Liposomal Amphotericin B Dosing in AKI and Chronic Liver Disease
For an immunocompromised patient with Acremonium citrinum infection, acute kidney injury, and chronic liver disease, use liposomal amphotericin B at 3-5 mg/kg/day IV without dose reduction, as the drug is not renally eliminated and causes significantly less nephrotoxicity than conventional amphotericin B. 1
Standard Dosing Regardless of Renal Function
Liposomal amphotericin B does not require dose adjustment in AKI or chronic kidney disease because it is not significantly eliminated by the kidneys and does not accumulate in renal impairment 1
The drug is not dialyzable, so no supplemental dosing is needed post-hemodialysis 1
For severe invasive fungal infections in immunocompromised patients, the standard dose is 3-5 mg/kg/day IV, which should be maintained regardless of baseline creatinine or AKI stage 2, 1
Rationale for Full Dosing in AKI
Liposomal amphotericin B causes significantly less nephrotoxicity than conventional amphotericin B deoxycholate, making it the formulation of choice when creatinine is elevated 1, 3
In critically ill patients with AKI receiving liposomal amphotericin B, no significant variations in serum creatinine were observed during treatment, and patients in the high-risk AKI subgroup actually showed decreased creatinine levels 4
Real-world data from 507 patients showed that while 37% developed AKI after liposomal amphotericin B initiation, the development of AKI was multifactorial and primarily associated with concomitant nephrotoxic medications (catecholamines, ACE inhibitors/ARBs, carbapenems, immunosuppressants) rather than the liposomal amphotericin B itself 5, 4
Specific Dosing Algorithm
For Acremonium citrinum (rare mold infection in immunocompromised host):
Start with liposomal amphotericin B 5 mg/kg/day IV (using the higher end of the 3-5 mg/kg range given the severity of infection and immunocompromised status) 2, 1
Infuse over 2-6 hours depending on tolerance 6
Continue for at least 1-2 weeks until clinical improvement, then consider transition to an azole if susceptibility testing permits 2
Critical Monitoring Parameters
Monitor serum creatinine, potassium, and magnesium levels during therapy, as electrolyte wasting can occur even with the liposomal formulation 1, 3
Ensure adequate hydration with 0.9% saline IV 30 minutes before infusion to minimize nephrotoxicity risk 3
Serum potassium <3.5 mEq/L before liposomal amphotericin B therapy is associated with severe AKI (stage 2-3), so aggressive potassium repletion is essential 5
Special Considerations for Chronic Liver Disease
Liposomal amphotericin B is safe in chronic liver disease as it does not require hepatic dose adjustment 2
The highest tissue concentrations occur in liver and spleen, which may be advantageous for treating systemic fungal infections in patients with liver disease 7
Monitor liver enzymes, but hepatotoxicity is uncommon with liposomal amphotericin B compared to azoles 2
Common Pitfalls to Avoid
Do not reduce the dose based solely on elevated baseline creatinine or AKI stage, as this is unnecessary and may compromise efficacy in a life-threatening infection 1
Do not confuse liposomal amphotericin B with conventional amphotericin B deoxycholate, which has nephrotoxicity rates up to 80% and should be avoided in patients with pre-existing renal impairment 3, 8
Avoid concomitant nephrotoxic medications when possible, particularly aminoglycosides, cyclosporine, ACE inhibitors/ARBs, and carbapenems, as these significantly increase AKI risk even with the liposomal formulation 8, 5
Never exceed 10 mg/kg/day total daily dose, as higher doses are associated with increased nephrotoxicity risk without proven additional benefit for most infections 2, 1
Risk Stratification for AKI Development
High-risk factors for AKI during liposomal amphotericin B therapy include: 5
- Concomitant catecholamine administration
- Concomitant immunosuppressant use
- Prior treatment with ACE inhibitors/ARBs or carbapenems
- Liposomal amphotericin B dosing ≥3.52 mg/kg/day
- Baseline serum potassium <3.5 mEq/L
If ≥3 risk factors are present, intensify monitoring but do not reduce the dose, as undertreating the fungal infection carries higher mortality risk than potential AKI 8, 5