Specificity of antibiotic therapy in patients with chronic kidney failure

Abstract

Chronic kidney diseases cause disruption of kidney function, but also of other organs which affects both the pharmacodynamics and the pharmacokinetics of many drugs. Prescribing drugs to patients with chronic kidney disease requires knowledge of changes in absorption, distribution, metabolism and excretion of drugs and their metabolites. Avoiding nephrotoxic drugs is the most important principle that we must follow in patients with chronic kidney disease. If administration of nephrotoxic drugs is necessary, regular control of glomerular filtration rate, serum electrolyte concentration, and serum drug concentration is required if possible. The dosing of drugs in patients with chronic renal insufficiency is very delicate, both when determining the initial dose and during the maintenance dose, so it is necessary to adjust the doses for each patient individually, depending on the degree of kidney damage. For most drugs, there are recommendations from the Agency for Drugs and Medical Devices of the Republic of Serbia on how to correct the dose of the drug in chronic kidney failure. If such a recommendation does not exist, general rules are used: the maintenance dose can be adapted to kidney function by reducing the dose, extending the intervals in which the unchanged dose of the drug is administered, or a combination of these two methods. In patients with chronic kidney damage, the infection accelerates the progression towards the terminal stage, when it is necessary to apply one of the methods to replace kidney function. The infection should be treated with appropriate doses of antibiotics and/or antifungals and for a sufficient period of time. Likewise, in dialysis patients, there are various causes of infections that must also be adequately treated in order not to compromise the dialysis method or endanger the patient's life. There are recommendations for the use of antibiotics and antimycotics in these cases, which should be applied and adjusted to the individual patient. In intensive care units, in hemodynamically unstable patients with sepsis and acute chronic kidney failure, instead of intermittent hemodialysis, the following methods can be used: prolonged intermittent hemodialysis (PID) and continuous procedures - continuous venovenous hemodialysis (CVVHD), continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodiafiltration (CVVHDF). The dosage of antibiotics in these patients is specific and adjusted to the individual patient and his kidney function. Peritoneal dialysis patients in the terminal phase of chronic kidney failure are at risk of developing peritonitis. The guides describe which antibiotics are used to start the treatment of peritonitis and how the antibiotics are then adjusted, according to the causative agent, after the dialysate culture is obtained. Treatment of peritonitis is mainly by intraperitoneal administration of antibiotics, but it is also possible with oral or parenteral antibiotics, i.e. their combination. The guidelines describe the initial and maintenance doses of antibiotics and antifungals. If treatment is not started on time, the dialysis method may be compromised and the patient may die. If fungi are isolated by culture, the treatment of the patient with peritoneal dialysis is stopped and the dialysis catheter is removed, and the treatment is continued with the administration of antibiotics intravenously.