Drug dosing in renal disease

Renal disease alters the effects of many drugs, particularly when active drug moieties are renally cleared. Drug doses should usually be reduced in renal disease in proportion to the predicted reduction in clearance of the active drug moiety. Patient factors to consider in adjusting drug doses include the degree of renal impairment and patient size. Drug factors to consider in adjusting doses include the fraction of the drug excreted unchanged in urine and the drug's therapeutic index. Estimates of renal function are useful to guide dosing of renally cleared drugs with medium therapeutic indices, but are not precise enough to guide dosing of drugs with narrow therapeutic indices. This article discusses principles of drug dose adjustment in renal disease.     

Antimalarial dosing regimens and drug resistance

The contribution of underdosing to antimalarial treatment failure has been underappreciated. Most recommended dosage regimens are based on studies in non-pregnant adult patients. Young children and pregnant women, who bear the heaviest malaria burden, have the highest treatment failure rates. This has been attributed previously to lower immunity, although blood concentrations of many antimalarial drugs are significantly lower in pregnant women and young children than in non-pregnant adults. Nevertheless, there have been no studies of higher dosages. Sub-therapeutic concentrations will certainly contribute to poorer responses to treatment and will fuel the emergence and spread of antimalarial drug resistance. There is an urgent need for studies to optimise antimalarial dosage regimens in infants, young children and pregnant women, both to improve cure rates and to prolong the useful therapeutic lives of antimalarial drugs.     

A theoretical analysis of interval drug dosing for cell-cycle-phase-specific drugs.

A formal method is provided for predicting the effect on treatment efficacy of cell-cycle-phase-specific drugs, such as the AIDS drug zidovudine (AZT) or the cancer drug cytosine arabinoside (ara-C). Our analysis shows that the elimination of somatic cells or viruses depends not only on the drug's pharmacokinetic and pharmacodynamic properties, but also the duration of the dosing interval per se and on the life-cycle parameters, that is, the duration of the drug-susceptible life phase, the duration of the whole life cycle, and the proliferation rate. The results support those of simplified models in showing that drug toxicity to the host may be minimized when the dosing interval is an integer multiple of the average cycle time of the host susceptible cells. This prediction has been verified in mice treated with AZT or ara-C.     

Therapeutic drug monitoring of eculizumab: Rationale for an individualized dosing schedule

The annual cost of eculizumab maintenance therapy in paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic–uremic syndrome (aHUS) exceeds $300,000 per patient. A better understanding of eculizumab pharmacokinetics and subsequent individual dose adjustment could reduce this cost. We measured the trough eculizumab concentration in 9 patients with maintenance therapy (aHUS, n = 7; PNH, n = 2) and determined: 1) the intra- and inter-individual variability; 2) the influence of weight on eculizumab pharmacokinetics; and 3) the rate of elimination of eculizumab following discontinuation. A one-compartment model was developed to describe the pharmacokinetics of eculizumab and predicted complement activity by body weight. Trough eculizumab concentrations were >50 µg/mL in 9/9, >100 µg/mL in 8/9, and >300 µg/mL in 5/9 of patients. Intra-individual variability was low but eculizumab concentrations, closely correlated with patient weight (R² = 0.66, p = 0.034), varied broadly (55 ± 12 to 733 ± 164 µg/mL). Pharmacokinetic modeling showed that the elimination half-life varied greatly, with an increase from 7.8 d in a patient weighing 100 kg to 19.5 d in a 40 kg patient. We predicted that infusions of 1200 mg could be spaced every 4 or 6 weeks in patients weighing <90 and <70 kg, respectively. In this pilot study, the current recommended use of a fixed eculizumab dose for maintenance therapy is associated with excessively high trough concentrations in many patients. Further prospective larger studies are now required to support an individualized schedule adjusted for patient weight and based on the observed trough serum eculizumab concentration.     

Therapeutic drug monitoring of eculizumab: Rationale for an individualized dosing schedule

The annual cost of eculizumab maintenance therapy in paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic–uremic syndrome (aHUS) exceeds $300,000 per patient. A better understanding of eculizumab pharmacokinetics and subsequent individual dose adjustment could reduce this cost. We measured the trough eculizumab concentration in 9 patients with maintenance therapy (aHUS, n = 7; PNH, n = 2) and determined: 1) the intra- and inter-individual variability; 2) the influence of weight on eculizumab pharmacokinetics; and 3) the rate of elimination of eculizumab following discontinuation. A one-compartment model was developed to describe the pharmacokinetics of eculizumab and predicted complement activity by body weight. Trough eculizumab concentrations were >50 µg/mL in 9/9, >100 µg/mL in 8/9, and >300 µg/mL in 5/9 of patients. Intra-individual variability was low but eculizumab concentrations, closely correlated with patient weight (R² = 0.66, p = 0.034), varied broadly (55 ± 12 to 733 ± 164 µg/mL). Pharmacokinetic modeling showed that the elimination half-life varied greatly, with an increase from 7.8 d in a patient weighing 100 kg to 19.5 d in a 40 kg patient. We predicted that infusions of 1200 mg could be spaced every 4 or 6 weeks in patients weighing <90 and <70 kg, respectively. In this pilot study, the current recommended use of a fixed eculizumab dose for maintenance therapy is associated with excessively high trough concentrations in many patients. Further prospective larger studies are now required to support an individualized schedule adjusted for patient weight and based on the observed trough serum eculizumab concentration.     

Estimating drug shelf-life with random batches.

The problem of assessing the shelf-lives of drug products in the market is considered. We focus on the situation where the drug characteristic of interest has a linear relationship over time and batch-to-batch variation is present. Two methods for assessing shelf-lives are proposed based on the weighted least squares method under a regression model with random coefficients. An application to some stability data from the pharmaceutical industry is presented.     

Major molecular differences between mammalian sexes are involved in drug metabolism and renal function

Many anatomical differences exist between males and females; these are manifested on a molecular level by different hormonal environments. Although several molecular differences in adult tissues have been identified, a comprehensive investigation of the gene expression differences between males and females has not been performed. We surveyed the expression patterns of 13,977 mouse genes in male and female hypothalamus, kidney, liver, and reproductive tissues. Extensive differential gene expression was observed not only in the reproductive tissues, but also in the kidney and liver. The differentially expressed genes are involved in drug and steroid metabolism, osmotic regulation, or as yet unresolved cellular roles. In contrast, very few molecular differences were observed between the male and female hypothalamus in both mice and humans. We conclude that there are persistent differences in gene expression between adult males and females. These molecular differences have important implications for the physiological differences between males and females.     

Effects on renal function of a drug antagonistic to morphine-like peptide systems after water load

Following i.v. administration of 0,4 mg Naloxone, a pure antagonist of opioid peptides, a study of renal function was performed in 5 patients who underwent oral water load equal to 20 cc/Kg water for 15-20 min. Within 15 min after administration of the drug all cases showed a further increase in urinary flow resulting from an increase in glomerular filtration rate and CH2O. The absence of systemic haemodynamic changes (BP, HR) suggested an intrarenal origin of the phenomena observed, as a sign of expansion of the system responsible for free water elimination. We put forward the hypothesis that Naloxone inhibits the antidiuretic activity of opioid peptides - in any case quiescent under water load conditions - which is masked by osmotic and volume mechanism.     

Eicosanoids in renal function

The major role of renal eicosanoid synthesis appears to be a protective one. In the cortex, prostaglandin synthesis minimises potential anoxic and ischaemic damage by vasodilatation. In the medulla, prostaglandin synthesis appears to stabilise the corticomedullary solute gradient and may play a role in cell volume regulation. Mono-oxygenase production at this site, by modifying blood flow and cellular active transport processes could again serve a protective function against anoxia and ischaemia. The release of erythropoietin also appears to be prostaglandin dependent. It is likely that leukotrienes released from inflammatory cells within the kidney will affect renal haemodynamics and capillary permeability as in other tissues.     

Development of renal function

The mammalian metanephric kidney develops following a general principle of organogenesis of epithelial organs, i.e., along the tree-like structure of an arborizing ductal system (the ureteric bud and cortical collecting duct). In parallel, the proximal portions of the uriniferous tubule develop by mesenchymal-to-epithelial transition of the neighbouring mesenchyme. On one hand, vectorial transport systems in nephrogenesis should be functional at the onset of glomerular filtration in any of the newly formed nephron generations to prevent loss of salt, water and metabolites. On the other hand, developing nephron epithelia must serve the needs of organ-formation such as cell proliferation and fluid-secretion for morphogenic purposes. This review intends to summarize current data and concepts on the development of renal epithelial functions with an emphasis on ion channels. Current model systems are introduced, such as ureteric bud cell monolayer culture, in vitro nephron culture, HEK293 cell culture, and the dissection of tubular cells for direct analysis. The current data on the developmental expression and functions of ENaC Na⁺ channels, the CFTR, ClC-2 Cl^ndash; channels, L-type Ca²⁺ channels, P2 purinoceptors, and the Kir6.1/SUR2, ROMK (Kir1.1), and Kv K⁺ channels are presented.     

Chitosan oligomers as drug carriers for renal delivery of zidovudine

Chitosan oligomers (COS) are water soluble and can be a potential drug carrier for renal targeting delivery. Zidovudine (AZT), a FDA approved antiretroviral drug, has a very short half life and is eliminated very quickly in human plasma and kidney after administration. In this study, AZT-COS conjugates were prepared and evaluated in terms of renal targeting. The in vitro release of AZT from AZT-COS conjugates was confirmed in mice plasma and renal homogenate. The pharmacokinetics study indicated longer mean retention time of AZT-COS conjugates with the values of about 1.5 h than 0.59 h of AZT. The AZT-COS conjugates were found accumulated in kidney other than heart, liver, spleen, lung and brain after i.v. administration, in line with the evidence of the fluorescence imaging of FITC labeled COS in 12 h. In conclusion, AZT-COS conjugates have the potential to be developed into a renal-targeting drug delivery system.