title: The recommended dose of ertapenem poses a potential risk for central nervous system toxicity in haemodialysis patients - case reports and literature reviews.
abstract: OBJECTIVE
  Dosage adjustment of 500 mg ertapenem daily is recommended for patients with advanced kidney disease. 30% of ertapenem is cleared by a session of haemodialysis (HD). However, because most published carbapenems studies have excluded patients on dialysis, little is known about the dosing of ertapenem to avoid central nervous system (CNS) toxicity in regular HD patients. We report of four patients who developed CNS toxicity in such patients.
  
  
  METHODS
  The 4 HD patients developed unexplained CNS toxicity manifested as seizures, hallucination and cognitive dysfunction after receiving 3-7 consecutive recommended doses of ertapenem. Their symptoms of CNS toxicity were completely resolved within 8 days after discontinuation of ertapenem. In one of our presented cases, we demonstrated the very high level of plasma ertapenem accumulating with several consecutive doses. Cognitive function gradually recovered in line with a corresponding decline in blood level of ertapenem.
  
  
  CONCLUSIONS
  This is the first report of ertapenem-associated CNS toxicity in patients on regular HD and utilizing the plasma ertapenem concentration to demonstrate the causal relationship. The recommended dosage of 500 mg ertapenem daily may be still too high in regular HD patients, especially in Asians, owing to their relatively small body size. An increased awareness of ertapenem-associated CNS toxicity would avoid unnecessary examinations, hospitalization, and potentially catastrophic complications.
authors.affiliation: Division of Nephrology, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.
authors.forename: K-H
authors.initials: KH
authors.lastname: Lee
authors.forename: Y-F
authors.initials: YF
authors.lastname: Ueng
authors.forename: C-W
authors.initials: CW
authors.lastname: Wu
authors.forename: Y-C
authors.initials: YC
authors.lastname: Chou
authors.forename: Y-Y
authors.initials: YY
authors.lastname: Ng
authors.forename: W-C
authors.initials: WC
authors.lastname: Yang
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000493:pharmacokinetics*; D044466:Asian People; D002493:Central Nervous System Diseases / Q000139:chemically induced*; D004305:Dose-Response Relationship, Drug; D000077727:Ertapenem; D005260:Female; D006801:Humans; D008297:Male; D006435:Renal Dialysis; D051437:Renal Insufficiency; D047090:beta-Lactams / Q000009:adverse effects* / Q000493:pharmacokinetics*
chemical_list: D000900:Anti-Bacterial Agents; D047090:beta-Lactams; D000077727:Ertapenem
keywords: CNS toxicity; encephalopathy; ertapenem; haemodialysis