Antimicrobial pharmacokinetics in pediatric patients on kidney replacement therapy: a comprehensive narrative review

Patients on dialysis frequently require antimicrobial administration for a variety of reasons, including sepsis. Studies in adults have demonstrated a need for antimicrobial dosing adjustment in patients on dialysis due to altered pharmacokinetics (PK) as compared with patients not on kidney replacement therapy (KRT). High-quality studies evaluating PK of frequently used antimicrobials in pediatric patients on KRT are lacking. Dosing recommendations in this population are extrapolated from adult studies, which relies on the assumption that PK between adult and pediatric patients are similar. We conducted a literature review to describe the existing literature on antimicrobial PK in pediatric patients on dialysis and outline gaps that should be the focus of future research. We identified 56 original studies evaluating PK of twelve different antimicrobials in pediatric patients on hemodialysis, peritoneal dialysis, or continuous KRT. This narrative review demonstrates that antimicrobial PK in pediatric patients on dialysis are understudied, despite this population being at increased risk of infection and vulnerable to drug toxicity. Future research should focus on drugs that are most used and drugs with known/suspected risk of toxicity at elevated concentrations.