Quick cards
Renal Dosing
Which ICU drugs to adjust for kidney function, dialysis and CRRT
Principles
- 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 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
| 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) |
More quick cards
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- Equivalents and Conversions
- IV Fluids
- Empiric Antibiotics
- Scales and Staging
- Tubes, Lines and Equipment
- Checklists
- ICU Bundles
- 12-Lead ECG
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For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.