Abstract
The use of sustained low-efficiency dialysis (SLED) as a renal replacement modality has increased in critically ill patients with both acute kidney injury (AKI) and hemodynamic instability. Unfortunately, there is a paucity of data regarding the appropriate dosing of medications for patients undergoing SLED. Dose adjustment in SLED often requires interpretation of pharmacodynamics and pharmacokinetic factors and extrapolation based on dosing recommendations from other modes of renal replacement therapy (RRT). This review summarizes published trials of antimicrobial dose adjustment in SLED and discusses pharmacokinetic considerations specific to medication dosing in SLED. Preliminary recommendation is provided on selection of appropriate dosing for medications where published literature is unavailable.
Highlights
Pharmacokinetic and Pharmacodynamic Principles during sustained low-efficiency dialysis (SLED)The pharmacokinetic parameters absorption, distribution, and clearance of medications are altered in critically ill patient population with acute kidney injury receiving SLED; these parameters need to be considered when making drug dosing adjustments
The use of sustained low-efficiency dialysis (SLED) as a renal replacement modality has increased in critically ill patients with both acute kidney injury (AKI) and hemodynamic instability
Hybrid therapies are known as prolonged intermittent renal replacement therapy (PIRRT), sustained low-efficiency dialysis (SLED), and extended daily dialysis (EDD)
Summary
The pharmacokinetic parameters absorption, distribution, and clearance of medications are altered in critically ill patient population with acute kidney injury receiving SLED; these parameters need to be considered when making drug dosing adjustments. There have been several small PK studies published in the past one to two decades attempting to determine the PK impact of these extended modes of dialysis and to identify optimal antimicrobial dosing to maximize efficacy while minimizing toxicity [8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47] This was done by examining the blood concentrations at multiple time points before, during, and after drug administration. For the purposes of simplicity, all extended dialysis modes will be referred to as SLED in the following summaries
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