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  • Image not available. Chronic kidney disease (CKD) results in minimal alterations in the absorption or bioavailability of most drugs.
  • Image not available. The volume of distribution (VD) of many drugs is increased in the presence of acute and chronic kidney disease as a consequence of volume expansion and/or reduced protein binding.
  • Image not available. In addition to the expected decrement in renal clearance, nonrenal clearance (i.e., GI and hepatic drug metabolism) of several drugs is also reduced in patients with CKD.
  • Image not available. Individualization of a drug dosage regimen for a patient with reduced kidney function is based on the pharmacodynamic/pharmacokinetic characteristics of the drug and the patient's degree of residual renal function.
  • Image not available. The drug dosing guidelines for patients with CKD in many drug information resources are highly variable and many are not optimal for clinical use.
  • Image not available. The effect of hemodialysis or peritoneal dialysis on drug elimination is dependent on the characteristics of the drug and the dialysis prescription.
  • Image not available. Hemodialysis clearance data can be used to guide the initial drug dosage regimen recommendation for hemodialysis patients; however, prospective monitoring of serum concentrations is often warranted especially for those with a narrow therapeutic index.

On completion of the chapter, the reader will be able to:

  1. State the mechanisms by which kidney disease can alter bioavailability of a drug.

  2. Describe the effect of chronic kidney disease (CKD) on protein binding, and list the types of drugs for which binding is typically decreased or increased.

  3. Discuss how a change in protein binding can alter the interpretation of serum drug concentrations.

  4. Compare the effect of acute kidney injury and CKD on drug metabolism.

  5. Discuss the mechanism(s) by which CKD can affect drug metabolism and list enzymes known to be effected.

  6. Calculate the dosage adjustment factor (Q) and use it to modify the dose and/or dosing interval for a drug when given drug- and patient-specific data, including the fraction of the drug eliminated renally unchanged in patients with normal renal function.

  7. Develop a loading and maintenance dosage regimen for a patient with CKD given patient-specific data and the relationships between the drug's pharmacokinetic parameters and renal function.

  8. Describe the processes by which drugs are removed by hemodialysis.

  9. List the factors that influence drug removal by hemodialysis including the relevant drug characteristics and dialysis conditions.

  10. Rate the relative efficiency of peritoneal dialysis, conventional hemodialysis, and high-flux hemodialysis in removing drugs.

  11. Compare and contrast the methods to determine/quantify the effect of hemodialysis on the pharmacokinetics of a drug.

Chronic kidney disease (CKD) is a common condition characterized by the presence of kidney damage, a urine albumin-to-creatinine ratio greater than 30 mg/g (3.4 mg/mmol) or a glomerular filtration rate (GFR) of less than 60 mL/min (1 mL/s) for greater than 3 months. It is estimated that 10% of adults, greater than 20 million people, in the United States have CKD.1 Between 2000 and 2008, the incidence of CKD has more than doubled in adults 65 years old and older.1 The combination of ...

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