacokinetic properties and safety of dapagliflozin in patients with kidney failure on regular dialysis regimens compared with those with type 2 diabetes and age- and sex-matched controls with normal kidney function. Peripheral blood samples were collected from both groups every 30 minutes for 4 hours and again after 48 hours after ingestion of dapagliflozin 10 mg, which occurred immediately before dialysis session initiation in the kidney failure group. This protocol occurred in drug-naïve patients and again after six daily doses of dapagliflozin to assess whether the drug had accumulated. The plasma and dialysate levels of dapagliflozin at each time point were determined by liquid chromatography and used to calculate pharmacokinetics parameters (peak concentration [C max ] and area under the plasma concentration-versus-time curve) for each participant. RESULTS Dapagliflozin C max was 117 and 97.6 ng/ml in the kidney failure and control groups, respectively, whereas the corresponding accumulation ratios were 26.7% and 9.5%. No serious adverse events were reported for either group. Dapagliflozin recovered from dialysate corresponded to 0.10% of the administered dose. CONCLUSIONS In patients with kidney failure on dialysis, dapagliflozin was well tolerated, was slightly dialyzable, and had nonaccumulating pharmacokinetic properties. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Pharmacokinetics and Dialyzability of Dapagliflozin in Dialysis Patients (DARE-ESKD 1), NCT05343078.
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Affiliation(s)
- Joaquim Barreto
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Cynthia Borges
- Laboratory for Evaluation of Mineral and Bone Disorders in Nephrology (LEMON), Nephrology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Tais Betoni Rodrigues
- Campinas Poison Control Center (CIATOX), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Daniel C. Jesus
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
| | | | - Wilson Nadruz
- Cardiology Division, Clinics Hospital, University of Campinas (Unicamp), Campinas, Brazil
| | - Jose Luiz da Costa
- Campinas Poison Control Center (CIATOX), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
- Faculty of Pharmaceutical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Rodrigo Bueno de Oliveira
- Laboratory for Evaluation of Mineral and Bone Disorders in Nephrology (LEMON), Nephrology Division, University of Campinas (Unicamp), Campinas, Brazil
| | - Andrei C. Sposito
- Laboratory of Atherosclerosis and Vascular Biology (Aterolab), Cardiology Division, University of Campinas (Unicamp), Campinas, Brazil
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Tsuruoka S, Endo T, Seo M, Hashimoto N. Pharmacokinetics and Dialyzability of a Single Oral Dose of Amenamevir, an Anti-Herpes Drug, in Hemodialysis Patients. Adv Ther 2020; 37:3234-3245. [PMID: 32440976 PMCID: PMC7467425 DOI: 10.1007/s12325-020-01375-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Indexed: 11/29/2022]
Abstract
Introduction Amenamevir (ASP2151), a herpesvirus helicase-primase inhibitor, is currently used for the treatment of herpes zoster in Japan. Amenamevir is mainly metabolized in the liver, and urinary excretion of amenamevir is approximately 10% in healthy adults. The increase of systemic exposure in non-dialysis patients with severe renal impairment was much less than that associated with nucleoside antiviral agents. The aim of this study was to evaluate the pharmacokinetics and dialyzability of a single oral dose (400 mg) of amenamevir in hemodialysis patients. Methods This was a single-arm, open-label, multicenter clinical pharmacology study. Nine patients aged 20–80 years with end-stage kidney disease and undergoing maintenance hemodialysis three times weekly were enrolled. Pharmacokinetics and dialyzability were investigated by serial collection of blood samples until 48 h post-dose during the study. Results The maximum plasma concentration and time to reach maximum plasma concentration during 24 h post-dose were 1585 ng/mL and 6.2 h, respectively. The area under the plasma concentration–time curve (AUC) from time zero to 24 h was 23,890 ng h/mL. The median terminal elimination half-life within 24 h before, during, and after hemodialysis was 14.7, 15.2, and 12.4 h, respectively. The AUC in hemodialysis patients was approximately double that in healthy adults. This increase in AUC was much less than that reported in nucleoside antiviral agents. The hemodialysis clearance, elimination fraction percentage, and amount of amenamevir removed were 37.8 mL/min, 28.1%, and 132.0 μg, respectively. The amount of amenamevir removed by hemodialysis was minimal. None of the hemodialysis parameters were associated with serum albumin. This study revealed no clinically relevant safety concerns. Conclusion There were no clinically relevant safety concerns when 400 mg of amenamevir was administered as a single dose to hemodialysis patients without dose adjustment and/or modification of the dosing schedule. Trial Registration JapicCTI-184242. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01375-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Takamasa Endo
- Clinical Development Department, Maruho Co., Ltd., Kyoto, Japan.
| | - Mizuna Seo
- Clinical Development Department, Maruho Co., Ltd., Kyoto, Japan
| | - Naoto Hashimoto
- Drug Development Research Laboratory, Maruho Co., Ltd., Kyoto, Japan
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Abstract
Renal failure delays elimination of many drugs thus prolonging their half lives. By knowing the half life and distribution volume, one can estimate total plasma clearance. When measured values have not been reported, endogenous total plasma clearance can be estimated and compared with peritoneal clearance to determine the effect of CAPD on half life. When peritoneal clearance has not been reported, it can be estimated knowing molecular mass and unbound plasma fraction. Such estimates suggest that elimination kinetics of most drugs are not appreciably affected by CAPD. Compared to those of untreated anuric patients, plasma levels of carbenicillin, ticarcillin, some cephalosporins, all aminoglycosides, vancomycin, sfluorocytosine, amantadine, atenolol, sotalol, timolol, chlorpropamide, theophylline and lithium may be reduced somewhat by CAPD. Thus one should monitor plasma levels of these agents to insure therapeutic concentrations rather than simply following the dosage guidelines for anuric patient.
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Affiliation(s)
- John F. Maher
- From the Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814–4799
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Basile JK, Vigani A. Treatment of phenobarbital intoxication using hemodialysis in two dogs. J Vet Emerg Crit Care (San Antonio) 2020; 30:221-225. [PMID: 31975513 DOI: 10.1111/vec.12908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/21/2018] [Accepted: 03/22/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To describe the use of hemodialysis in 2 dogs with severe clinical signs from phenobarbital intoxication. SERIES SUMMARY Two dogs ingested a toxic dose of phenobarbital, leading to severe neurological dysfunction and a comatose state. Both dogs received a 3-hour session of hemodialysis with complete resolution of clinical signs and returned to normal mentation by the end of the therapy. No negative side effects occurred and phenobarbital concentrations returned to therapeutic range during treatment. NEW INFORMATION PROVIDED This is the first report on the utility and safety of using hemodialysis for phenobarbital intoxication in dogs.
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Affiliation(s)
- Jessica Kielb Basile
- Emergency and Critical Care Service, North Carolina State Veterinary Hospital, Raleigh, NC
| | - Alessio Vigani
- Emergency and Critical Care Service, North Carolina State Veterinary Hospital, Raleigh, NC
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Palmer K, Walker S, Richardson R, Jassal SV, Battistella M. Pharmacokinetic Study of Cefazolin in Short Daily Hemodialysis. Ann Pharmacother 2018; 53:348-356. [DOI: 10.1177/1060028018809695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: A number of centers across the world offer short daily hemodialysis (SDHD) treatments. To date, cefazolin pharmacokinetics have not been described in patients undergoing SDHD. Objective: The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics of cefazolin. Methods: This was a prospective, open-label, pharmacokinetic study of cefazolin during SDHD in 10 noninfected patients. Participants received a 1-g intravenous (IV) infusion of cefazolin after SDHD on study day 1 and a second dose after SDHD on study day 2. To determine the concentration of cefazolin, 6 blood samples were drawn at 0, 1, 2, 2.3, 4, and 24 hours after initiation of dialysis on day 2, and 2 dialysate samples were drawn at 1 and 2 hours after initiation of dialysis on day 2. Samples were analyzed using high-performance liquid chromatography, and pharmacokinetic parameters were determined. Results: Median interdialysis clearance was 0.16 L/h (interquartile range [IQR]: 0.11-0.21 L/h), and median intradialysis clearance was 1.95 L/h (IQR: 1.66-2.45 L/h). Median interdialysis half-life was 28.2 hours (IQR: 23.5-59.3 hours) as compared with a median intradialysis half-life of 2.3 hours (IQR: 1.7-2.7 hours). The median percentage removal of cefazolin during dialysis was 41% (IQR: 35%-53%). Conclusion and Relevance: Estimated cefazolin dialysis clearance is similar to previous estimates with conventional thrice-weekly regimens. Current dosing recommendations of 1 g IV post-SDHD achieve total serum drug concentrations greater than 40 mg/L in all patients, which is the total drug concentration required for bactericidal activity against Staphylococcus species.
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Affiliation(s)
- Katie Palmer
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Scott Walker
- University of Toronto, Toronto, ON, Canada
- Sunnybrook & Women’s College Health Sciences Centre, Toronto, ON, Canada
| | - Robert Richardson
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Sarbjit V. Jassal
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Marisa Battistella
- University Health Network, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Hernandez SH, Howland M, Schiano TD, Hoffman RS. The pharmacokinetics and extracorporeal removal of N-acetylcysteine during renal replacement therapies. Clin Toxicol (Phila) 2015; 53:941-9. [PMID: 26484583 DOI: 10.3109/15563650.2015.1100305] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Acetaminophen-induced fulminant hepatic failure is associated with acute kidney injury, metabolic acidosis, and fluid and electrolyte imbalances, requiring treatment with renal replacement therapies. Although antidote, acetylcysteine, is potentially extracted by renal replacement therapies, pharmacokinetic data are lacking to guide potential dosing alterations. We aimed to determine the extracorporeal removal of acetylcysteine by various renal replacement therapies. METHODS Simultaneous urine, plasma and effluent specimens were serially collected to measure acetylcysteine concentrations in up to three stages: before, during and upon termination of renal replacement therapy. Alterations in pharmacokinetics were determined by applying standard pharmacokinetic equations. RESULTS Over 2 years, 10 critically ill patients in fulminant hepatic failure requiring renal replacement therapy coincident with acetylcysteine were consecutively enrolled. All 10 patients required continuous venovenous hemofiltration (n = 10) and 2 of the 10 also required hemodialysis (n = 2). There was a significant alteration in the pharmacokinetics of acetylcysteine during hemodialysis; the area under the curve (AUC) decreased 41%, the mean extraction ratio was 51%, the mean hemodialytic clearance was 114.01 ml/kg/h, and a mean 166.75 mg/h was recovered in the effluent or 41% of the hourly dose. Alteration in the pharmacokinetics of acetylcysteine during continuous venovenous hemofiltration did not appear to be significant: the AUC decreased 13%, the mean clearance was 31.77 ml/kg/h and a mean 62.12 mg/h was recovered in the effluent or 14% of the hourly dose. CONCLUSIONS There was no significant extraction of acetylcysteine from continuous venovenous hemofiltration. In contrast, there was significant extracorporeal removal of acetylcysteine during hemodialysis. A reasonable dose adjustment may be to double the IV infusion rate or possibly supplement with oral acetylcysteine during hemodialysis.
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Affiliation(s)
- Stephanie H Hernandez
- a Division of Medical Toxicology, Department of Emergency Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Maryann Howland
- b St. John's University College of Pharmacy and Health Sciences , Queens , NY , USA.,c New York City Poison Control Center, New York City Department of Health , New York , NY , USA.,d Division of Medical Toxicology, Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA
| | - Thomas D Schiano
- e Division of Liver Diseases, Department of Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Robert S Hoffman
- c New York City Poison Control Center, New York City Department of Health , New York , NY , USA.,d Division of Medical Toxicology, Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA
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Yamamoto J, Toublanc N, Kumagai Y, Stockis A. Levetiracetam pharmacokinetics in Japanese subjects with renal impairment. Clin Drug Investig 2015; 34:819-28. [PMID: 25312351 DOI: 10.1007/s40261-014-0237-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVE The anti-epileptic drug levetiracetam is excreted renally. The objective of this trial was to evaluate the pharmacokinetics of levetiracetam in Japanese patients with renal impairment including end-stage renal disease (ESRD) to confirm that existing dosing instructions-based on data from European patients-are appropriate in a Japanese population. METHODS This was a nonrandomised, open-label trial. Six participants were allocated to each of five groups (normal renal function, mild, moderate and severe renal impairment and ESRD); 30 participants in total. Participants received a single dose of levetiracetam 500 mg (normal or mild), 250 mg (moderate or severe), or 500 mg followed by 250 mg post-haemodialysis (ESRD). Blood and urine samples were obtained serially for levetiracetam and metabolite determinations. Noncompartmental pharmacokinetic parameters were calculated and steady-state profiles were simulated using the superposition method. RESULTS In this trial, levetiracetam total clearance decreased proportionally with creatinine clearance: 52, 31, 25, 20 and 11 mL/min/1.73 m(2) in healthy controls and in patients with mild, moderate, severe renal impairment, and ESRD, respectively. Simulated levetiracetam plasma profiles using the recommended dose adjustments were within the range for normal renal function. Overall, results from this trial were consistent with historical European data. CONCLUSION These findings confirm that the dosing instructions are appropriate for Japanese patients with renal impairment including ESRD.
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Affiliation(s)
- Junichi Yamamoto
- UCB Pharma, Shinjuku Grand Tower, 8-17-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan,
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Abstract
The first article in this series discussed the cephalosporin antibiotic agents as a class, including the similarities in their structure, antimicrobial action, and toxicity. Part II focuses on the difference between commercially available first- and second-“generation” agents.The cephalosporins are classified using various criteria, including vulnerability to beta-lactamase hydrolysis and antibacterial activity. The latter classification is based on the in vitro activity of the individual agents, with each succeeding “generation” possessing a greater spectrum of activity than the previous generation(s).
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Türck D, Weber W, Sigmund R, Budde K, Neumayer HH, Fritsche L, Rominger KL, Feifel U, Slowinski T. Pharmacokinetics of Intravenous, Single-Dose Tiotropium in Subjects with Different Degrees of Renal Impairment. J Clin Pharmacol 2013; 44:163-72. [PMID: 14747425 DOI: 10.1177/0091270003261315] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tiotropium, a new potent anticholinergic bronchodilator, is excreted mainly by the kidney. To investigate the pharmacokinetics of tiotropium in renal impairment, the authors evaluated the pharmacokinetics and safety after administration of a single dose of intravenous tiotropium 4.8 microg, given as an infusion over 15 minutes in subjects with normal renal function and a wide range of renal impairment based on measured creatinine clearance (normal: > 80 mL/min, n = 6; mild impairment: > 50-80 mL/min, n = 5; moderate impairment: 30-50 mL/min, n = 7; severe impairment: < 30 mL/min, n =6). As expected for a drug excreted predominantly in unchanged form by the kidneys, tiotropium plasma concentrations increased as renal impairment worsened, with mean values of 55.5 (16.2 percent geometric coefficient of variation [%gCV]), 77.1 (20.1 %gCV), 101 (29.8 %gCV), and 108 (27.3 %gCV) pgh/mL for AUC(0-4h) in the normal renal function and the mild, moderate, and severe renal impairment groups, respectively. The percentage of tiotropium dose excreted unchanged in the urine decreased from 60.1% of dose (17.7 %gCV) to 59.3% (14.4 %gCV), 39.9% (34.5 %gCV), and 37.4% (10.2 %gCV) in the normal renal function and the mild, moderate, and severe renal impairment groups, respectively. Plasma protein binding of tiotropium did not significantly change in the renal-impaired subjects. Two subjects with normal renal function experienced headache 10 hours after the infusion, which was mild and transient. No adverse events occurred in subjects with renal impairment. There were no clinically relevant changes in blood pressure, pulse rate, 12-lead ECG, physical examination, hematology, or clinical chemistry, compared with baseline values, in any subject after intravenous administration of tiotropium. Tiotropium should only be used in patients with moderate to severe renal insufficiency if the potential benefit outweighs the potential risks.
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Affiliation(s)
- Dietrich Türck
- Drug Metabolism and Pharmacokinetics Department, Boehringer Ingelheim Pharma GmbH & Co KG, Birkendorfer Strasse 65, 88397 Biberach an der Riss, Germany
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Tortorici MA, Cutler D, Zhang L, Pfister M. Design, conduct, analysis, and interpretation of clinical studies in patients with impaired kidney function. J Clin Pharmacol 2012; 52:109S-18S. [PMID: 22232746 DOI: 10.1177/0091270011416364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic kidney disease has been shown to alter the pharmacokinetics of drugs that are eliminated not only via the renal pathway but also by metabolism or nonrenal transport. Guidance documents from regulatory agencies on the pharmacokinetics of drugs in patients with impaired kidney function provide a framework for facilitating study design, conduct, data analysis, and the generation of dosing recommendations. Design considerations include establishment of appropriate enrollment criteria, selection of appropriate matched control group(s), and staging of impaired kidney function by estimated glomerular filtration rate or creatinine clearance. When studies in hemodialysis patients are conducted, optimizing the timing of characterization of the pharmacokinetics profile based on the schedule of hemodialysis sessions will allow for a robust assessment in these patients. In addition to traditional noncompartmental approaches, the use of pharmacometric approaches can integrate data from multiple clinical studies and provide a quantitative rationale for dose selection in patients with impaired kidney function. This article addresses the challenges and opportunities associated with the design, conduct, analysis, and interpretation of clinical studies to allow for their future facilitation and for the establishment of safe and efficacious dosing in patients with impaired kidney function.
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Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:1122-37. [PMID: 21918498 DOI: 10.1038/ki.2011.322] [Citation(s) in RCA: 291] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Drug dosage adjustment for patients with acute or chronic kidney disease is an accepted standard of practice. The challenge is how to accurately estimate a patient's kidney function in both acute and chronic kidney disease and determine the influence of renal replacement therapies on drug disposition. Kidney Disease: Improving Global Outcomes (KDIGO) held a conference to investigate these issues and propose recommendations for practitioners, researchers, and those involved in the drug development and regulatory arenas. The conference attendees discussed the major challenges facing drug dosage adjustment for patients with kidney disease. In particular, although glomerular filtration rate is the metric used to guide dose adjustment, kidney disease does affect nonrenal clearances, and this is not adequately considered in most pharmacokinetic studies. There are also inadequate studies in patients receiving all forms of renal replacement therapy and in the pediatric population. The conference generated 37 recommendations for clinical practice, 32 recommendations for future research directions, and 24 recommendations for regulatory agencies (US Food and Drug Administration and European Medicines Agency) to enhance the quality of pharmacokinetic and pharmacodynamic information available to clinicians. The KDIGO Conference highlighted the gaps and focused on crafting paths to the future that will stimulate research and improve the global outcomes of patients with acute and chronic kidney disease.
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Daptomycin pharmacokinetics in critically ill patients receiving continuous venovenous hemodialysis. Crit Care Med 2011; 39:19-25. [PMID: 20890189 DOI: 10.1097/ccm.0b013e3181fa36fb] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate daptomycin pharmacokinetics in critically ill patients receiving continuous venovenous hemodialysis to develop dosing recommendations. DESIGN Prospective, open-label pharmacokinetic study. SETTING : Intensive care units located within a teaching medical center. PATIENTS Eight adults with known/suspected Gram-positive infections receiving continuous venovenous hemodialysis and daptomycin. INTERVENTIONS Daptomycin at 8 mg/kg intravenously over 30 mins. Serial blood and effluent samples were collected over the next 48 hrs. Daptomycin protein binding was determined by equilibrium dialysis. Daptomycin continuous venovenous hemodialysis transmembrane clearance was determined by dividing daptomycin effluent by serum concentrations and multiplying by mean effluent production rate for each subject. Equations describing a two-compartment, open-pharmacokinetic model were fitted to each subject's daptomycin concentration-time data and pharmacokinetic parameters were determined by standard methods. Serum concentration-time profiles were simulated for two daptomycin regimens (8 mg/kg every 48 hrs and 4 mg/kg every 24 hrs). MEASUREMENTS AND MAIN RESULTS A total of 7.7 ± 0.6 mg/kg (mean ± sd) of daptomycin was administered, resulting in an observed peak concentration of 81.2 ± 19.0 μg/mL. Daptomycin steady-state volume of distribution (0.23 ± 0.14 L/kg) and free fraction (17.5% ± 5.0%) were increased in critically ill subjects receiving continuous venovenous hemodialysis compared with previous values reported in healthy volunteers. Daptomycin transmembrane clearance (6.3 ± 2.9 mL/min) accounted for more than half of total clearance (11.3 ± 4.7 mL/min). Simulations demonstrated 8 mg/kg daptomycin every 48 hrs would result in higher peak (88.8 ± 20.0 μg/mL vs. 53.0 ± 12.3 μg/mL) and lower trough concentrations (7.2 ± 5.2 μg/mL vs. 12.3 ± 5.1 μg/mL) than 4 mg/kg every 24 hrs. CONCLUSIONS Daptomycin at 8 mg/kg every 48 hrs in critically ill patients receiving continuous venovenous hemodialysis resulted in good drug exposure, achieved high peak concentrations to maximize daptomycin's concentration-dependent activity, and resulted in trough concentration that would minimize the risk of myopathy. CLINICALTRIALS.GOV IDENTIFIER: NCT00663403.
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Pharmacokinetics. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e3181f0c12a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Renal replacement therapies (RRT) are increasingly used for the treatment of acute and chronic kidney diseases as well as intoxications and accidental drug overdoses. These therapies offer a mechanism for the removal of toxic substances from the patient's blood and supplement the standard detoxification protocols. If instituted early, RRT can have a significant effect on the course of the toxicity; however, this process is not selective for the removal of only harmful products and can also result in the clearance of medications intended for therapeutic use.
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Abstract
Critically ill patients with multisystem organ failure often require daily administration of large volumes of fluid to provide electrolyte and nutrition support, medications, and blood products. This often results in fluid overload, which has historically been managed with intermittent hemodialysis (IHD). Unfortunately, IHD entails a high rate of fluid and solute removal that often exacerbates hemodynamic instability. Accordingly, continuous renal replacement therapy (CRRT), involving slow and continuous removal of water and solutes from the plasma, is currently preferred for managing these patients.
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Affiliation(s)
- G M Susla
- Medical Information, MedImmune, Inc., Frederick, Maryland, USA.
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Atkinson AJ, Umans JG. Pharmacokinetic Studies in Hemodialysis Patients. Clin Pharmacol Ther 2009; 86:548-52. [DOI: 10.1038/clpt.2009.147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Czock D, Rasche FM, Boesler B, Shipkova M, Keller F. Irinotecan in Cancer Patients with End-Stage Renal Failure. Ann Pharmacother 2009; 43:363-9. [DOI: 10.1345/aph.1l511] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objective: To observe and report on the pharmacokinetics of irinotecan in a patient with end-stage renal failure (ESRF) who was undergoing hemodialysis. Case Summary: A 64-year-old man with metastatic colorectal cancer who was on hemodialysis was treated with Irinotecan 50 mg/m2 weekly for 3 weeks, followed by 1 week with no treatment. As the drug was well tolerated, the dosage was increased to 80 mg/m2 after 2 cycles. Diagnostic testing of a hepatic lesion after 2 and 6 treatment cycles showed stable disease. The carcinoembryonic antigen value decreased to 40% of its pretreatment level. Pharmacokinetically, our patient had a lower apparent clearance and a higher maximum concentration of the active metabolite SN-38 (130 L/h/m2, maximum concentration 0.4 μg/L per mg of irinotecan) compared with published values from patients with normal renal function. Removal of irinotecan and its metabolites by hemodialysis was negligible. Discussion: The reason for the unexpectedly low clearance of SN-38 in our patient remains unclear. We speculate that inhibition of the OATP1B1 transporter by uremic toxins could be an explanation. Such a mechanism would explain excessive irinotecan toxicity, as reported in previous case reports of patients undergoing hemodialysis. Conclusions: We conclude that approximately two-thirds of the standard weekly irinotecan dosage regimen should be considered in patients with ESRF.
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Affiliation(s)
- David Czock
- Senior Physician, University Hospital Heidelberg, Heidelberg, Germany
| | - Franz Maximilian Rasche
- Clinical Specialist, Medical Department I, Division of Nephrology, University Hospital Ulm, Ulm, Germany
| | - Benjamin Boesler
- Clinical Specialist, Medical Department I, Division of Nephrology, University Hospital Ulm
| | - Maria Shipkova
- Head of the Laboratory, Laboratory for Therapeutic Drug Monitoring and Clinical Toxicology, Central Institute of Clinical Chemistry and Laboratory Medicine, Stuttgart Hospital, Stuttgart, Germany
| | - Frieder Keller
- Nephrology, Head of Division, Medical Department I, Division of Nephrology, University Hospital Ulm
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Isla A, Maynar J, Sánchez-Izquierdo JA, Gascón AR, Arzuaga A, Corral E, Pedraz JL. Meropenem and continuous renal replacement therapy: in vitro permeability of 2 continuous renal replacement therapy membranes and influence of patient renal function on the pharmacokinetics in critically ill patients. J Clin Pharmacol 2006; 45:1294-304. [PMID: 16239363 DOI: 10.1177/0091270005280583] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pharmacokinetics of meropenem were characterized in 20 patients with different degrees of renal function who underwent continuous renal replacement therapy. Previously, no differences were detected in vitro in the removal of meropenem by continuous venovenous hemofiltration or continuous venovenous hemodialysis or when AN69 or polysulfone membranes were compared. In patients, no significant differences in the sieving coefficient or the saturation coefficient with the renal function were found, and the mean sieving coefficient/saturation coefficient value (0.80 +/- 0.12) was similar to the unbound fraction (0.79 +/- 0.08). An increase in total clearance and a decrease in elimination half-life were observed to the extent that the patient's creatinine clearance was higher. Likewise, the contribution of continuous renal replacement therapy to total clearance diminished in patients with less renal impairment. The results suggest that the renal function of the patient may influence meropenem pharmacokinetics during continuous renal replacement therapy. The lower trough plasma levels observed in nonrenal patients would not lead to adequate time during which serum drug concentrations are above the minimum inhibitory concentration values in many infections.
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Affiliation(s)
- Arantxazu Isla
- Laboratory of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
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21
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Isla A, Gascón AR, Maynar J, Arzuaga A, Toral D, Pedraz JL. Cefepime and continuous renal replacement therapy (CRRT): In vitro permeability of two CRRT membranes and pharmacokinetics in four critically ill patients. Clin Ther 2005; 27:599-608. [PMID: 15978309 DOI: 10.1016/j.clinthera.2005.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2005] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cefepime is a fourth-generation cephalosporin with a broad spectrum of antimicrobial activity against gram-positive and gram-negative micro-organisms. It is a useful option for treating infections in critically ill patients in intensive care due to its high degree of activity and its tolerability. OBJECTIVE The aim of this study was to characterize in vitro the permeability to cefepime of 2 membranes frequently used in continuous renal replacement therapies (CRRTs). An in vivo study was also carried out to determine the pharmacokinetics of cefepime in critically ill patients undergoing CRRT. METHODS In vitro procedures were conducted in 3 different fluids using polyacrylonitrile (AN69) or polysulfone (PS) membranes. Continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodialysis (CVVHD) were simulated. Four male patients undergoing CVVH or continuous venovenous hemodiafiltration, who received 2000 mg of cefepime intravenously every 8 hours, entered the in vivo study. Prefilter and ultrafiltrate samples were collected, and concentrations of cefepime were measured using high-performance liquid chromatography. The sieving coefficient (Sc), defined as the fraction of drug eliminated across the membrane, and the saturation coefficient (Sa), defined as the fraction of drug diffused through the membrane to the dialysate fluid, were analyzed. Pharmacokinetic parameters were determined according to a noncompartmental analysis. RESULTS The patients ranged in age from 18 to 75 years and weighed from 65 to 80 kg. By analyzing Sc and Sa values in the in vitro procedures, no differences were detected in the permeability of AN69 or PS membranes to cefepime in CVVH or CVVHD. Sc/Sa values were between 0.93 and 1.03 in Ringer's lactate and in bovine albumin-containing Ringer's lactate samples, but Sc/Sa values were lower in plasma samples (0.82-0.95). In the in vivo portion of the study, the patients' mean (SD) Sc/Sa value was 0.76 (0.21) and correlated well with the fraction unbound to proteins (0.79 [0.09]). Clearance by CRRT (mean [SD]) was 29.0 (16.8)% of the total clearance. Serum elimination t(1/2) was 4.6 (0.9) hours, and the volume of distribution at steady state was 0.6 (0.3) L/kg (mean [SD] values). CONCLUSIONS Cefepime was significantly removed by CRRT. No significant differences were found in the Sc or Sa of cefepime between AN69 and PS membranes used in the CVVH or CVVHD procedures. The clearance of cefepime by CRRT must be considered when dosing critically ill patients.
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Affiliation(s)
- Arantxazu Isla
- Laboratory of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of the Basque Country, Vitoria-Gasteiz, Spain
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22
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Grossman EB, Swan SK, Muirhead GJ, Gaffney M, Chung M, DeRiesthal H, Chow D, Raij L. The pharmacokinetics and hemodynamics of sildenafil citrate in male hemodialysis patients. Kidney Int 2005; 66:367-74. [PMID: 15200445 DOI: 10.1111/j.1523-1755.2004.00739.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Erectile dysfunction (ED) is highly prevalent in men with renal disease. The clearance of sildenafil citrate, a highly effective oral treatment for ED, is decreased in men with severe renal insufficiency, but the pharmacokinetic and hemodynamic profiles during maintenance hemodialysis in men with end-stage renal disease have not been studied. METHODS Fifteen men undergoing chronic outpatient maintenance hemodialysis received a single 50-mg oral dose of sildenafil on 2 occasions, once 2 hours before, and once 2 hours after hemodialysis, with randomized assignment to sequence. Blood and dialysate samples were collected, and hemodynamic measurements were made. RESULTS Hemodialysis did not significantly clear either sildenafil or its primary metabolite, UK-103,320. Administration after hemodialysis was associated with a 17% higher peak plasma concentration and earlier time to peak, which were not clinically meaningful, whereas the overall extent of absorption and the elimination half-life were not affected. The average extent of drug bound to plasma protein was approximately 96% in hemodialysis patients. Intradialytic hypotension was not observed more frequently when sildenafil was administered before hemodialysis. Systolic blood pressure tended to decrease less during hemodialysis when subjects were treated with sildenafil before dialysis. CONCLUSION The present study demonstrates that sildenafil is not cleared by hemodialysis, and the pharmacokinetic profile resembles more closely that observed in normal volunteers than that observed in patients with severe renal insufficiency. In addition, we found that sildenafil does not promote intradialytic hypotension.
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23
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Kambia NK, Dine T, Odou P, Bah S, Azar R, Gressier B, Dupin-Spriet T, Luyckx M, Brunet C. Pharmacokinetics and dialysability of naltrexone in patients undergoing hemodialysis. Eur J Drug Metab Pharmacokinet 2004; 29:225-30. [PMID: 15726882 DOI: 10.1007/bf03190603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The disposition of naltrexone (NLT) (REVIA), an opioid antagonist intended for patients with impaired renal function and with severe intractable itching refractory to regular antipruritic therapy, was characterized. Hemodialysis effects on both efficacy and elimination of NLT also were assessed. We developed a simple, sensitive and selective reverse-phase high-performance liquid chromatographic (HPLC) method for measuring NLT plasma concentration in hemodialysis patients treated to relieve pruritus. NLT and the internal standard, naloxone (NLX) were extracted from plasma using a solid-phase extraction method with sep-pack C18 cartridge. The method was employed to determine both naltrexone pharmacokinetics and dialysability parameters during 4-h in dialyzed patients with chronic renal impairment. Thus, seven patients (2 men, 5 women) with end-stage renal disease and pruritus on regular hemodialysis were included. They received one tablet of NLT (Revia, 50 mg) orally prior dialysis session. The Cmax at the inlet and at the outlet the dialyzer were higher (255+/-117 ng/mL and 206+/-137 ng/ml respectively) in comparison with healthy subjects (9 - 44 ng/mL). The decrease hepatic first-pass metabolism of NLT consecutive to end-stage renal disease and the renal impairment could explain the increased levels of the drug in plasma. Tmax before and after dialysis plates remain unchanged as healthy subjects (approximately 1h). With regard to dialysability, a high dialyzer extraction ratio averating 30 % was found with a low dialysis clearance of 58.70+/-17 mL/min. The amount removed by dialysis is only 1.27 mg. We concluded that hemodialysis has little effect on NLT blood levels, and consequently on drug pharmacokinetics, when the drug is delivered to dialyzed patients following oral route. Thus, dosage adjustement is not required in the presence of advanced dialysis-dependant renal failure. In patients with end-stage renal disease, hemodialysis does not result in clinically significant alterations in the disposition of NLT. Post-dialysis supplementation is not required. These data suggest that there is no pharmacokinetic basis for modification of the initial dosage, but in view of NLT plasma concentration levels in the patients, a clinician could determine whether dosage adjustment are necessary and, if so, make the required calculations accurately.
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Affiliation(s)
- Nicolas K Kambia
- Pharmacology, Pharmacokinetic and Clinical Pharmacy Department, Faculty of Pharmaceutical and Biological Sciences, France
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24
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Tomita M, Aoki Y, Tanaka K. Effect of haemodialysis on the pharmacokinetics of antineoplastic drugs. Clin Pharmacokinet 2004; 43:515-27. [PMID: 15170366 DOI: 10.2165/00003088-200443080-00002] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Since renal failure itself creates an immunocompromised situation, malignant tumours in haemodialysis patients are increasing due to the prolonged lifespan of these patients. In treating these patients with anticancer agents, dosage reduction is often recommended to avoid adverse drug reactions, particularly for drugs with extensive renal excretion. On the other hand, if an anticancer drug is removed significantly by haemodialysis, dosage increase would be required to ensure adequate therapeutic efficacy. We address in this review the clinical pharmacokinetic aspects of antineoplastic therapy, and the application of pharmacokinetic principles to the adjustment of dosage of anticancer agents in haemodialysis patients.
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Affiliation(s)
- Masatoshi Tomita
- Division of Obstetrics and Gynecology, Niigata Prefectural Tokamachi Hospital, Niigata, Japan.
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25
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Ijiri Y, Inoue T, Fukuda F, Suzuki K, Kobayashi T, Shibahara N, Takenaka H, Tanaka K. Dialyzability of the Antiepileptic Drug Zonisamide in Patients Undergoing Hemodialysis. Epilepsia 2004; 45:924-7. [PMID: 15270757 DOI: 10.1111/j.0013-9580.2004.30603.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The influence of hemodialysis on plasma zonisamide (ZNS) concentration has not been clarified. In this study, the dialyzability of ZNS during hemodialysis was investigated in four ZNS-treated women with systemic lupus erythematosus complicated by seizures. METHODS The total and unbound plasma concentrations of ZNS were measured before and after hemodialysis. The concentration of ZNS in the spent dialysate also was determined. RESULTS The reduction in plasma ZNS concentration after a 4.5-h hemodialysis was 52.0 +/- 7.6%, and the dialyzer (BLF-16GW) clearance of ZNS was 55.1 +/- 7.0 ml/min. Dosage was gradually increased up to 200 to 500 mg/day, and the seizures were controlled satisfactorily. CONCLUSIONS The plasma concentration of ZNS was reduced by approximately 50% during one session of dialysis. For patients undergoing daytime hemodialysis sessions every 2 or 3 days, the usual dosage of ZNS (4-8 mg/kg/day) may be prescribed once a day in the evening. If seizures occur after hemodialysis, a supplemental daily dose may be prescribed in the morning.
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Affiliation(s)
- Yoshio Ijiri
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
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26
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Hirata S, Uenishi K, Izumi S, Furukubo T, Ota M, Fujita M, Yamakawa T, Ohtani H, Sawada Y. Various Dosing Weights and Correction to Serum Digoxin Assays in Hemodialysis Patients. J Pharm Technol 2004. [DOI: 10.1177/875512250402000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Digoxin is distributed in skeletal muscles in high concentrations. The most reliable parameter to measure the distribution of digoxin in patients undergoing hemodialysis is not known. Objective: To estimate which distribution parameter—estimated lean body mass (E-LBM) calculated by subtracting the fat mass from the dry weight, lean body mass, dry weight, and ideal body weight—is the most reliable predictor for assessing the accuracy of a digoxin dosing regimen in patients undergoing hemodialysis. Methods: A retrospective study was conducted to evaluate 21 patients undergoing hemodialysis who were administered digoxin. The patients were divided into 2 groups: digoxin 0.125 mg administered twice a week (low-dose group) or 3 times per week (high-dose group). The differences between E-LBM, lean body mass, dry weight, and ideal body weight for the low- and high-dose groups were determined. The relationships between serum digoxin concentrations and the weekly digoxin dose per E-LBM, lean body mass, dry weight, and ideal body weight were also determined. Results: E-LBM, lean body mass, dry weight, and ideal body weight in the high-dose group were significantly larger than those in the low-dose group (p = 0.021, 0.015, 0.024, and 0.0029, respectively), although no significant difference in serum digoxin concentrations was evident. Significant correlation was found between serum digoxin concentrations and the weekly digoxin dosage per E-LBM, dry weight, lean body mass, and ideal body weight (r = 0.746, p < 0.0001; r = 0.638, p = 0.0014; r = 0.645, p < 0.0011; r = 0.553, p = 0.0083, respectively). Conclusions: E-LBM appears to reflect the best parameter for predicting serum digoxin concentrations. The use of the dry weight parameter could be generally useful for adjusting the dosage of digoxin in patients undergoing hemodialysis.
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Affiliation(s)
- Sumio Hirata
- SUMIO HIRATA BSc, Pharmacist, Director, Department of Laboratory and Pharmacy Services, Shirasagi Hospital, Osaka, Japan
| | - Koji Uenishi
- KOJI UENISHI MSc, Pharmacist, Department of Pharmacy, Aino Hospital, Osaka
| | - Satoshi Izumi
- SATOSHI IZUMI BSc, Pharmacist, Director, Department of Pharmacy Service, Shirasagi Hospital
| | - Taku Furukubo
- TAKU FURUKUBO MSc, Pharmacist, Department of Pharmacy Service, Shirasagi Hospital
| | - Miyuki Ota
- MIYUKI OTA BSc, Pharmacist, Department of Pharmacy Service, Shirasagi Hospital
| | - Minori Fujita
- MINORI FUJITA BSc, Pharmacist, Department of Pharmacy Service, Shirasagi Hospital
| | - Tomoyuki Yamakawa
- TOMOYUKI YAMAKAWA MD, President, Department of Medicine, Shirasagi Hospital
| | - Hisakazu Ohtani
- HISAKAZU OHTANI PhD, Assistant Professor, Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University
| | - Yasufumi Sawada
- YASUFUMI SAWADA PhD, Professor, Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University
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Akaho E, Maekawa T, Uchinashi M, Kanamori R. A study of streptomycin blood level information of patients undergoing hemodialysis. Biopharm Drug Dispos 2002; 23:47-52. [PMID: 11932958 DOI: 10.1002/bdd.293] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pharmacokinetic feature of streptomycin (SM) was investigated before and during hemodialysis (HD) in four patients with renal failure undergoing HD. SM concentrations were assayed by using TDX SM KIT (DAINABOT). Patients received 10 mg/kg of SM by intramuscular injection before HD. Pharmacokinetic parameters of SM intramuscular injection before HD were k(a)=2.38+/-0.53 h(-1); k(e)=0.0130+/-0.0025 h(-1); V(d)=0.313+/-0.026l/kg and t(1/2)=55.6+/-10.4 h. The maximum concentration (C(max)) of SM was observed at about 2 h after the SM administration and the mean serum concentration of SM was 30.4 microg/ml; even 4 h after the SM injection, the concentration still remained in a range over 30 microg/ml. The data suggest that a possible toxicity might have appeared in the patients. During the hemodialysis an average t(1/2) value was 3.32 h. This value is close to the value of a healthy person. The k(e) value of patient A during the hemodialysis became 24 times as large as that observed before the hemodialysis. On the average it was 17 times as large as that observed before the hemodialysis. Thus, it was found that the values of pharmacokinetics parameters such as k(e) and t(1/2) during the hemodialysis were similar to those of a healthy person, although there are some variations.
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Affiliation(s)
- Eiichi Akaho
- School of Pharmacy and High Technology Research Center, Kobe Gakuin University, 518 Arise Ikawadani-cho, Nishi-ku, Kobe 651-2180, Japan
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Abstract
BACKGROUND Acquired immunodeficiency syndrome (AIDS)-related kidney disorders concern 30% of those patients and can lead to end-stage renal disease (ESRD; 6 to 10%). Therefore, the administration of antiretroviral drugs in human immunodeficiency virus (HIV) patients with nephropathy is not uncommon. METHODS The influence of ESRD on the different phases of the pharmacokinetic profile of drugs in general is examined in light of bioavailability, distribution, protein binding, metabolism, and elimination. Then, the pharmacokinetics of antiretroviral drugs in hemodialysis are detailed. RESULTS From these data, dosing recommendations are given for nucleoside reverse transcriptase inhibitors (NRTIs), non-NRTIs, and protease inhibitors (PIs). CONCLUSION Dosage adjustments are often necessary for patients with renal insufficiency. These adaptations have to be carefully performed to optimize drug exposure and reduce the risk of side effects.
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Affiliation(s)
- H Izzedine
- Department of Nephrology, Pitie Salpetriere Hospital, Paris, France.
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29
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Kovacs SJ, Tenero DM, Martin DE, Ilson BE, Jorkasky DK. Pharmacokinetics and protein binding of eprosartan in hemodialysis-dependent patients with end-stage renal disease. Pharmacotherapy 1999; 19:612-9. [PMID: 10331824 DOI: 10.1592/phco.19.8.612.31518] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To compare eprosartan pharmacokinetics in hemodialysis patients and in volunteers with normal renal function, and to determine the effect of hemodialysis on these values. DESIGN Open-label, parallel-group, single-dose study. SETTING Outpatient hemodialysis treatment center and an industry-affiliated clinical pharmacology unit. PATIENTS Ten healthy volunteers and nine hemodialysis patients. INTERVENTION A single oral dose of eprosartan 400 mg was administered to volunteers on 1 day and to patients on 2 days (a nondialysis and a dialysis day). Patients underwent high-flux hemodialysis. MEASUREMENTS AND MAIN RESULTS Concentrations of eprosartan in plasma and dialysate were assayed by high-performance liquid chromatography; plasma protein binding was determined by ultrafiltration. Eprosartan pharmacokinetics showed greater variability in patients than in volunteers. However, six of nine patients had exposures that were within the range observed for volunteers. Mean total AUC(0-t) was increased approximately 60% (95% CI-22, 225) in patients. Total Cmax was similar between groups (PE = 1.01, 95% CI -40, 71). Mean percent fraction unbound (%f(u)) in patients (3.02%) was significantly greater than that in volunteers (1.74%). Unbound AUC(0-t) and unbound Cmax were, on average, approximately 172% (95% CI 28, 479) and 73% (95% CI -1, 199) greater, respectively, in patients. After hemodialysis, the mean %f(u) decreased from 3.19-2.01%. Mean recovery of eprosartan in dialysate was 6.8 mg (range 0-23.1 mg) and hemodialytic clearance was approximately 11 ml/minute, which does not represent a significant portion of total clearance. CONCLUSIONS Eprosartan was safe and well tolerated in both groups. Based on its known safety profile and because of its exaggerated pharmacokinetic variability in patients undergoing hemodialysis, treatment should be individualized based on tolerability and response. Supplemental doses of eprosartan after hemodialysis are unnecessary.
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Affiliation(s)
- S J Kovacs
- SmithKline Beecham Clinical Pharmacology Unit, Presbyterian Medical Center-University of Pennsylvania Health System, Philadelphia 19104, USA
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30
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Abstract
The evidence from animal sepsis models that hemofiltration may ameliorate the hemodynamic changes that occur in septic shock has led to speculation that continuous renal replacement therapy may have nonrenal benefits in septic patients. Much of the subsequent work has been done to elucidate the mechanisms of this benefit, in particular the role of removal of inflammatory mediators including cytokines and complement. The significance of extracorporeal removal of such products is dependent on the relative importance of endogenous production and clearance in the setting of sepsis and multiple organ failure and on the method of blood purification. This article reviews the evidence thus far, consisting of in vitro, animal, and human studies; a range of mediators (TNFalpha, IL-1beta, IL-6, IL-8, complement factors C3a, C5a, and D); various membranes (polyacrylonitrile, polysulfone, and polyamide); and clearance by diffusion, convection, and adsorption. The most consistent results suggest that the plasma levels of some mediators are lowered by a combination of membrane adsorption and convection, the clinical significance of which is still uncertain. The review shows the need for further work to unravel the role of CRRT in treating septic patients.
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Affiliation(s)
- W Silvester
- Department of Intensive Care Medicine, Austin and Repatriation Medical Centre, Melbourne, Australia.
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31
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Zoer J, Schrander-van der Meer AM, van Dorp WT. Dosage recommendation of vancomycin during haemodialysis with highly permeable membranes. PHARMACY WORLD & SCIENCE : PWS 1997; 19:191-6. [PMID: 9297732 DOI: 10.1023/a:1008600104232] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The standard dosage of vancomycin in haemodialysis patients is usually 1 gram, once a week. The aim of our study was to investigate vancomycin clearance by two highly permeable membranes and to determine whether dosage adjustment is necessary in regular haemodialysis settings when using these type of dialyzers. 12 patients on regular haemodialysis and treated with vancomycin either prophylactically or therapeutically were prospectively randomised to either dialysis with a polyacrylonitril parallel membrane (AN-69) or a cellulose-acetate hollow fiber membrane. After administering vancomycin to the patient vancomycin plasma levels were measured at different intervals. The vancomycin clearance by the dialyzer was calculated from blood samples taken 1 hour after commencing dialysis. The data were used for pharmacokinetic computer simulation in order to develop a vancomycin dosage regimen for patients on regular haemodialysis with highly permeable membranes. The mean vancomycin dialysis clearance was 46 +/- 5 ml/min and did not differ between the two artificial kidneys. Dialysis clearance of vancomycin was independent of blood flow rate. Together with the dialyzer data a pharmacokinetic profile of each patient was calculated from the plasma samples. The average non-renal clearance was 3.3 ml/min/1.73 m2 while renal vancomycin clearance, as a fraction of creatinine clearance, was found to be 0.83 +/- 0.20. The computer calculations predicted that, irrespective of residual renal function, in most patients on regular haemodialysis and treated with these type of artificial kidneys, therapeutic and non-toxic vancomycin levels could be obtained by giving 1000 mg of vancomycin intravenously as a loading dosage and 500 mg during every subsequent dialysis.
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Affiliation(s)
- J Zoer
- Central Pharmacy of the Haarlem Hospitals, The Netherlands
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32
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Knupp CA, Hak LJ, Coakley DF, Falk RJ, Wagner BE, Raasch RH, van der Horst CM, Kaul S, Barbhaiya RH, Dukes GE. Disposition of didanosine in HIV-seropositive patients with normal renal function or chronic renal failure: influence of hemodialysis and continuous ambulatory peritoneal dialysis. Clin Pharmacol Ther 1996; 60:535-42. [PMID: 8941026 DOI: 10.1016/s0009-9236(96)90149-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the pharmacokinetics of didanosine in patients with normal kidney function or chronic kidney failure. METHODS Three groups of patients with human immunodeficiency virus (HIV) infection were studied: group I, six men with normal kidney function (creatinine clearance > 90 ml/min/1.73 m2); group II, six men with chronic renal failure maintained on continuous ambulatory peritoneal dialysis (CAPD); and group III, four men and two women with chronic renal failure receiving hemodialysis three times a week. A 300 mg dose of didanosine was administered orally and intravenously according to a two-period randomized crossover design. Patients in group III were studied between hemodialysis sessions during the crossover periods. In addition, patients in group III were studied in a third period after administration of a 300 mg oral dose of didanosine 4 hours before hemodialysis. RESULTS After intravenous administration in group I, the mean (+/-SD) total clearance (CLT) was 13.0 +/- 1.6 ml/min/kg and the elimination half-life (t 1/2) was 1.56 +/- 0.43 hour. In groups II and III, the CLT decreased significantly to 3.4 +/- 1.2 and 3.2 +/- 1.2 ml/min/kg, respectively, whereas the t1/2 increased to 3.60 +/- 0.82 hours and 3.11 +/- 0.88 hours, respectively. The absolute bioavailability of didanosine in groups I, II, and III was 42% +/- 12%, 52% +/- 6%, and 38% +/- 11%, respectively, and did not differ significantly. CAPD had little effect on the removal of didanosine, whereas approximately 30% of the drug present in the body at the start of dialysis was eliminated by an average 3-hour dialysis session. CONCLUSION The clearance of didanosine is impaired in patients with chronic renal failure. To compensate, the dose and schedule of administration should be adjusted. It is recommended that one-fourth of the total daily dose of didanosine be administered once a day in this patient population.
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Affiliation(s)
- C A Knupp
- Department of Metabolism and Pharmacokinetics, Bristol-Myers Squibb Company, Princeton, NJ 08543, USA
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Abstract
The pharmacokinetics of the new benzimidazole proton pump inhibitor lansoprazole and five of its metabolites were assessed after single oral dose administration to five hemodialysis patients. Patients were studied on dialysis and nondialysis days. Multiple blood and dialysate samples were collected after dosing and were assayed for lansoprazole and metabolite content via high-performance liquid chromatography. The degree of lansoprazole plasma protein binding was lower in hemodialysis patients than in subjects with normal renal function or patients with renal impairment not requiring dialytic therapy, although this tended to moderate when assessed immediately after dialysis. Examination of venous plasma concentration, paired arterial-venous concentration, and dialysate data revealed that lansoprazole and its metabolites were poorly dialyzable. No dosage adjustment of lansoprazole is necessary in hemodialysis patients nor is supplementation after hemodialysis sessions necessary.
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Affiliation(s)
- M D Karol
- Department of Pharmacokinetics and Biopharmaceutics, Abbott Laboratories, Abbott Park, Illinois 60064-3500, USA
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34
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Schetz M, Ferdinande P, Van den Berghe G, Verwaest C, Lauwers P. Pharmacokinetics of continuous renal replacement therapy. Intensive Care Med 1995; 21:612-20. [PMID: 7593908 DOI: 10.1007/bf01700172] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- M Schetz
- Department of Intensive Care Medicine, UZ Gasthuisberg, Leuven, Belgium
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35
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Abstract
The Dosing in Renopathy by Easy-To-Use Multipliers (DREM) System is a simple method for dose adjustments of anti-infectives in renal insufficiency. The simple 2-step method involves: (1) estimating creatinine clearance (CLcr) from age, sex, and serum creatinine, and (2) calculating the adjusted dose or dosing interval with the use of multipliers. By multiplying the normal dose or dosing interval with the dose (CLcr/100) or interval (100'CLcr) multiplier, the adjusted dose or dosing interval is obtained, respectively. Dose estimates with this method are reasonably accurate and compare favorably with previously published methods of correction.
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Affiliation(s)
- E G Maderazo
- Department of Medicine, William W. Backus Hospital, Norwich, Connecticut, USA
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36
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Schetz M, Ferdinande P, Van den Berghe G, Verwaest C, Lauwers P. Removal of pro-inflammatory cytokines with renal replacement therapy: sense or nonsense? Intensive Care Med 1995; 21:169-76. [PMID: 7775699 DOI: 10.1007/bf01726541] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M Schetz
- Department of Intensive Care Medicine, U. Z. Gasthuisberg, Leuven, Belgium
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37
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Mac-Kay MV, Fernandez IP, Herrera Carranza J, Sancez Burson J. An in vitro study of the influence of a drug's molecular weight on its overall (Clt), diffusive (Cld) and convective (Clc) clearance through dialysers. Biopharm Drug Dispos 1995; 16:23-35. [PMID: 7711281 DOI: 10.1002/bdd.2510160104] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The dialyser clearance of a drug is the sum of two components: one diffusive, arising from the concentration gradient across the membrane, and the other convective, arising from the ultrafiltration of plasma water, produced by the increases in hydraulic pressure that the membrane undergoes. To demonstrate the importance of these clearances during haemodialysis, this study analyses the influence of a drug's molecular weight on them. To this end, an experimental study of dialysis in vitro was carried out to determine the clearances, in aqueous solution, of five drugs of increasing molecular weights (theophylline, quinidine, tobramycin, digoxin, and vancomycin), using two series of dialysers with the same type of membrane (Cuprophan), differing in effective surface area and ultrafiltration coefficient. From the data obtained in this study, the importance of quantifying convective clearance during haemodialysis becomes apparent since if it is not taken into account errors of up to 20% and more may be made. This is particularly so if the drug is of high molecular weight and if a high filtration rate is being used.
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Affiliation(s)
- M V Mac-Kay
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Seville, Spain
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38
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Evers J, Büttner-Belz U. Fatal lorcainide poisoning. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1995; 33:157-9. [PMID: 7897755 DOI: 10.3109/15563659509000466] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A case of lorcainide poisoning with fatal outcome is reported. A young girl of 15 ingested, without high lethality of intent, 2500 mg lorcainide, an antiarrhythmic agent. Bradycardia, shock, coma, and cerebral convulsions rapidly occurred. Despite immediate resuscitative measures with high doses of catecholamines and hypertonic sodium bicarbonate the patient died three hours later. The course of lorcainide poisoning was similar to that of other class Ic antiarrhythmic agents.
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Affiliation(s)
- J Evers
- Medizinische Klinik, Kliniken Köln-Merheim, Germany
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39
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Mac-Kay MV, Liger IPF, Bursón JS, Carranza JH. A Graphical Approach to Aminoglycoside Dosage Regimens in End-Stage Renal Disease Patients Undergoing Haemodialysis. Clin Drug Investig 1994. [DOI: 10.1007/bf03257442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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40
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Leflour C, Dine T, Luyckx M, Brunet C, Gressier B, Cazin M, Robert H, Durocher A, Cazin JC. Solid phase extraction and high performance liquid chromatographic determination of dobutamine in plasma of dialysed patients. Biomed Chromatogr 1994; 8:309-12. [PMID: 7888736 DOI: 10.1002/bmc.1130080613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
An isocratic reversed-phase high performance liquid chromatographic method has been developed for th e determination of dobutamine in the plasma of dialysed patients. A solid phase extraction method with a Sep-Pak C18 cartridge was used to isolate the drug and isoxsuprine (internal standard) from plasma. The separation was carried out on an ODS-Hypersil column with 0.1 M phosphate buffer:acetonitrile:methanol (72:20:8 v/v/v) as the mobile phase. The recovery of dobutamine added to plasma by the extraction procedure was 87 +/- 2.3% (mean +/- SD). The accuracy and reproducibility of the method were within acceptable limits over the concentration range 0-1000 ng/mL. Quantification was by fluorescence detection at 275 nm excitation and 310 nm emission wavelengths with a detection limit of 5 ng/mL for dobutamine. This procedure was applied to ascertain the pharmacokinetics of dobutamine infusion in nine patients with cardiogenic shock and end-stage renal disease undergoing haemodialysis.
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Affiliation(s)
- C Leflour
- Laboratoire de Pharmacologie, Pharmacocinétique et Pharmacie Clinique, Faculté de Pharmacie, Lille, France
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41
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Kuranari M, Nawata T, Sato Y, Sakata T, Kodama Y, Takeyama M. Effect of hemodialysis on serum concentration of isepamicin in a patient with endstage renal failure. Ann Pharmacother 1993; 27:1284-5. [PMID: 8251702 DOI: 10.1177/106002809302701022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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42
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Reetze-Bonorden P, Böhler J, Keller E. Drug dosage in patients during continuous renal replacement therapy. Pharmacokinetic and therapeutic considerations. Clin Pharmacokinet 1993; 24:362-79. [PMID: 8504621 DOI: 10.2165/00003088-199324050-00002] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The advantages of continuous haemofiltration and haemodialysis over intermittent haemodialysis for the treatment of acute renal failure are well recognised. In intensive care patients, 4 different continuous procedures, arteriovenous and venovenous haemofiltration (CAVH and CVVH) or haemodialysis (CAVHD and CVVHD), are employed. These effective detoxification treatments require knowledge of their influence on drug disposition. Data on kinetics of drugs during continuous treatment are scarce and limited almost exclusively to the oldest and least effective procedure (CAVH). Selected dialysis membranes may adsorb drugs, as in the case of aminoglycosides. In addition, elimination of substances with large molecular weights may vary depending on the pore size of the membrane, as in the case of vancomycin. Thus, even if drug dosages can be based on pharmacokinetic studies, selection of a dialysis membrane not studied may cause unpredictable drug concentrations. With these limitations in mind and considering the available literature on pharmacokinetics in patients with renal failure, general guidelines for drug dosage during continuous renal replacement therapy can be given. In haemofiltration, drug protein binding is the major factor determining sieving, i.e. the appearance of the drug in the ultrafiltrate. In haemodialysis, diffusion is added to ultrafiltration, and therefore the saturation of the combined dialysate and ultrafiltrate will decrease further with increasing dialysate flow rate. In continuous haemofiltration or haemodialysis the extracorporeal clearance can be calculated by multiplying the saturation value (estimated or, better, measured) with the ultrafiltrate and dialysate flow rate. Dividing the extracorporeal clearance by the total clearance (including the nonrenal clearance) gives the fraction of the dose removed due to extracorporeal elimination. Whether dosage recommendations available for anuric patients have to be modified or not can be decided on the basis of this value. In case of high nonrenal clearance, the degree of saturation is without clinical significance. Based on these considerations guidelines have been constructed for the effect of extracorporeal elimination on more than 120 different drugs commonly used in intensive care patients.
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Affiliation(s)
- P Reetze-Bonorden
- Department of Nephrology, University of Freiburg, Federal Republic of Germany
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43
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Chang DB, Kuo SH, Yang PC, Shen FH, Luh KT. Clearance of theophylline by hemodialysis in one patient with chronic renal failure. Chest 1992; 102:1621-3. [PMID: 1424911 DOI: 10.1378/chest.102.5.1621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The clearance of theophylline by hemodialysis was determined in one patient who had polycystic kidney with chronic renal failure and bronchial asthma. The serum levels of theophylline were determined by enzymatic immunoassay on two consecutive days, once on a dialysis day and again on a nondialysis day. Clearance of theophylline by hemodialysis was 119 ml/min, and the extraction efficiency was 0.56. The elimination half-life of theophylline shortened from 5.7 h to 1.6 h during hemodialysis. The dialysis rate constant (Kd) was 0.32/h, and 79 percent of the total body store of the drug was removed during a 4-h dialysis. Patients receiving theophylline who are maintained on hemodialysis should be closely monitored for bronchospasm during and after the hemodialysis procedure. Measurement of serum concentrations of theophylline should be employed to facilitate increases in dosage during hemodialysis.
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Affiliation(s)
- D B Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, ROC
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44
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Singlas E, Taburet AM, Borsa Lebas F, Parent de Curzon O, Sobel A, Chauveau P, Viron B, al Khayat R, Poignet JL, Mignon F. Didanosine pharmacokinetics in patients with normal and impaired renal function: influence of hemodialysis. Antimicrob Agents Chemother 1992; 36:1519-24. [PMID: 1510449 PMCID: PMC191614 DOI: 10.1128/aac.36.7.1519] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The pharmacokinetics of didanosine were investigated following oral administration of a single 375-mg dose to eight human immunodeficiency virus-seropositive patients with normal renal function and eight human immunodeficiency virus-seropositive uremic patients. In uremic patients, the plasma half-life was longer than that in control patients (respectively, 4.5 +/- 2.2 and 1.6 +/- 0.4 h). The ratio of total plasma clearance to absolute bioavailability was four- to fivefold lower in uremic patients than in patients with normal renal function (respectively, 491 +/- 181 and 2,277 +/- 738 ml/min). Because of the decrease in elimination, concentrations in plasma were higher for uremic patients than for control patients; the maximum concentrations of drug in plasma were, respectively, 3,978 +/- 1,607 and 1,948 +/- 994 ng/ml; the areas under the concentration-time curve were, respectively, 14,050 +/- 4,262 and 3,000 +/- 956 ng.h/ml. Didanosine was removed by hemodialysis with an extraction ratio of 53% +/- 8%, a hemodialysis clearance value of 107 +/- 21 ml/min, and a fractional drug removal during a 4-h dialysis of 20% +/- 8% of the dose. Dosage adjustments are necessary in uremic patients.
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Affiliation(s)
- E Singlas
- Hôpital Universitaire Bicêtre, Le Kremlin Bicetre, France
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Böhler J, Reetze-Bonorden P, Keller E, Kramer A, Schollmeyer PJ. Rebound of plasma vancomycin levels after haemodialysis with highly permeable membranes. Eur J Clin Pharmacol 1992; 42:635-9. [PMID: 1623904 DOI: 10.1007/bf00265928] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vancomycin is usually given only once a week to haemodialysis (HD) patients. If highly permeable dialysis membranes are used, however, high clearance values have been reported, so the aim of the study was to determine whether high clearance of vancomycin resulted in sufficient drug elimination to induce subtherapeutic plasma levels after one week. In 18 chronic HD patients, treated with polysulfone dialyzers (1.2 m2), the pharmacokinetics of vancomycin were studied after administration of 1 g. Concentrations were determined by fluorescence polarisation immunoassay. At a blood flow of 219 ml.min-1, HD clearance of vancomycin was 62.3 ml.min-1. Immediately after dialysis plasma concentrations were 38% lower than predialysis levels. However, marked rebound in the vancomycin level was observed 5 h later, resulting in plasma levels only 16% lower than prior to dialysis. 3 HD treatments in 1 week removed about one third of the initial dose. After one week 15 of 18 patients still had a therapeutic plasma level (greater than 4 micrograms.ml-1). In conclusion, polysulfone membranes show high clearance of vancomycin. However, transfer of drug from blood to dialysate appears to be faster than from tissues to blood. Because of a marked rebound in plasma level after treatment, therapeutic drug concentrations will still be present in most patients after one week.
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Affiliation(s)
- J Böhler
- Department of Nephrology, University of Freiburg, FRG
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46
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Yuk-Choi JH, Nightingale CH, Williams TW. Considerations in dosage selection for third generation cephalosporins. Clin Pharmacokinet 1992; 22:132-43. [PMID: 1551290 DOI: 10.2165/00003088-199222020-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pharmacokinetic parameters of third generation cephalosporins vary widely, requiring different dosage regimens and adjustment methods for each agent. Although their antibacterial spectrum favours their usage in infections caused by aerobic Gram-negative organisms, due to their limited post-antibiotic effect against these organisms, dosage regimens should ensure that free drug concentrations at the site of infection remain above the minimum inhibitory concentration for as much of the dosage interval as possible in patients with normal host defence mechanisms and for the entire dosage interval in immunocompromised patients. Altered protein binding encountered in various disease states can affect both microbiological and pharmacokinetic properties especially for drugs with high protein binding. Since the concentrations at the site of action are often different from those in serum, a higher or lower range of dosages needs to be selected depending on the target site. Decreased renal function affects the elimination of most third generation cephalosporins, whereas the presence of hepatic disease does not generally necessitate dosage adjustment. Because of the complex age-related physiological changes in paediatric and elderly patients, dosage should be adjusted on the basis of the reported pharmacokinetic data in these populations. The usual recommended dose may or may not be optimal in a given condition depending on the complex interactions between pharmacokinetic, microbiological and other host factors.
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Affiliation(s)
- J H Yuk-Choi
- Department of Pharmacy Services, Methodist Hospital, Baylor College of Medicine, Houston, Texas
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47
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Kroh UF, Lennartz H. Evaluation and first validation study on a simplified drug dosage algorithm for multiple organ failure patients. Ren Fail 1992; 14:579-85. [PMID: 1462011 DOI: 10.3109/08860229209047669] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
As reported previously, drug concentrations during continuous hemofiltration (HF) and extracorporeal lung assist (ELA) follow certain rules, which can be expressed by a simplified algorithm for dosage adjustment: Drug sieving (S, fu) depends on the protein free fraction with small limitations, while the extrarenal elimination rate is not a constant but correlates inversely with the clinical state, r = -0.34, p = 0.00067, n = 96. Up to now, more than 218 cases of drug dosage adjustments have been performed, following the described regimen: The expected concentration is obtained in 79-84% already from the first estimation for drugs such as aminoglycosides, vancomycin, teicoplanin, beta-lactam antibiotics, heart glycosides, and theophylline. Skilled therapeutic drug monitoring (TDM) with elaborated pharmacokinetic programs fails to improve these results significantly. Nevertheless, sporadic TDM is essential in these patients according to their rapidly changing clinical states.
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Affiliation(s)
- U F Kroh
- Department of Anesthesiology and Intensive Therapy, Philipps-University of Marburg, Germany
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48
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Konishi K, Suzuki H, Saruta T, Hayashi M, Deguchi N, Tazaki H, Hisaka A. Removal of imipenem and cilastatin by hemodialysis in patients with end-stage renal failure. Antimicrob Agents Chemother 1991; 35:1616-20. [PMID: 1929334 PMCID: PMC245229 DOI: 10.1128/aac.35.8.1616] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The removal of imipenem and cilastatin by hemodialysis was studied in 14 (for imipenem) and 6 (for cilastatin) subjects. Following intravenous infusion of imipenem and cilastatin at a combined concentration of 10 mg/kg of body weight, drug levels in plasma were determined serially during off- and on-hemodialysis periods, which were 2 and 4 h, respectively. The biexponential decay of the drug levels in plasma was evident in each subject for both imipenem and cilastatin. Hemodialysis accelerated the elimination of both imipenem and cilastatin: the mean elimination-phase half-life of imipenem was shortened from 200 to 78 min, and that of cilastatin was shortened from 445 to 115 min. Hemodialysis clearance of imipenem and cilastatin was calculated by five different methods, each with intrinsic assumptions. The mean hemodialysis clearance of imipenem was estimated to be 74.08 +/- 13.29 ml/min, and that of cilastatin was estimated to be 65.0 +/- 8.6 ml/min, after consideration of various methodological limitations. It was estimated that in a hypothetical anephric patient weighing 60 kg, a 4-h hemodialysis treatment would remove 54.8% of the imipenem and 62.9% of the cilastatin present in the body at the start of dialysis.
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Affiliation(s)
- K Konishi
- Department of Medicine, School of Medicine, Keio University, Tokyo, Japan
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49
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Konishi K, Suzuki H, Saruta T, Deguchi N, Fugono T. Pharmacokinetics of carumonam (AMA-1080) in patients with impaired renal function and in those undergoing hemodialysis. Antimicrob Agents Chemother 1991; 35:1048-52. [PMID: 1929242 PMCID: PMC284284 DOI: 10.1128/aac.35.6.1048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The pharmacokinetics of carumonam (AMA-1080) were studied after a single intravenous 1.0-g dose was given to 26 subjects grouped according to their renal functions. Creatinine clearance (CLCR) was above 85, 50 to 84, 10 to 49, and below 10 ml/min/1.73 m2 in groups 1, 2, 3, and 4, respectively. All of the six patients in groups 4 were receiving maintenance hemodialysis, and they were studied both during and between hemodialysis sessions. Carumonam obeyed two-compartment model kinetics in all four group. The volume of distribution based on the area under serum concentration-time curve (Varea) did not differ significantly among the four groups, the mean value being 0.309 +/- 0.084 liter/kg. The elimination-phase (beta) half-lives were 1.53 +/- 0.36, 2.00 +/- 0.64, 5.08 +/- 1.85, and 12.8 +/- 4.1 h in groups 1, 2, 3, and 4, respectively. The 0- to 24-h cumulative urinary recoveries of carumonam were 83 +/- 11, 76 +/- 20, 58 +/- 25, and 12 +/- 9% of the administered dose in groups 1, 2, 3, and 4, respectively. The systemic and the renal clearances of carumonam decreased according to the severity of renal dysfunction, and the nonrenal clearance, which was calculated as the difference between renal and systemic clearances also decreased as CLCR decreased. A significant positive correlation existed between beta and CLCR (r = 0.847, P less than 0.01), and the beta of carumonam could be predicted by the following equation: beta (h-1) = 0.00460 X CLCR (ml/min/1.73 m2) + 0.049. Hemodialysis shortened the elimination-phase half-lives from 12.8 +/- 4.1 to 2.66 +/- 1.49 h in the six subjects in group 4. A 5-h hemodialysis in a hypothetical anephric subject weighing 60 kg was estimated to remove 51.4% of the drug present in the body at the start of hemodialysis.
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Affiliation(s)
- K Konishi
- Department of Medicine, School of Medicine, Keio University, Tokyo, Japan
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50
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Affiliation(s)
- Susan M Pond
- University of Queensland Department of MedicinePrincess Alexandra HospitalIpswich RoadWoolloongabbaQLD4102
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