Medication Management in the Critically Ill Patient with Acute Kidney Injury

Michael L. Behal, Alexander H. Flannery, Erin F. Barreto

Research output: Contribution to journalArticlepeer-review


AKI occurs frequently in critically ill patients. Patients with AKI, including those who require KRT, experience multiple pharmacokinetic and pharmacodynamic perturbations that dynamically influence medication effectiveness and safety. Patients with AKI may experience both subtherapeutic drug concentrations, which lead to ineffective therapy, and supratherapeutic drug concentrations, which increase the risk for toxicity. In critically ill patients with AKI not requiring KRT, conventional GFR estimation equations, especially those based on serum creatinine, have several limitations that can limit the accuracy when used for medication dosing. Alternative methods to estimate kidney function may be informative, including use of measured urinary creatinine clearance, kinetic eGFR, and equations that integrate novel kidney biomarkers. For critically ill patients with AKI requiring KRT, physicochemical properties of the drug, the KRT prescription and circuit configuration, and patient-specific factors each contribute to medication clearance. Evidence-based guidance for medication dosing during AKI requiring KRT is often limited. A working knowledge of the basic tenets of drug elimination during KRT can provide a framework for how to approach decision making when the literature is lacking. Iterative re-evaluation of a patient’s progress toward therapeutic goals with a medication must occur over the arc of critical illness, including and especially in the setting of dynamic kidney function.

Original languageEnglish
Pages (from-to)1080-1088
Number of pages9
JournalClinical Journal of the American Society of Nephrology
Issue number8
StatePublished - Aug 2023

Bibliographical note

Funding Information:
This project was supported in part by the National Institutes of Health under awards K23AI143882 (PI: EFB) and K23DK128562 (PI: AHF).

Funding Information:
E.F. Barreto reports employment with Mayo Clinic, research funding from AHRQ and NIAID, honoraria from Vifor Pharma, and advisory or leadership roles for FAST Biomedical advisory board (paid as needed for consulting services) and Wolters Kluwer (paid as needed for consulting services). A.H. Flannery reports consultancy agreements with and research funding from La Jolla Pharmaceutical Company. The remaining author has nothing to disclose.

Publisher Copyright:
© 2023 by the American Society of Nephrology.

ASJC Scopus subject areas

  • Epidemiology
  • Critical Care and Intensive Care Medicine
  • Nephrology
  • Transplantation


Dive into the research topics of 'Medication Management in the Critically Ill Patient with Acute Kidney Injury'. Together they form a unique fingerprint.

Cite this