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Renal Dosing

Which ICU drugs to adjust for kidney function, dialysis and CRRT

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Principles

Estimating clearance and timing doses

Drug labels use Cockcroft-Gault creatinine clearance; it needs a stable creatinine
In AKI the creatinine lags: give full loading doses and the first day of an antimicrobial before reducing
Obesity: use adjusted body weight in Cockcroft-Gault; low muscle mass overestimates clearance
Augmented renal clearance (young trauma, sepsis, burns): clearance over 130 mL/min underdoses beta-lactams and vancomycin
Intermittent hemodialysis: give dialyzable drugs after the session
CRRT at 20–25 mL/kg/h clears like a creatinine clearance of roughly 25–50 mL/min; dose closer to normal than for intermittent HD
Check levels where available (vancomycin, aminoglycosides, digoxin, lithium)

Antimicrobials

Adjust, or no change

Adjust for kidney function

Vancomycin	Load by weight; maintenance by AUC or levels
Piperacillin-tazobactam	Reduce at CrCl under 40; extended infusion common
Cefepime	Reduce at CrCl 60 or less; neurotoxicity (confusion, myoclonus, nonconvulsive seizures) in AKI
Meropenem	Reduce at CrCl 50 or less
Aminoglycosides	Extended-interval by levels; nephro- and ototoxic
Acyclovir	Reduce; hydrate to prevent crystal nephropathy
Fluconazole	Full load, then half the dose at CrCl 50 or less
TMP-SMX	Reduce at CrCl under 30; raises potassium and creatinine
Levofloxacin	Reduce at CrCl under 50

Usually no change

No renal adjustment	Ceftriaxone, azithromycin, doxycycline, linezolid, clindamycin, metronidazole, micafungin

Other ICU drugs

Anticoagulants, analgesics, sedatives and more

Anticoagulants

Enoxaparin	CrCl under 30: 1 mg/kg once daily (treatment), 30 mg daily (prophylaxis); heparin preferred in severe AKI or dialysis
DOACs	Each has its own kidney thresholds; dabigatran is the most kidney-dependent
Bivalirudin	Reduce; argatroban needs no kidney adjustment

Analgesia and sedation

Morphine	Avoid: active metabolites accumulate (sedation, respiratory depression)
Hydromorphone	Use lower doses; metabolite causes neuroexcitation
Fentanyl	Preferred opioid in kidney failure (no active metabolites)
Meperidine	Avoid (normeperidine seizures)
Midazolam	Active metabolite accumulates with infusions
Gabapentin, pregabalin	Reduce; toxicity causes sedation and myoclonus

Others

Levetiracetam	Reduce; supplement after hemodialysis
Digoxin	Reduce and follow levels
Famotidine	Halve the dose at CrCl under 50 (confusion)
Metformin	Hold at eGFR under 30, in AKI, and around iodinated contrast per protocol
Insulin	Needs fall as kidney function falls (less insulin clearance)
Magnesium, potassium, phosphate replacement	Smaller doses and closer levels
NSAIDs, IV contrast	Avoid or minimize in AKI
Baclofen	Avoid in kidney failure (encephalopathy)

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For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow your local protocols and medical direction.