Dialysis and continuous renal replacement therapy

Antimicrobial dosage modification in kidney impairment provides dosage guidance for adults undergoing continuous renal replacement therapy (CRRT), peritoneal dialysis (PD), and intermittent haemodialysis (IHD).

The most common CRRT modalities currently used in intensive care units are continuous venovenous haemofiltration (CVVH), continuous venovenous haemodialysis (CVVHD), and continuous venovenous haemodiafiltration (CVVHDF). Many of the dosing recommendations for CRRT are based on limited clinical data, or extrapolated from clinical experience and the pharmacokinetic and pharmacodynamic properties of the drug. CRRT settings can vary markedly between hospitals, which may result in different drug clearances. Consequently, the dosing recommendations in Antimicrobial dosage modification in kidney impairment are a guide only; consult a clinical pharmacist or other health professional with experience with the local CRRT settings for dosing advice where possible1. Monitor patients undergoing CRRT for drug efficacy and potential adverse effects, and, if possible, monitor the plasma concentration of the drug (see Monitoring antimicrobial blood concentrations).

Emerging prolonged intermittent renal replacement therapy techniques, including sustained low-efficiency dialysis (SLED) and extended daily diafiltration (EDD-f), are beyond the scope of these guidelines; consult published reviews for guidance on antimicrobial dosing23.

Peritoneal dialysis may be provided as continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). There are insufficient data to recommend different antimicrobial dosages for each peritoneal dialysis form, because most dosing information has been derived from continuous ambulatory peritoneal dialysis rather than automated peritoneal dialysis.

Drug clearance achieved by intermittent haemodialysis is consistent across institutions, because similar dialysis settings are used. Consequently, the dosage adjustments for intermittent haemodialysis recommended in Antimicrobial dosage modification in kidney impairment do not need to be modified locally. For drugs that are readily removed by intermittent haemodialysis, the dose should generally be withheld until after the dialysis session. To reduce the risk of missed doses, some haemodialysis units prefer to maintain the normal dosing schedule (ie dose at the same time as on nondialysis days) for drugs that are administered more than once daily. For patients undergoing automated peritoneal dialysis, it is also reasonable to administer once-daily doses of antimicrobials that are significantly dialysed (eg meropenem) after dialysis is completed.

1 For a review of the principles of dose optimisation in critically ill patients undergoing continuous renal replacement therapy, as well as a summary of available data, see Choi G, Gomersall CD, Tian Q, Joynt GM, Freebairn R, Lipman J. Principles of antibacterial dosing in continuous renal replacement therapy. Crit Care Med 2009;37(7):2268-82. [URL]Return
2 Bogard KN, Peterson NT, Plumb TJ, Erwin MW, Fuller PD, Olsen KM. Antibiotic dosing during sustained low-efficiency dialysis: special considerations in adult critically ill patients. Crit Care Med 2011;39(3):560-70. [URL]Return
3 Jamal JA, Economou CJ, Lipman J, Roberts JA. Improving antibiotic dosing in special situations in the ICU: burns, renal replacement therapy and extracorporeal membrane oxygenation. Curr Opin Crit Care 2012;18(5):460-71. [URL]Return