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KEY CONCEPTS

KEY CONCEPTS

  • imageChronic kidney disease (CKD) results in minimal alterations in the absorption or bioavailability of most drugs.

  • imageThe volume of distribution (VD) of many drugs is increased in the presence of acute and CKD as a consequence of volume expansion and/or decreased protein binding.

  • imageIn addition to the expected decrement in renal clearance, nonrenal clearance (ie, gastrointestinal and hepatic drug metabolism and transport) of several drugs is also decreased in CKD patients.

  • imageIndividualization of a drug dosage regimen for a patient with impaired kidney function is based on the pharmacodynamic/pharmacokinetic characteristics of the drug, the patient’s degree of residual renal function, and their overall clinical condition.

  • imageThe drug dosing guidelines for CKD patients in many drug information resources are highly variable and many are not optimal for clinical use.

  • imageThe effect of hemodialysis (HD) or peritoneal dialysis on drug elimination is dependent on the characteristics of the drug and the dialysis prescription.

  • imageHD clearance data can be used to guide the initial drug dosage regimen recommendation for HD patients; however, prospective monitoring of serum concentrations is often warranted especially for narrow therapeutic index drugs.

PRECLASS ACTIVITY

Preclass Engaged Learning Activity

Visit the US National Library of Medicine website DailyMed. DailyMed is the official provider of US Food and Drug Administration (FDA) approved drug label information (ie, package inserts). Identify a drug approved by the FDA within the last 5 years that requires dose adjustment for impaired kidney function. Review renal drug dosing adjustment recommendations, focusing on the kidney function cutoffs for dose adjustment and the kidney function estimate (eg, creatinine clearance, glomerular filtration rate) upon which the recommendations are based. This website is useful to enhance student understanding of renal drug dosing information.

INTRODUCTION

Chronic kidney disease (CKD) is defined by the presence of abnormalities of kidney function or structure.1 In its earliest stages, it is characterized by either an estimated glomerular filtration rate (eGFR) less than 89 mL/min/1.73 m2 or the persistence of one or more markers of kidney damage (eg, albuminuria) for more than 3 months in those with eGFR more than or equal to 90 mL/min/1.73 m2 (see Chapters e59 “Evaluation of Kidney Function” and 61 “Chronic Kidney Disease”).1 The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for evaluation and management of CKD eGFR and albuminuria categories are outlined in Table 61-5. It is estimated that 10% to 15% of the global population has CKD and the number of deaths from CKD has risen by more than 80% in the past two decades.2–4 The prevalence varies widely across the world in part because of true differences in the prevalence of CKD; heterogeneity of the laboratory methods used to detect CKD; environmental factors, public health policies, and genetics.4 The incidence of CKD has more than doubled in the past 20 years in adults ...

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