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Drug Dosing in Continuous Renal Replacement Therapy (CRRT)

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Core Concepts in Dialysis and Continuous Therapies

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Abstract

Continuous renal replacement therapy (CRRT) is considered superior to intermittent haemodialysis (IHD) in maintaining haemodynamic stability and has become the technique of choice for dealing with acute kidney injury (AKI) in the intensive care setting. Correct dosing of drugs in patients undergoing CRRT is extremely challenging, since it is necessary to consider both extracorporeal drug removal by the CRRT process itself and pharmacokinetic perturbations caused by organ dysfunction, sepsis and/or other aspects of critical illness. Drug removal during CRRT depends on the physicochemical properties and pharmacokinetic behaviour of that drug, the CRRT technique used, and other physical and patient factors including membrane selection, effluent flow rate and systemic pH. Patients with AKI who require CRRT comprise a very heterogeneous population and they frequently require complex drug therapy. It is therefore essential that drug dosing is appropriately prescribed and adjusted so as to be clinically safe and effective in optimising clinical outcomes. Well-designed pharmacokinetic studies in critically ill patients receiving CRRT are relatively rare, and while there are multiple published dosing recommendations that are widely used, in reality these have not been adequately validated in prospective studies to see if their implementation either increases the attainment of target therapeutic serum concentrations of drugs or, more importantly, improves patient outcomes. Here, we discuss the general principles determining whether a dose adjustment is necessary during CRRT and provide some practical guidance enabling clinicians to avoid ineffective drug dosing in this setting.

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Authors and Affiliations

  1. School of Medicine & Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin, Ireland

    Helen C. Gallagher BSc (Pharm), MPharm, PhD

  2. School of Medicine, University College Dublin, Dublin, Ireland

    Patrick T. Murray MB, BCh, BAO, MD

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  1. Helen C. Gallagher BSc (Pharm), MPharm, PhD
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Correspondence to Patrick T. Murray MB, BCh, BAO, MD .

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Editors and Affiliations

  1. Department of Nephrology, Beaumont Hospital, Dublin, Dublin, Ireland

    Colm C. Magee

  2. Department of Medicine/Renal Division, Brigham and Women's Hospital, BOSTON, Massachusetts, USA

    J. Kevin Tucker

  3. Global and Continuing Education, Harvard Medical School, Boston, Massachusetts, USA

    Ajay K. Singh

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Gallagher, H., Murray, P. (2016). Drug Dosing in Continuous Renal Replacement Therapy (CRRT). In: Magee, C., Tucker, J., Singh, A. (eds) Core Concepts in Dialysis and Continuous Therapies. Springer, Boston, MA. https://doi.org/10.1007/978-1-4899-7657-4_19

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