Remdesivir in Patients with Acute or Chronic Kidney Disease and COVID-19

The paper published in Journal of the American Society of Nephrology (JASN) is an expert opinion on the risks of remdesivir treatment in patients with kidney disease. [1]. Concerns about the drug’s potential toxicity in patients with kidney disease relate both to remdesivir’s actions and to the potential accumulation of its sulfobutylether-β-cyclodextrin (SBECD) carrier.

Much of what is known about the pharmacokinetics and clinical effects of SBECD in kidney failure is gleaned from literature of intravenous voriconazole, which also uses this carrier. Short courses are generally well tolerated, without significant adverse events noted despite documented accumulation of SBECD above levels in patients with normal kidney function. Further, SBECD is readily removed by continuous renal replacement therapy (RRT) and hemodialysis, and significant accumulation only occurs in patients when dialysis is held for prolonged periods. Although SBECD exposure is higher than in patients with normal kidney function, RRT seems to keep this exposure within a limit that is generally considered safe.

Evaluating treatments for patients with COVID-19 who have AKI and ESKD is a major unmet clinical need given that these patients are at high risk of suffering excess morbidity and mortality.  The magnitude and pace of the current pandemic and the vulnerability of these patients create an immediate call to action for trials and systematic retrospective studies that can inform clinical decision making and increase access to a potentially life-saving therapy in this patient population.