Evaluation of renal effects of liposomal amphotericin B in children with malignancies with KDIGO and RIFLE criteria

Therapeutic drug monitoring of liposomal amphotericin B in children. Are we there yet? A systematic review

INTRODUCTION

Therapeutic drug monitoring (TDM) is a tool that supports personalized dosing, but its role for liposomal amphotericin B (L-amb) is unclear. This systematic review assessed the evidence for L-amb TDM in children.

OBJECTIVES

To evaluate the concentration-efficacy relationship, concentration-toxicity relationship and pharmacokinetic/pharmacodynamic (PK/PD) variability of L-amb in children.

METHODS

We systematically reviewed PubMed and Embase databases following PRISMA guidelines. Eligible studies included L-amb PK/PD studies in children aged 0-18 years. Review articles, case series of

RESULTS

In total, 4220 studies were screened; 6 were included, presenting data on 195 children. Invasive candidiasis and aspergillosis were the two most common infections treated with L-amb. Studies showed significant PK variability due to age (mean age ranged from 14 days to 17 years), body weight, non-linear PK and changes in the volume of distribution. Limited evidence supported a peak concentration/MIC (Cmax/MIC) of 25-50 for optimal efficacy and an AUC24 of >600 mg·h/L for nephrotoxicity. L-amb doses of 2.5-10 mg/kg/day were reported to achieve Cmax/MIC > 25 using an MIC of 1 mg/L.

CONCLUSIONS

While significant PK variability was observed in children, evidence to support routine L-amb TDM was limited. Further studies on efficacy and toxicity benefits are required before routine TDM of L-amb can be recommended.

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MESH Headings

• Humans
• Amphotericin B/pharmacokinetics
• Amphotericin B/administration & dosage
• Amphotericin B/adverse effects
• Amphotericin B/therapeutic use
• Drug Monitoring
• Child
• Antifungal Agents/pharmacokinetics
• Antifungal Agents/administration & dosage
• Antifungal Agents/adverse effects
• Antifungal Agents/therapeutic use
• Child, Preschool
• Adolescent
• Infant
• Infant, Newborn
• Aspergillosis/drug therapy
• Microbial Sensitivity Tests

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Grants

• Australian Government (RTP) Scholarship

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Affiliation(s)

Tony Lai Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
Chin-Yen Yeo Pharmacy Department, Concord Hospital, Sydney, Australia
Bradley Rockliff Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
Michael Stokes Pharmacy Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
Hannah Yejin Kim Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia Pharmacy Department, Westmead Hospital, Sydney, Australia
Ben J Marais The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia
Andrew J McLachlan Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
Jan-Willem C Alffenaar The University of Sydney Infectious Diseases Institute (Sydney ID), Sydney, NSW, Australia Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia Pharmacy Department, Westmead Hospital, Sydney, Australia

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Incidence of Antimicrobial-Associated Acute Kidney Injury in Children: A Structured Review

Acute kidney injury (AKI) is a commonly reported adverse effect of administration of antimicrobials. While AKI can be associated with poorer outcomes, there is little information available to understand rates of AKI in children exposed to various antimicrobials. We performed a structured review using the PubMed and Embase databases. Articles were included if they provided an AKI definition in patients who were < 19 years of age receiving an antimicrobial and reported the frequency of AKI. Author-defined AKI rates were calculated for each study and mean pooled estimates for each antimicrobial were derived from among all study participants. Pooled estimates were also derived for those studies that reported AKI according to pRIFLE (pediatric risk, injury, failure, loss, end stage criteria), AKIN (acute kidney injury network), or KDIGO (kidney disease improving global outcomes) creatinine criteria. A total of 122 studies evaluating 28 antimicrobials met the inclusion criteria. Vancomycin was the most commonly studied drug: 11,514 courses across 44 included studies. Among the 27,285 antimicrobial exposures, the overall AKI rate was 13.2% (range 0-42.1% by drug), but the rate of AKI varied widely across studies (range 0-68.8%). Cidofovir (42.1%) and conventional amphotericin B (37.0%) had the highest pooled rates of author-defined AKI. Eighty-one studies used pRIFLE, AKIN, or KDIGO AKI criteria and the pooled rates of AKI were similar to author-defined AKI rates. In conclusion, antimicrobial-associated AKI is reported to occur frequently in children, but the rates of AKI varies widely across studies and drugs. Most published studies examined hospitalized patients and heterogeneity in study populations and in author definitions of AKI are barriers to a comparison of nephrotoxicity risk among antimicrobials in children.