Effect of CKD and dialysis modality on exposure to drugs cleared by nonrenal mechanisms

Am J Kidney Dis. 2015 Apr;65(4):574-82. doi: 10.1053/j.ajkd.2014.09.015. Epub 2014 Nov 21.


Background: Patients with kidney disease frequently experience adverse effects from medication exposure, even when drugs are cleared by nonrenal pathways. Although many studies suggest that nonrenal drug clearance is decreased in chronic kidney disease (CKD), there remains a paucity of in vivo studies in patients with varying degrees of decreased kidney function and those comparing the impact of dialysis modality (eg, hemodialysis [HD] and peritoneal dialysis [PD]).

Study design: We performed in vivo clinical pharmacokinetic studies of midazolam, a nonrenally cleared specific probe for CYP3A4, and fexofenadine, a nonspecific probe for hepatic and intestinal transporters.

Setting & participants: Healthy controls (n=8), patients with non-dialysis-dependent (NDD)-CKD (n=8), and patients receiving HD (n=10) or PD (n=8).

Outcomes: Exposure to midazolam and fexofenadine were quantified using area under the curve (AUC). Comprehensive pharmacokinetic parameters also were calculated for both probes.

Results: Midazolam AUC was significantly higher in the HD group (382.8 h·ng/mL) than in the healthy-control (63.0 h·ng/mL; P<0.001), NDD-CKD (84.5 h·ng/mL; P=0.002), and PD (47.4 h·ng/mL; P<0.001) groups. Fexofenadine AUC was significantly higher in each of the NDD-CKD (2,950 h·ng/mL; P=0.003), HD (2,327 h·ng/mL; P=0.01), and PD (2,095 h·ng/mL; P=0.04) groups compared with healthy controls (1,008 h·ng/mL).

Limitations: Small study groups had different proportions of diabetic patients, early stages of CKD not available.

Conclusions: Our data suggest that selection of dialysis modality is a major determinant of exposure to the CYP3A4 probe midazolam. Exposure to the intestinal and hepatic transporter probe fexofenadine is altered in patients with NDD-CKD and PD and HD patients. Thus, drug development and licensing of nonrenally cleared drugs should include evaluation in these 3 patient groups, with these results included in approved product information labeling. This reinforces the critical need for more in vivo studies of humans that evaluate the exposure to drugs cleared by these pathways.

Keywords: CYP3A4; Nonrenal drug clearance; adverse effects; chronic kidney disease (CKD); cytochrome P450; drug metabolism; hemodialysis (HD); hepatic and intestinal drug transporters; medication exposure; peritoneal dialysis (PD); pharmacokinetics.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anti-Allergic Agents / pharmacokinetics
  • Anti-Anxiety Agents / pharmacokinetics
  • Cytochrome P-450 CYP3A / metabolism
  • Female
  • Humans
  • Kidney / metabolism
  • Male
  • Midazolam / pharmacokinetics*
  • Middle Aged
  • Peritoneal Dialysis*
  • Renal Dialysis*
  • Renal Insufficiency, Chronic / therapy*
  • Severity of Illness Index
  • Terfenadine / analogs & derivatives*
  • Terfenadine / pharmacokinetics


  • Anti-Allergic Agents
  • Anti-Anxiety Agents
  • Terfenadine
  • fexofenadine
  • Cytochrome P-450 CYP3A
  • Midazolam