Lorazepam Use in End-Stage Renal Disease

Pharmacokinetics and Safety

Lorazepam is primarily metabolized by the liver through glucuronidation, not by the kidneys, which means that the parent drug clearance is not significantly altered in renal failure, according to the Critical Care Medicine guidelines 1, 2, 3
Propylene glycol can accumulate and cause metabolic acidosis and acute kidney injury in ESRD patients, with toxicity occurring at total daily IV doses as low as 1 mg/kg, as noted by the Critical Care Medicine guidelines 1, 2
Monitoring serum osmol gap is recommended, with values >10-12 mOsm/L suggesting propylene glycol accumulation, as suggested by the Critical Care Medicine guidelines 1, 2

Lorazepam is safer than other benzodiazepines, such as midazolam and diazepam, in renal failure, because its glucuronide metabolite is inactive, eliminating the concern of prolonged sedation, according to the Critical Care Medicine guidelines 1, 2, 3