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Section VI — Safe Prescribing

Renal Drug Dosing

GFR-adjusted dosing for high-risk medications — anticoagulants and antibiotics — to reduce accumulation, bleeding, and nephrotoxicity. Match the patient's eGFR band to the correct column.

eGFR ≥ 50

Normal / mild

eGFR 30–49

Moderate

eGFR < 30 / HD

Severe / dialysis

Tip: Use the eGFR calculator (right edge of screen) to determine the patient's band before selecting a dose.

Medication

Standard Dose

eGFR ≥ 50

eGFR 30–49

eGFR < 30 / HD

Clinical Note

Warfarin

Anticoagulant

Vitamin K antagonist

2–10 mg PO daily

No adjustment (INR-guided)

No adjustment

Monitor INR; ↑bleeding risk in CKD; avoid rapid shifts

Enoxaparin

Anticoagulant

LMWH

1 mg/kg SC q12h (tx); 40 mg q24h (prophylaxis)

Standard

1 mg/kg q24h (tx); 30 mg q24h (prophylaxis); dose after HD

Contraindicated if CrCl <30 without dose reduction; ↑bleeding risk

Heparin (UFH)

Anticoagulant

Unfractionated heparin

80 U/kg bolus → 18 U/kg/hr IV infusion

No adjustment

No adjustment; safe in HD

Titrate to aPTT/anti-Xa; no renal clearance but ↑bleeding risk in CKD

Apixaban

Anticoagulant

DOAC (Factor Xa)

5 mg PO BID (AF)

Standard

5 mg BID; → 2.5 mg BID if 2 of: age ≥80, ≤60 kg, SCr ≥1.5

5 mg BID (↓ to 2.5 mg BID per criteria); use caution on HD

Avoid CrCl <15 per some guidance; reassess bleeding risk annually

Rivaroxaban

Anticoagulant

DOAC (Factor Xa)

20 mg PO daily (AF)

20 mg daily

15 mg daily

15 mg daily (CrCl 15–50); avoid if CrCl <15

Avoid CrCl <15; ↑bleeding risk; not dialyzable

Dabigatran

Anticoagulant

DOAC (direct thrombin)

150 mg PO BID (AF)

150 mg BID

150 mg BID (110 mg BID if high bleeding risk)

75 mg BID (CrCl 15–30); avoid if CrCl <15

Contraindicated CrCl <15; ~50% dialyzable — give after HD

Edoxaban

Anticoagulant

DOAC (Factor Xa)

60 mg PO daily (AF)

60 mg daily

30 mg daily

30 mg daily (CrCl 15–50); avoid if CrCl <15

Avoid CrCl <15; ineffective if CrCl >95

Vancomycin

Antibiotic

Glycopeptide

15–20 mg/kg IV q8–12h

Standard, trough-based

Extend interval q12–24h

Per level; HD: redose at trough 15–20 mg/L (q3–7 days)

Therapeutic drug monitoring; nephrotoxic; avoid concurrent nephrotoxins

Gentamicin / Tobramycin

Antibiotic

Aminoglycoside

5–7 mg/kg IV q24h (extended interval)

q24h

q24–36h

Per level; HD: 2–3 mg/kg after dialysis

Nephro- & ototoxic; limit ≤5–7 days; monitor levels + trough

Cefepime

Antibiotic

β-lactam (4th gen ceph)

2 g IV q8h (severe)

Standard

q24h

q48h; HD: 1 g q24h (supplement post-HD)

Dose to eGFR to avoid neurotoxicity (encephalopathy, myoclonus)

Levofloxacin

Antibiotic

Fluoroquinolone

750 mg IV/PO q24h

Standard

750 mg q48h

750 mg load → 500 mg q48h; HD: 500 mg q48h

Tendonopathy; QT prolongation; CNS effects; dysglycemia

Ciprofloxacin

Antibiotic

Fluoroquinolone

400 mg IV q8h or 500–750 mg PO q12h

Standard

q8–12h

q12–18h; HD: q24h (post-HD)

Tendonopathy; QT prolongation; avoid with theophylline

Meropenem

Antibiotic

Carbapenem

1 g IV q8h

Standard

1 g q12h

500 mg q12h (CrCl 10–29); <10: 500 mg q24h; HD: 500 mg q24h post-HD

Seizure risk in high dose / renal impairment; reduce dose

Piperacillin-tazobactam

Antibiotic

β-lactam + inhibitor

3.375–4.5 g IV q6–8h

Standard

q8h

q12h; HD: 2.25 g q8h (post-HD, extended infusion)

Monitor Na load; adjust for renal function to prevent neurotoxicity

Trimethoprim-Sulfamethoxazole

Antibiotic

Sulfonamide

8–20 mg/kg/day TMP divided

Standard

Half dose or q12–24h

Avoid if possible; half dose; HD: dose after dialysis

Blocks Cr secretion (false ↑Cr) & causes hyperkalemia; avoid in late CKD

Nitrofurantoin

Antibiotic

Urinary antiseptic

100 mg PO BID × 5 days (uncomplicated UTI)

Standard

Avoid (CrCl <30)

Contraindicated

Ineffective + peripheral neuropathy risk if CrCl <30; cystitis only

Amoxicillin-clavulanate

Antibiotic

β-lactam + inhibitor

875/125 mg PO BID

Standard

q12h

q24h; HD: q24h (post-HD)

Clavulanate accumulates; hepatotoxicity risk with prolonged use

Metronidazole

Antibiotic

Nitroimidazole

500 mg IV/PO q8h

Standard

Standard; HD: supplement post-HD

Minimal adjustment needed; supplement after HD

Aztreonam

Antibiotic

Monobactam

2 g IV q8h

Standard

q12h

q24h; HD: load 1–2 g → 1 g q12h

Safe in penicillin-allergic patients; adjust per CrCl

Darbepoetin (Aranesp)

ESRD

Erythropoiesis-stimulating agent

0.45 mcg/kg SC/IV weekly (naïve)

Per Hgb protocol

No renal clearance

Same; HD: give post-dialysis

Target Hgb 10–11 g/dL; hold if >11.5; see ESA calculator for conversion

Epoetin alfa (Epogen)

ESRD

ESA (recombinant EPO)

50–100 U/kg SC/IV 3×/week

Per Hgb protocol

No renal clearance

Same; HD: IV post-dialysis

Convert to darbepoetin: weekly units ÷ 200 = mcg/week

Methoxy PEG-epoetin β (Mircera)

ESRD

ESA (long-acting)

0.6 mcg/kg SC/IV q2weeks (naïve)

Per Hgb protocol

No renal clearance

Same; HD: IV post-dialysis; monthly once stable

C3 pegylated; less frequent dosing; same CV warnings

Calcitriol (Rocaltrol)

ESRD

Active vitamin D (1,25-OH₂D)

0.25 mcg PO daily or 0.5 mcg 3×/wk

Per PTH/Ca/Phos

Per PTH

Titrate to PTH; hold if Ca↑/Phos↑

Use CKD-MBD calculator; monitor Ca, Phos, PTH q3mo

Paricalcitol (Zemplar)

ESRD

Vitamin D analog (19-nor D₂)

1 mcg IV/PO daily or 2–4 mcg 3×/wk (HD)

Per PTH

Titrate to PTH; less Ca/Phos effect

Less hypercalcemia/hyperphosphatemia than calcitriol

Cinacalcet (Sensipar)

ESRD

Calcimimetic

30 mg PO daily → titrate q2–4wk

Standard

Standard; titrate to PTH ≥150 & Ca ≥8.4

Lowers PTH & Ca; risk hypocalcemia; avoid in primary HPT post-transplant

Sevelamer carbonate (Renvela)

ESRD

Non-calcium phosphate binder

800–1600 mg PO with meals

Standard

Standard; titrate to Phos

No calcium load; lowers LDL; high pill burden

Lanthanum carbonate (Fosrenol)

ESRD

Non-calcium phosphate binder

500–1000 mg PO with meals

Standard

Standard; chew tablets

Potent binder; minimal systemic absorption; GI effects

Sucroferric oxyhydroxide (Velphoro)

ESRD

Iron-based phosphate binder

500 mg PO 3×/day with meals

Standard

Standard; low pill burden

Iron-based; minimal absorption; discolors stools

Ferric carboxymaltose (Injectafer)

ESRD

IV iron

750 mg IV ×2 (≥7 d apart)

Per iron indices

HD: 100 mg IV q1–2wk to TSAT 30–50%

Target TSAT 30–50% & ferritin 200–500 ng/mL; test dose obsolete

Clinical disclaimer: These ranges are a quick-reference for adult dosing only. Always confirm against current package inserts, institutional protocols, and the patient's actual eGFR, weight, and indication. Therapeutic drug monitoring (vancomycin, aminoglycosides) is required — adjust to levels, not the table alone.

References & Further Reading

01Drug Dosing in Patients with CKD and Requiring Dialysis — KDIGO Clinical Practice Guideline — Kidney International Reports (2019)
02Sanford Guide to Antimicrobial Therapy (Renal Dosing) — Sanford Guide (2023)
03FDA Drug Labeling — Renal Impairment Dosing — U.S. Food & Drug Administration (current)
04Aronoff GR et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults — American College of Physicians (2007)
05KDIGO Clinical Practice Guideline for Anemia in CKD — KDIGO (2012)
06KDIGO Clinical Practice Guideline for CKD-MBD — KDIGO (2017)