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• GFR = 141 × min (Scr /κ, 1)α × max(Scr /κ, 1)-1.209 × 0.993Age × 1.018 [if
female] × 1.159 [if black]
• where:
• Scr is serum creatinine in mg/dL,
• κ is 0.7 for females and 0.9 for males,
• α is -0.329 for females and -0.411 for males,
• min indicates the minimum of Scr /κ or 1, and
• max indicates the maximum of Scr /κ or 1.
Calculator at:
https://www.niddk.nih.gov/health-information/health-communication-
programs/nkdep/lab-evaluation/gfr-calculators/adults-conventional-unit-ckd-
epi/Pages/default.aspx
Cockcroft and Gault (CG) equation
• This equation provides an estimate of measured CLcr and
has been widely used as an estimate of GFR as well,
despite the fact that creatinine also undergoes tubular
secretion.
• The CG equation is reported in units not adjusted for body
surface area, which is appropriate for drug dosage
adjustment.
• The CG equation has been shown to overestimate GFR
with the use of standardized creatinine assays.
• Many have considered that an advantage of the CG
equation for individual drug dose adjustment is that the
body weight is considered; however, this has not been
validated.
• The MDRD Study equation has been shown to
overestimate measured GFR in those with values
>60 ml/min per 1.73m2,and hence specific values
are only reported for values <60 ml/min per
1.73m2.
• The CKD-Epidemiology Collaboration (CKD-EPI)
equation was recently developed specifically to
overcome this limitation. It is more accurate than
the MDRD Study equation, particularly at higher
levels GFR
which one of the many GFR
estimation equations should be used
for assessment of an individual
patient’s GFR as the guide to the
degree of adjustment of their drug
dosage regimens?
• The National Kidney Disease Education Program
(NDKEP) in the United States recommends that the
GFR estimated from the MDRD Study or CLcr
estimates from the CG equation for adults or the
Schwartz equation for children can be used for
drug dosing.
National Kidney Foundation K/DOQI Staging System for Chronic Kidney Disease
NSAIDs Mild impairment; Use lowest effective dose and monitor renal
function, sodium and water retention
Moderate and Severe; avoid if possible
Simvastatin < 30 mL/min; Doses above 10 mg daily should be used with
caution
Ranitidine < 20 mL/min; use half the normal dose
* Some references recommend avoiding metformin
even in mild renal impairment but metformin can
be used with caution if the dose is reduced. All
patients should be advised to withhold treatment
and seek medical advice if they experience vomiting
and diarrhoea and if they have planned medical,
surgical or radiological procedures.
• Drugs that can further impair renal function in
high-risk patients (underlying CKD, heart
failure (HF), liver disease, hypoperfusion)
should be used with caution or avoided
altogether in preference for safer alternatives.
Red Flag Drugs That May Cause
Renal Impairment
PHARMACOKINETICS CHANGES
Absorption
• Intestinal absorption and bioavailability (the fraction of
medication that reaches systemic circulation) are influenced
by many variables and are the result of numerous
physiologic processes.
• Gastroparesis: Patients with CKD often suffer from
gastroparesis. This results in delayed gastric emptying and
prolongs the time to maximum drug concentrations (Cmax).
The overall extent of absorption is not commonly affected,
but delayed Cmax can be important when rapid onset of
action is desired.
• Gastric alkalinization: As a result of the common use of
medications, including phosphate binders, antacids, H2-
receptor antagonists, and proton pump inhibitors, the
absorption of many medications requiring an acidic
environment (e.g., furosemide and ferrous sulfate) is
reduced.
• Cationic chelation: Ingestion of cation-containing antacids
(e.g., calcium, magnesium, aluminum hydroxide, sodium
polystyrene sulfonate) decreases the absorption of many
coadministered medications because of chelation
(quinolone antibiotics, warfarin, levothyroxine, tetracycline,
and so forth).
• Alterations to intestinal first-pass metabolism and p-
glycoprotein efflux system:
• Many medications are subject to intestinal metabolism by
the cytochrome P450 enzyme system. In CKD, reductions in
metabolism occur 30% decrease in function.
• p-Glycoprotein, an efflux transport protein in the intestinal
tract, also exhibits decreased activity.
• Increased medication bioavailability occurs as a result of
both of these changes.
• Two medications with narrow therapeutic index (TI) affected
by these variations are cyclosporine and tacrolimus.
Distribution
• Drug distribution or volume of distribution (Vd) is
the total amount of drug present in the body,
divided by the plasma concentration, expressed in
liters.
• Plasma protein binding, tissue binding, active
transport, and body composition can all impact the
Vd.
• Plasma drug concentrations are representative of
both bound and unbound drug, but only free drug
is capable of crossing cellular membranes and
exerting pharmacologic effects
Altered protein binding:
• Hypoalbuminemia due to the nephrotic syndrome
often leads to an increase in the free drug fraction of
Acidic drugs (e.g., penicillins, cephalosporins,
phenytoin, furosemide, salicylates) leading to drug-
related toxicities.
• Alternatively, an increase in α1-glycoprotein (an acute
phase protein) associated with renal dysfunction will
lead to increase in protein binding Alkaline drugs (e.g.,
propranolol, morphine, oxazepam, vancomycin, and so
forth) concentrations are decreased.
Altered tissue binding:
Changes in tissue binding are most often irrelevant
except for digoxin, in which the Vd is reduced by 50% in
stage 5 CKD.
Changes in body composition:
• Fluid retention can increase the Vd of hydrophilic
drugs (e.g., pravastatin, fluvastatin, morphine,
codeine) and may cause decreased serum
concentrations; whereas increased adipose tissue
and muscle wasting would be expected to
increase serum concentrations secondary to a
reduced Vd
Metabolism
• Phase I reactions (more common) include hydrolysis,
reduction, and oxidation. These serve to increase drug
hydrophilicity to prepare for excretion or further phase II
metabolism.
• Phase II reactions or conjugation reactions include
glucuronidation, sulfation, glutathione conjugation,
acetylation, and methylation.
• Effects of renal failure
• Renal insufficiency significantly slows both phase I and phase
II reactions leading to increased serum drug concentrations.
• Accumulation of renally excreted active metabolites: Dosage
adjustments may be necessary for certain medications in
order to prevent toxicity from active metabolites
Elimination
• Elimination is typically reported as a half-life (T½),
or the time needed to reduce medication plasma
concentrations by 50%. Approximately five half-
lives are required to eliminate 97% of drug from
the body.
• The rate of renal elimination is dependent on
GFR, renal tubular secretion, and reabsorption.
• Medication-specific characteristics (e.g.,
molecular weight and protein binding) determine
glomerular filtration with filtration rate
dependent on free fraction.
• Reduced glomerular filtration: Decreased GFR
results in prolonged free drug elimination T½.
• Reduced secretion by active transport (e.g.,
ampicillin, furosemide, penicillin G, dopamine,
trimethoprim).
• Reduced passive reabsorption (e.g., aspirin,
lithium).
References
1. GR Matzke et al.: Drug dosing in kidney disease. Kidney
International (2011) 80, 1122–1137;
doi:10.1038/ki.2011.322.
2. © bpacnz
3. Matthew P Doogue, Thomas M Polasek. Drug Dosing in
Renal Disease. Clin Biochem Rev.2011. 32: 69-73.
4. MYRNA Y. MUNAR and HARLEEN SINGH. Drug Dosing
Adjustments in Patients with Chronic Kidney Disease. Am
Fam Physician 2007;75:1487-96.