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Patterns of Medication Exposures in Hospitalized Pediatric Patients With Acute Renal Failure Requiring Intermittent or Continuous Hemodialysis*

Rizkalla, Nicole A. MD1; Feudtner, Chris MD, PhD, MPH2; Dai, Dingwei PhD2; Zuppa, Athena F. MD, MSCE3

Pediatric Critical Care Medicine: November 2013 - Volume 14 - Issue 9 - p e394–e403
doi: 10.1097/PCC.0b013e31829f5bc8
Online Clinical Investigations

Objectives: Care for the pediatric patient with acute renal failure who requires hemodialysis (including continuous renal replacement therapy) is made more complex, as this intervention may significantly affect drug clearance, potentially altering, to a degree that is largely unknown, the effectiveness and safety of the multiple medications used to manage this complex patient population. This study aims to describe patterns of drug utilization among a large cohort of pediatric patients requiring hemodialysis and to document the easily accessible existing data available for dosing guidance of frequently prescribed medications.

Study Design: Retrospective cohort using the Pediatric Health Information System database.

Setting: Forty freestanding children’s hospitals throughout the United States.

Patients: Two thousand seven hundred thirty-eight pediatric patients with acute renal failure treated with hemodialysis from 2007 to 2011.

Intervention: A retrospective review of all patients requiring hemodialysis from 2007 to 2011 was conduction using the Pediatric Health Information System Database.

Main Results: Over 6% of pediatric patients with acute renal failure treated with hemodialysis were exposed to hemodialysis for over 2 weeks. Cumulative exposure to distinct drugs increased substantially with more prolonged courses of hemodialysis. Of the 50 most frequently prescribed medications in the cohort with acute renal failure treated with hemodialysis, 10% have readily available and easily accessible information to guide dosing adjustments with the use of hemodialysis. Furthermore, only 18% of these medications have clear recommendations for dosing in pediatric patients of all age groups with renal failure.

Conclusions: Pediatric patients with acute renal failure managed with hemodialysis are exposed to a broad variety of medications, with a high prevalence of polypharmacy. There is a trend for longer courses of hemodialysis in these patients, which leads to an increase in cumulative drug exposure, complexity of drug interactions, and potential toxicity. For the vast majority of medications that are being used to treat this complex patient population, pediatric dosing guidance is not easily accessible. These findings underscore the need for targeted pharmacologic studies of medications used in the pediatric population managed with hemodialysis.

1Department of Anesthesiology and Critical Care Medicine, Bloomberg Children’s Center, Johns Hopkins University Hospitals, Baltimore, MD.

2Center for Pediatric Clinical Effectiveness and Policy Lab, The Children’s Hospital of Philadelphia, Philadelphia, PA.

3Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA.

* See also p. 904.

Supported, in part, by the Agency for Healthcare Quality and Research (1R01HS018425).

Dr. Feudtner received grant support from AHRQ-RO1 regarding pediatric drug exposures. Dr. Dai received grant support from AHRQ – RO1 regarding pediatric drug exposures. Dr. Zuppa received support from NIH grants. Dr. Rizkalla disclosed that she does not have any potential conflicts of interest.

For information regarding this article, E-mail: nrizkal1@jhmi.edu

©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies