What medications are recommended for a patient on Peritoneal Dialysis (PD) with End-Stage Renal Disease (ESRD) who is oliguric?

Medication Management for Oliguric Patients on Peritoneal Dialysis with ESRD

For patients on peritoneal dialysis (PD) with end-stage renal disease (ESRD) who are oliguric, medication dosing must be adjusted to account for decreased drug clearance, with specific attention to avoiding nephrotoxic agents and adjusting doses of renally cleared medications.

Medication Dosing Principles for PD Patients

Antimicrobials

• Antibiotics:
  • Trimethoprim-sulfamethoxazole: Reduce to half dose or use alternative agent if creatinine clearance <15 mL/min 1
  • Rifampin: 50-100% of full dose; add extra 50-100% of full dose after peritoneal dialysis 1
  • Ciprofloxacin and other fluoroquinolones: Require dose adjustment based on renal function 1
  • Acyclovir: Requires significant dose reduction in PD patients to avoid neurotoxicity 1

Cardiovascular Medications

• Antihypertensives:
  • ACE inhibitors/ARBs: May help preserve residual kidney function, especially important in PD patients 1
  • Beta-blockers: Consider atenolol with post-dialysis administration 2
  • Calcium channel blockers: Associated with lower cardiovascular mortality in dialysis patients 2
  • Diuretics: May help preserve residual diuresis and limit fluid overload in patients who still produce urine 1

Bone and Mineral Metabolism

• Phosphate Binders:

  • Calcium-based binders: Must be limited in oliguric PD patients due to risk of calcium accumulation 1
  • Non-calcium containing binders: Consider in oliguric patients to avoid calcium overload 1

• Cinacalcet: Effective for secondary hyperparathyroidism in PD patients; no dose adjustment needed for renal function 3

Anemia Management

• HIF-PHI inhibitors (daprodustat, roxadustat): Newer agents for anemia management that may have different properties and effects on lipid metabolism 1

Special Considerations for Oliguric PD Patients

Volume Management

• Oliguric PD patients require careful attention to fluid balance and ultrafiltration 4
• Salt restriction is crucial for blood pressure control in PD patients with limited or no urine output 4

Medication Reconciliation

• Critical at all care transitions to prevent medication errors 1
• Particular attention to high-risk medications that require renal dosing 1

Common Pitfalls to Avoid

1. Failure to adjust medication doses: Many medications require dose adjustments in PD patients, especially those who are oliguric 1

2. Inappropriate use of nephrotoxic agents: Avoid nephrotoxic drugs that may further compromise residual kidney function 1

3. Inadequate monitoring: Regular monitoring of drug levels for medications with narrow therapeutic indices is essential 1

4. Overlooking dialyzability: Consider whether medications are removed by PD when determining dosing schedules 1

5. Ignoring residual kidney function: Even small amounts of residual function can affect drug clearance and should be assessed regularly 1

Practical Approach to Medication Management

1. Assess residual kidney function every 2 months if peritoneal clearance is less than 1.7/week 1

2. Adjust medication doses based on both renal function and peritoneal clearance

3. Administer medications after dialysis when appropriate to avoid premature removal

4. Monitor for adverse effects more frequently than in patients with normal kidney function

5. Perform medication reconciliation at all care transitions to prevent medication errors 1

By following these principles, medication management can be optimized for oliguric patients on peritoneal dialysis with ESRD, potentially improving outcomes and reducing complications.