UNIVERSITY OF MARYLAND MEDICAL CENTER

DEPARTMENT OF PHARMACY SERVICES

Pharmacotherapeutic Considerations for Patients with End Stage Renal Disease

End stage renal disease (ESRD) patients are followed closely by nephrology as
outpatients. Therefore, many of the manifestations of ESRD are managed long-term in
the outpatient setting. The following "guidelines" will be useful in caring for these
patients while they are inpatients at UMMC. (Epoetin alfa and calcitriol dosing is done
by nephrology. Intact PTH, aluminum levels, and iron studies are checked quarterly.
These values may be obtained by calling the patient’s dialysis center.)

A. Drug Dosing Considerations:

1) Assume a creatinine clearance < 5 mL/min for hemo- and peritoneal dialysis
patients.
2) Refer to your pharmacist (8-5644) to ensure appropriate renal dosing of all
medications.

B. Anemia:

1) Blood should be transfused during hemodialysis.

2) Epoetin alfa: see guidelines for use in UMMC formulary for appropriate
dosing.
3) Virtually all patients on epoetin alfa may require iron therapy (i.e. ferrous sulfate
or ferrous gluconate 325 mg PO daily - TID).
4) Goal iron stores: Transferrin saturation > 20 % and Ferritin > 100 ng/mL.

C. Secondary Hyperparathyroidism:

1) Calcium phosphate product > 65-70: results in soft tissue and vascular
calcification/deposition.
2) Phosphate binders must be given with meals and bedtime snacks to bind
dietary phosphate. Hold phosphate binders if patient is NPO.
a) Calcium phosphate product < 65-70: Give calcium carbonate 650
-1300 mg PO with meals and bedtime snack
b) Calcium phosphate product > 65-70: Give aluminum hydroxide 1920 –
3840 mg(30-60 cc) PO with meals and bedtime snack
c) If calcium phosphate product is > 65-70 and the patient has
symptomatic hypocalcemia: give aluminum hydroxide PO with meals
and treat the hypocalcemia with CaCO3 500 mg elemental calcium
PO TID with meals or IV calcium gluconate as needed.
d) Hold phosphate binder if serum PO4 < 3.

3) Calcitriol:
a) if PTH < 3 X normal: do not give calcitriol
b) if PTH > 3 X normal: administer calcitriol 0.25 - 0.5 mcg PO daily
 c) Hold calcitriol when calcium phosphate product > 65-70 and/or if
patient is hyperphosphatemic.

D. Miscellaneous:
1) All dialysis patients should receive Nephro-vite one tablet PO daily for
vitamin supplementation.
2) Pain Relief: try acetaminophen first before non-steroidal anti-inflammatory
agents or aspirin because of increased risk of bleeds with these agents.
AVOID Meperidine (Demerol ): accumulation of active metabolite will result in
SEIZURES.
3) Goal Albumin: > 3.5 gm/dl
4) AVOID antacids, etc... containing aluminum and/or magnesium since they will
accumulate in ESRD patients.
5) AVOID potassium supplements or high sodium content products. However,
CAPD patients may often require potassium supplementation.

E. Dietary considerations: The following are general recommendations. All are

subject to individualization, based on each patient's
nutritional status. Contact the Registered Dietitian (R.D.)
for patient specific recommendations.

PROTEIN Na+ K+ FLUID

g/kg/day
(based on dry wt)
CRF without 0.8 - 1 2 - 4g < 3g if high Individualize
Dialysis serum levels
CRF on 1 - 1.2 (non- 2 - 4g 2 - 3g 700-1000cc + 24h
Hemodialysis stressed) U.O.P.
CRF on 1.2 - 1.5 4g No restriction Unrestricted if wt
CAPD unless serum and BP controlled.
levels high.
 ANTIMICROBIAL DOSAGE ADJUSTMENT FOR ADULT DIALYSIS PATIENTS

ANTIBIOTICS HEMODIALYSIS (HD) PERITONEAL DIALYSIS PERITONITIS:

(CAPD) DOSE PER
EACH 2L
EXCHANGE
(give IP)*
Acyclovir (PO) HSV: 200 mg q12h and HSV: 200 mg q12h
after HD HZV: 400 - 800 mg q12h
HZV: 400 - 800 mg q12h HSV encephalitis: 800
and after HD mg q12h
HSV encephalitis: 800
mg q12h and after HD
Acyclovir (IV) HSV: 2.5 mg/kg/d and HSV: 2.5 mg/kg/d
after HD HZV + HSV
HZV + HSZ encephalitis: encephalitis: 5 mg/kg/d
5 mg/kg/d and after HD
Amikacin 5-7.5 mg/kg load, then 5-7.5 mg/kg load, then
dose per levels after HD dose per levels
Amoxicillin 250 - 500 mg q24h and 250 mg q12h
(PO) 250 mg after HD
Amoxicillin/ 250 - 500 mg q12-24h 250 mg q12h
Clavulanate and 250 mg after HD
(Augmentin)
(PO)
Amphotericin No Dosage Adjustment No Dosage Adjustment
B (IV) Necessary Necessary
Ampicillin 250 - 500 mg q12-24h 250 mg q12h
(PO) and after HD
Ampicillin (IV) 1 - 2 g q12h and after HD 1 - 2 g q12h
Ampicillin/ 1.5 - 3 g q24h and after 1.5 - 3 g q24h
Sulbactam HD
(Unasyn) (IV)
Aztreonam 1 - 2 g load, then 250 – 1-2 g load, then 250 - Load: 1 g
(IV) 500 mg q8-12h and after 500 mg q8-12h Maint: 500 mg
HD
Cefamandole 1 - 2 g load, then 250 – 250 - 1000 mg q12h Load: 1 g
(IV) 750 mg q12h and after Maint: 500 mg
HD
Cefazolin (IV) 0.5 - 1 g q24h and after 0.5 g q12h Load: 0.5 - 1 g
HD Maint: 250 -
500 mg
Cefepime (IV) 1-2 g load then 250-500 1-2 g q 48h
mg q24h and 1-2 gm after
HD
Cefixime 300 mg after HD 200 mg q24h
(PO)
Cefotetan HD days: 500 mg - 2g 1 g q24h
(IV) q24h
Non-HD days: 250 mg - 1
g q24h
Cefoxitin (IV) 0.5 - 1 g q24h and 1 - 2 g 1 g q24h Load: 1 g
after HD Maint: 200 mg
Cefpodoxime 200 mg after HD, three 200 mg q24h
(PO) days per week
Ceftriaxone No Dosage Adjustment No Dosage Adjustment Load: 1 g
(IV) Necessary Necessary Maint: 250 -
500 mg
Cephalexin 250 - 500 mg q12h and 250 - 500 mg q12h
(PO) after HD
Ciprofloxacin 250 - 500 mg qPM 250 - 500 mg q12h
(PO) (severe infection: 750 mg) (severe infection: 750
mg)
Ciprofloxacin 200 - 400 mg q24h 200 - 400 mg q24h Load: 500 mg
(IV) PO
Maint: 50 mg
Clarithromycin 250 - 500 mg q24h and 250 - 500 mg q24h
(PO) after HD
Dicloxacillin No Dosage Adjustment No Dosage Adjustment
(PO) Necessary Necessary
Didanosine <60 kg: 125 mg after HD < 60 kg: 125 mg q48h >
(DDI) (PO) >60 kg: 200 mg after HD 60 kg: 200 mg q48h
Dicloxacillin No Dosage Adjustment No Dosage Adjustment
(PO) Necessary Necessary
Didanosine <60 kg: 125 mg after HD < 60 kg: 125 mg q48h >
(DDI) (PO) >60 kg: 200 mg after HD 60 kg: 200 mg q48h
Erythromycin No dosage adjustment No dosage adjustment
(PO/IV) necessary, but may necessary, but may
consider q8-12h dosing consider q8-12h dosage
interval. interval.
Ethambutol 15 mg/kg after HD (three 15 mg/kg QOD
times per week)
Famciclovir Zoster: 250 mg after HD Dose Unknown in CAPD
(PO) 3x/week
Simplex: 125 mg after HD
3x/week
Fluconazole Normal loading dose, then 25% of normal dose 100 mg PO qd
(PO/IV) normal dose after HD only q24h or 50% of dose or
q48h 150 mg IP
QOD
Flucytosine 25 mg/kg q24h and after 25 mg/kg q24h (Adjust Load: 2 g PO
(PO) HD (Adjust dose to keep dose to keep Cp peak Maint: 1 g PO
Cp peak < 100). <100). qd
Foscarnet Dose Unknown in Dose Unknown in CAPD
(IV) Hemodialysis
Ganciclovir Induction: 2.5 mg/kg after Induction: 2.5 mg/kg
(PO/IV) HD and on a day off HD QOD
day. Maintenance: 1.25 Maintenance: 1.25
mg/kg after HD and on a mg/kg QOD
day off HD day.
Gatifloxacin Load: 400 mg; then 200 Load: 400 mg; then 200
(IV/PO) mg q24h after HD mg q24h
Gentamicin Load: 2 mg/kg; then 1 - Load: 2 mg/kg; then 1 - Load: 2 mg/kg
(IV/IM) 1.5 mg/kg after HD if 1.5 mg/kg q 2-3 days Maint: 8 - 12
Serum Concentration < 2 when serum mg
mcg/mL. concentration <2
mcg/mL.
Imipenem/ 125 mg - 250 mg q12h 125 - 500 mg q12h Load: 1 g
Cilastatin and after HD Maint: 200 mg
(Primaxin) (IV)
INH No Dose Adjustment No Dose Adjustment
(Isoniazid) Necessary; dose qPM Necessary
(removed by HD)
Itraconazole/ No Dosage Adjustment No Dosage Adjustment
Ketoconazole Necessary Necessary
Levofloxacin 250 mg q48h after HD 250 mg q48h after
(PO/IV) dialysis
Linezolid 600 mg q12h and
(PO/IV) 200 mg after HD
Metronidazole No Dosage Adjustment No Dosage Adjustment
(PO/IV) Necessary Necessary
Nafcillin (IV) No Dosage Adjustment No Dosage Adjustment
Necessary Necessary
Penicillin V 250 mg q6h 250 mg q6h
(PO)
Penicillin G 2 - 4 mu q8h and 500,000 2 - 4 mu q8h
(IV) mu after HD
Pentamidine No Dosage Adjustment No Dosage Adjustment
(IV) Necessary Necessary
Piperacillin 3 g q12h and 1 g after HD 3 - 4 g q12h Load: 4 g IV
(IV) Maint: 500 mg
Piperacillin/ 2.25 g q8h and 0.75 g after 2.25 g q8h
Tazobactam HD
(Zosyn) IV
Pyrazinamide 15 mg/kg/day qPM 15 mg/kg/day
(removed by HD)
Dalfopristin/ No Dosage Adjustment No Dosage Adjustment
Quinupristin Necessary Necessary
(Synercid)
(IV)
Rifampin No Dosage Adjustment No Dosage Adjustment
(PO/IV) Necessary (max dose per Necessary (Max dose
day = 600 mg). per day = 600 mg).
SMX-TMP Bacterial Infx: 2.5 mg/kg Bacterial Infx: 2.5 mg/kg
(Bactrim) q12-24h and after HD q12-24h
(IV/PO) PCP: 5 mg/kg q12h PCP: 5 mg/kg q12h
Tetracycline 250-500 mg qhs 250-500 mg q24h
(PO)
Ticarcillin/ 2 g q12h and 3.1 g after 3.1 g q12h
Clavulanate HD
(Timentin)
(IV)
Tobramycin Load: 2 mg/kg; then 1 - Load: 2 mg/kg; then 1 -
(IV) 1.5 mg/kg after HD if 1.5 mg/kg after HD if
Serum Concentration < 2 Serum Concentration < 2
mcg/mL. mcg/mL.
Trimethoprim 100 - 200 mg qPM 100 - 200 mg q24h
(IV)
Vancomycin 1 g q 5-7d when random 1 g (IV / IP) q 5-7d when 2 g IP q 5-7
(IV) level is < 15 mcg/ml random level is < 15 days
mcg/ml
Zalcitabine 0.75 mg qPM 0.75 mg qPM
(DDC) (PO)
Zidovudine 100 mg q8h 100 mg q8h
(AZT) (PO)
* Doses given IP unless otherwise noted.