Includes Appendix and Index

Acute kidney injury (AKI) is a common cause of morbidity and mortality rates in
critically ill patients requiring intensive care therapies (40–50 %). The incidence of
AKI varies from 5 % of all hospitalized patients to 30–40 % of patients admitted to
the pediatric intensive care unit. The critically ill children with AKI often have multiple organ dysfunctions and are frequently treated with several drugs including
antibiotics, anticonvulsants, vasopressors, and antihypertensive and cardiovascular
agents or which require appropriate dosing and interval. Despite significant improvements in the care of critically ill patients, the mortality and morbidity associated
with AKI remains high (>50 %) and can lead to end-stage renal disease.
Approach to the treatment of AKI patients requiring dialysis has gone under
evolution with the advent of continuous renal replacement therapy (CRRT) techniques over the last two decades. Critically ill and hemodynamic instable children
better tolerate CRRT than the intermittent hemodialysis. CRRT technology attempts
to replace the excretory function of the kidney. CRRT provides a slow and gentle
fluid removal from body much like the native kidneys and removes inflammatory
mediators of sepsis such as interleukin, TNF-alpha, and complement. CRRT also
provides adequate nutritional support for the catabolic AKI patients, a controlled
desired fluid balance.
Many AKI patients receiving CRRT suffer from multiple organ dysfunctions and
have various types of medications including antibiotics, anticonvulsants, anticoagulants, and cardiovascular agents. Drugs predominantly eliminated by the normal
kidneys often undergo substantial changes by CRRT. Therefore, a dose adjustment
is required to prevent under dosing of the medication or drug toxicity.
Unfortunately, few clinical studies have been published, and few drugs have been
studied pharmacoclinically in intensive care patients. Many guidelines for drug dosing during CRRT are extrapolated from experiences with adult chronic hemodialysis, and there has been a relative paucity of published data about drug dosing during
CRRT in critically ill children. Doses used in adults CRRT cannot be directly
applied to these children, as the CRRT dialysate prescription and pharmacokinetics
are different in adults compared with children. Failure to correctly dose may result
in either drug toxicity or treatment failure. In order to understand the optimal drug dosing for children receiving CRRT, one must understand the pattern of water and
solutes transport through a semipermeable membrane by all forms of CRRT.
In this book, we review the current understanding of CRRT techniques, with a
focus on drug dosing in critically ill children receiving CRRT. The effect of CRRT
on drug pharmacokinetics, which provides guidelines whether or not dose adjustment is required, is provided in an accompanying reference table. Variations in the
drug properties regarding their molecular weights, dialysis and blood flow rates, and
dialysis membranes are discussed. The book also provides a simple and easy method
for estimating drug clearance as a function of total creatinine clearance when the
information on the pharmacokinetics of a particular drug is not available.
In this book, we provide a series of challenging, clinically oriented case studies.
The selected case reports focus on the essential aspects of the patient’s presentation
and laboratory data and management to accelerate recovery. A series of logical
questioning from the presentation is followed by a detailed explanation that reviews
recent publications and translates emerging areas of science into data that is useful
at the bedside.
We hope that the book will expand the clinical knowledge of nephrology and
critical care trainees and other practicing physicians from different specialties who
are frequently involved in the care of critically ill children suffering from severe
AKI to improve and sustain their quality of life.
We are grateful to the staff at Springer Publishers, Inc., for their outstanding
editorial contributions to this endeavor and all those who have dedicated their skills
to make this effort entirely possible.