Abstract
Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than the Cockcroft-Gault equation in the setting of AKI. The objective of this study is to assess the degree of antimicrobial dosing discordance using different glomerular filtration rate (GFR) estimating equations. This is a retrospective evaluation of antimicrobial dosing using different estimating equations for kidney function in AKI and comparison to Cockcroft-Gault estimation as a reference. Considering the Cockcroft-Gault estimate as the criterion standard, antimicrobials were appropriately adjusted at most 80.7% of the time. On average, kidney function changed by 30 mL/min over the course of an AKI episode. The median clearance at the peak serum creatinine was 27.4 (9.3–66.3) mL/min for Cockcroft Gault, 19.8 (9.8–47.0) mL/min/1.73 m2 for MDRD and 20.5 (4.9–49.6) mL/min for the Modified Jelliffe equations. The discordance rate for antimicrobial dosing ranged from a minimum of 8.6% to a maximum of 16.4%. In the event of discordance, the dose administered was supra-therapeutic 100% of the time using the Modified Jelliffe equation. Use of estimating equations other than the Cockcroft Gault equation may significantly alter dosing of antimicrobials in AKI.
Highlights
Acute kidney injury (AKI) has been reported to occur in approximately 6% of hospitalized patients [1]
A total of 719 antimicrobial episodes from 32 unique patients were included in the analysis
In order to show the spectrum of AKI, we calculated the median clearance at peak and nadir serum creatinine concentrations (Scr) and this ranged from 19.8 to 27.4 and 46.9 to 58.8 mL/min, respectively (Figures 1 and 2)
Summary
Acute kidney injury (AKI) has been reported to occur in approximately 6% of hospitalized patients [1]. An accurate assessment of kidney function is important in order to optimize drug administration in this population [5,6,7]. The most accurate way to determine glomerular filtration rate (GFR) in chronic kidney disease (CKD) is by formal measurement using an intravenous injection of inulin or a radioisotope and subsequently collecting urine and serum samples at timed intervals [8,9]. The direct measurement of GFR is cumbersome, expensive and time consuming, and rarely performed in the acute hospital setting. These procedures are even more complicated in AKI. Pharmacists generally employ the Cockcroft-Gault (CG) equation to estimate kidney function, altering either or both the dose and frequency of drugs based on varying degrees of evidence in the setting of impaired kidney function and/or dialysis [10,11,12,13,14,15,16]
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