International Journal of Hepatology / 2012 / Article / Tab 6

Review Article

Fungal Infections: Their Diagnosis and Treatment in Transplant Recipients

Table 6

(a) Experience in patients with prexisting renal disease

AgentEffects on the kidneyDosing modifications for preexisting renal disease

(1) Amphotericin BNephrotoxic-elevation of BUN, creatinineSodium loading to ameliorate toxicity

(2) AmBisomeNephrotoxicUsed in pt with pre-existing renal impairment

(3) ABCDNephrotoxic

(4) ABLCDose-limited renal toxicity

(5) VoriconazoleSBECD component of iv formulation No adjustment for oral vori in pts with mild-to-severe renal impairment
associated with renal toxicityI.V. should be avoided if creatinine clearance <30 mL/min

(6) Fluconazole50–400 mg creatinine clearance >50–100% creatinine clearance <50 (no dialysis)-adm. 50% of dose
regular dialysis-admin 100% of dose after each dialysis

(7) ItraconazoleSBECD component of iv formulation I.V. should not be used if creatinine clearance <30 mL/min
associated with renal toxicity

(8) PosaconazoleNo dose adjustment for mild-to-moderate
severe-monitor for breakthrough IFI

(9) AnidulafunginNoneNo dose adjustment, not dialyzable

(10) CaspofunginNoneNo dose adjustment, not dialyzable

(11) MicafunginNoneNo dose adjustment

(b) Experience in individuals with pre-existing hepatic disease

AntifungalNormal PatientsMild Moderate Severe Effects on the liver
(Child-Pugh 5-6) (Child-Pugh 7–9) (Child-Pugh >9)

Anidulafungin200 mg loading dose on day 1 followed by 100 mg once/day200 mg loading dose on day 1 followed by 100 mg once/day200 mg loading dose on day 1 followed by 100 mg once/day200 mg loading dose on day 1 followed by 100 
mg once/day
None

Micafungin100 mg once/day100 mg once/day100 mg once/dayNot studiedNone

Caspofungin70 mg loading dose on day 1 followed by 50 mg once/day70 mg loading dose on day 1 followed by 50 mg once/day70 mg loading dose on day 1 followed by 35 mg once/dayNot studiedNone

FluconazoleLoading dose of 2x the daily dose, then up to 400 mg daily No dosage adjustments initially, monitor LFTs in patients for worsening hepatic functionHepatotoxic

Itraconazole200 mg q12 IV 100–200 mg q12 po-solution No studies have been conducted looking at patients with hepatic impairment, use with cautionHepatotoxic, prolonged elimination half-life in cirrhotic patients (meds metabolized by CYP3A4)

Voriconazole6 mg/kg IV q12h for the first 24 hours loading dose followed by 3-4 mg/kg IV q12h maintenance dose then 200 mg q12h oral6 mg/kg IV q12h for the first 24 hours loading dose followed by 1.5–2 mg/kg IV q12h maintenance dose6 mg/kg IV q12h for the first 24 hours loading dose followed by 1.5–2 mg/kg IV q12h maintenance doseNot studiedHepatotoxic

PosaconazoleOral Suspension 200 mg (5 mL) three times a day with a full meal or liquid nutritional supplement, monitoring of LFT's is recommended Data was not sufficient to determine dosing, should be used with cautionMild-to-moderate elevation of liver enzymes, bilirubin-generally reversible

Amphotericin B deoxycholate0.6 to 1 mg/kg/day Data was not sufficient to determine dosingElevation of liver enzymes

Ampho B lipid complex (Abelcet)5 mg/kg/day Data was not sufficient to determine dosingElevation of liver enzymes

Ampho B colloidal dispersion (Amphotec)3-4 mg/kg/day can be increased up to 6 mg/kg/day Data was not sufficient to determine dosingElevation of liver enzymes

Ampho B liposomal (AmBisome)3-4 mg/kg/day can be increased up to 6 mg/kg/day Data was not sufficient to determine dosingElevation of liver enzymes

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