Practical considerations to drug dosing in children with acute kidney injury.

Medication dosing for children with acute kidney injury (AKI) needs to be individualized based on pharmacokinetic and pharmacodynamic principles of the prescribed drugswhenever possible to optimize therapeutic outcome and to minimize toxicity. The pediatric RIFLE criteria should be prospectively utilized to identify patients at highest risk of developing AKI. Serum creatinine and urine output along with volume status should be utilized to guide drug dosing when urinary biomarkers including kidney injury molecule 1, interleukin-18, or neutrophil gelatinase-associated lipocalin are not readily available. Because of the presence of a positive fluid balance in early stages of AKI, the dosing regimen for many drugs, especially antimicrobial agents, should be initiated at a larger loading dose based on the expected volume of distribution to achieve target serum concentrations.When possible, therapeutic drug monitoring should be utilized for those medications where serum drug concentrations can be obtained in a clinically relevant time frame. For these medications, close monitoring of serum drug concentrations is highly recommended. This review addresses drug-dosing strategies in pediatric patients with AKI including the roles of therapeutic drug monitoring and newer kidney injury biomarkers.