Definition
- ESRD = final stage of chronic kidney disease (CKD stage 5), when GFR <15 mL/min/1.73 m².
- Kidneys cannot maintain fluid, electrolyte, acid–base, and metabolic balance.
- Patients usually require renal replacement therapy (hemodialysis, peritoneal dialysis, or kidney transplant).
Clinical Pharmacist Perspective
Causes
- Diabetes mellitus
- Hypertension
- Polycystic kidney disease
- Glomerulonephritis
- Long-standing CKD
Complications
- Uremia → fatigue, confusion, pericarditis
- Fluid overload → pulmonary edema, hypertension
- Electrolyte imbalances → hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis
- Anemia → decreased erythropoietin
- Bone-mineral disorder (CKD-MBD) → renal osteodystrophy
Pharmacist’s Role
- Renal dose adjustment: Many drugs need modification (antibiotics, antivirals, anticoagulants, analgesics).
- Avoid nephrotoxins: NSAIDs, aminoglycosides, IV contrast.
- Dialysis considerations: Some drugs are removed by dialysis → require post-dialysis dosing.
- Supportive therapy:
- Erythropoiesis-stimulating agents (ESAs) for anemia
- Phosphate binders for hyperphosphatemia
- Vitamin D analogs and calcimimetics for secondary hyperparathyroidism
- Sodium bicarbonate for metabolic acidosis
Oncology Pharmacist Perspective
Why ESRD is Critical in Oncology
- Chemotherapy and targeted agents: Many are renally cleared → require dose adjustment or avoidance (e.g., methotrexate, cisplatin, carboplatin, capecitabine).
- Dialysis impact: Some chemo drugs are dialyzable (e.g., cytarabine, fludarabine, some antibiotics used in neutropenic fever).
- Nephrotoxicity risk: Several cancer drugs cause or worsen kidney injury:
- Cisplatin → acute tubular necrosis
- Ifosfamide → Fanconi syndrome
- Methotrexate (high dose) → crystal nephropathy
- Immune checkpoint inhibitors (e.g., nivolumab, pembrolizumab) → immune-mediated nephritis
- Supportive care:
- Antifungals/antivirals for prophylaxis often need renal adjustment (e.g., acyclovir, fluconazole).
- Pain management: Morphine and codeine accumulate in ESRD → use fentanyl or methadone instead.
- Tumor lysis syndrome (TLS): ESRD patients are at higher risk; avoid nephrotoxic drugs and use rasburicase (contraindicated in G6PD deficiency).
Practical Oncology Pharmacy Considerations
- Always check creatinine clearance/GFR before chemotherapy dosing.
- Adjust hydration protocols for cisplatin (difficult in dialysis-dependent patients).
- Select non-renal cleared agents when possible (e.g., doxorubicin, vincristine).
- Collaborate closely with nephrology and oncology teams for dosing schedules around dialysis.
Key Takeaways
- ESRD = irreversible kidney failure, requiring dialysis/transplant.
- For clinical pharmacists: focus on renal dosing, dialysis timing, supportive therapies.
- For oncology pharmacists: extra caution with nephrotoxic chemotherapy, tumor lysis, drug clearance, and supportive care agents.