# Drug Dosing in CKD Quick Reference

## Overview

Drug dosing in chronic kidney disease requires systematic assessment of renal function (eGFR-based or creatinine clearance), understanding of drug metabolism/elimination, and knowledge of dialyzability \[1\]. This guide provides practical quick-reference tables for common medications requiring adjustment in CKD, organized by drug class and GFR stage. Principles, contraindications, and special considerations for dialysis dosing are included.

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## Key Clinical Pearl

**“Estimated GFR-based dosing is standard for most drugs; however, actual creatinine clearance (CG equation or measured) may be more accurate for certain drugs (e.g., aminoglycosides, vancomycin). Always verify actual dose in individual patients; extrapolation from tables is a starting point, not absolute.”**

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## Part 1: Principles of Drug Dosing in CKD

### GFR Estimation Methods

**Recommended by KDIGO for drug dosing:**

1.  **MDRD Study Equation (4-variable):** eGFR = 175 × (SCr)^(−1.154) × (Age)^(−0.203) × 0.742 (if female) × 1.212 (if Black)

2.  **Kidney function for dosing:** Use an appropriate contemporary race-free eGFR equation in adults and follow the equation/units used in the medication’s prescribing information. Near dose thresholds or when creatinine is unreliable, consider creatinine–cystatinC eGFR or measured clearance. Do not apply a race multiplier. [2021 CKD-EPI equations](https://pubmed.ncbi.nlm.nih.gov/34554658/).

3.  **Cockcroft-Gault (Creatinine clearance estimation):** \$\$\text{CCr (mL/min)} = \frac{(140-\text{Age}) \times \text{Weight (kg)} \times 0.85 \text{ (if female)}}{72 \times \text{SCr (mg/dL)}}\$\$

**Choice of equation:** Use a current race-free eGFR equation for kidney assessment and follow the kidney-function measure specified by the drug label or validated dosing protocol. Cockcroft–Gault estimates creatinine clearance; it does not measure actual clearance. Consider body size, non-steady-state creatinine, and drug-level monitoring, especially for aminoglycosides and vancomycin.

### Dosing Adjustment Approaches

**Two main strategies:**

1.  **Dose reduction:** Decrease individual dose; maintain normal dosing interval
    - Preferred for drugs with therapeutic index requiring steady levels
    - Examples: Antimicrobials, cardiac glycosides
2.  **Interval prolongation:** Maintain normal dose; increase interval between doses
    - Preferred for drugs where peak serum level important (beta-lactams, fluoroquinolones)
    - Examples: Antibiotics
3.  **Combination:** Reduce both dose and interval (for severe renal failure)

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## Part 2: Antibiotics (GFR-Based Adjustment)

### Beta-Lactams (Penicillins, Cephalosporins, Carbapenems)

| Agent | Normal Dose | eGFR \>50 | eGFR 30–50 | eGFR 10–30 | eGFR \<10 | Dialyzed |
|----|----|----|----|----|----|----|
| **Penicillin G** | 2–4 million units IV Q4-6h | No change | 2M Q6–8h | 2M Q8–12h | 1–2M Q12h | Yes (15–50%) |
| **Ampicillin** | 500 mg IV Q6h | No change | 500 mg Q6h | 250–500 mg Q6–12h | 250–500 mg Q12h | Yes |
| **Ceftriaxone** | 1–2 g IV Q12h | No change | No change | 1 g Q12–24h | 0.5–1 g Q24h | Minimal |
| **Cefazolin** | 1 g IV Q8h | No change | 0.5–1 g Q12h | 0.5 g Q12–24h | 0.25–0.5 g Q24h | Yes |
| **Cefepime** | 1 g IV Q12h | No change | 1 g Q12h | 0.5 g Q12–24h | 0.5 g Q24h | Yes |
| **Meropenem** | 0.5–1 g IV Q8h | No change | 0.5–1 g Q8–12h | 0.5 g Q12h | 0.25–0.5 g Q12h | Yes |
| **Amoxicillin** | 500 mg PO Q8h | No change | 250–500 mg Q8h | 250–500 mg Q12h | 250–500 mg Q24h | Yes |

### Aminoglycosides (Nephrotoxic; Use with Caution)

**Principle:** Accumulates in renal cortex; dose-dependent nephrotoxicity. Use **extended-interval dosing** (more effective, less toxic).

| Agent | Extended-Interval Dose | Dosing Interval by eGFR |
|----|----|----|
| **Gentamicin** | 5–7 mg/kg IV | eGFR \>50: Q24h; \>20: Q36–48h; \<20: Q48–72h or avoid |
| **Tobramycin** | 5–7 mg/kg IV | Same as gentamicin |
| **Amikacin** | 15 mg/kg IV | eGFR \>50: Q24h; \>20: Q36–48h; \<20: Avoid or prolonged interval |

**Monitoring:** Serum levels required; trough \<1 mg/L (gentamicin/tobramycin), \<5 mg/L (amikacin); peak 15–30 mg/L (tobramycin).

**Contraindication:** eGFR \<20 mL/min (alternative antibiotics preferred).

### Vancomycin (Glycopeptide Antibiotic)

**Principle:** Kidney function, actual body weight, infection and measured concentrations guide an individualized regimen. Static eGFR tables are inadequate during changing kidney function.

**Serious MRSA infection:** The 2020 consensus guideline recommends AUC-guided monitoring, targeting AUC/MIC 400–600 when MIC is assumed to be 1 mg/L. Trough-only targeting of 15–20 μg/mL is no longer recommended for this indication because of nephrotoxicity concerns \[2\].

**Timing:** Assess target exposure early, ideally within 24–48 hours, using a validated pharmacy protocol. Do not automatically extrapolate the serious-MRSA target to every organism or infection.

**Hemodialysis:** Modern high-flux dialysis can remove vancomycin. Coordinate dosing, dialysis timing and concentration sampling with the local dialysis/pharmacy protocol.

### Fluoroquinolones

| Agent | Normal Dose | eGFR 30–50 | eGFR \<30 | Dialyzed |
|----|----|----|----|----|
| **Ciprofloxacin** | 500–750 mg PO/IV Q12h | 250–500 mg Q12–24h | 250 mg Q24h | Yes (minimal) |
| **Levofloxacin** | 500–750 mg daily | 250 mg daily or Q48h | 250 mg Q48h | Minimal |
| **Moxifloxacin** | 400 mg daily | No change | No change (but caution) | Minimal |

**Note:** Fluoroquinolones generally safe in renal failure; dose reduction for quinolone accumulation and CNS toxicity risk.

### Macrolides

| Agent | Normal Dose | eGFR \<30 | Note |
|----|----|----|----|
| **Azithromycin** | 500 mg PO daily | No change needed | Hepatic metabolism; minimal renal involvement |
| **Clarithromycin** | 500 mg PO Q12h | 250 mg PO Q12h | Renal elimination; dose reduce to avoid toxicity |
| **Erythromycin** | 500 mg PO Q6–8h | 250 mg Q6–8h | Hepatic; not eliminated by kidneys; caution with QT prolongation |

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## Part 3: Anticoagulants and Antiplatelet Drugs

### Direct Oral Anticoagulants (DOACs)

**Principle:** Renal clearance varies by agent; eGFR thresholds critical for dose selection.

| Agent | Type | Dosing by eGFR | Contraindication |
|----|----|----|----|
| **Apixaban** | Fxa inhibitor | eGFR ≥30: 5 mg BID; eGFR 15–29: 5 mg BID (caution); \<15: Avoid | eGFR \<15 (ESRD) |
| **Rivaroxaban** | Fxa inhibitor | eGFR ≥30: 20 mg daily; eGFR 15–29: 15 mg daily; \<15: Avoid | eGFR \<15 (ESRD) |
| **Dabigatran** | Direct thrombin inhibitor | eGFR ≥30: 150 mg BID; eGFR \<30: REDUCE or avoid | eGFR \<15 (ESRD); significant renal clearance (~80%) |
| **Edoxaban** | Fxa inhibitor | eGFR ≥50: 60 mg daily; eGFR 30–50: 30 mg daily; \<30: Caution | eGFR \<15 (no data) |

**Key point:** DOACs removed by dialysis; redose AFTER dialysis session if timing convenient.

### Warfarin

**No renal adjustment needed** (hepatic metabolism). However, CKD patients have enhanced INR sensitivity; monitor INR closely.

### Antiplatelet Drugs

| Agent | eGFR \<30 | Notes |
|----|----|----|
| **Aspirin** | No dosage change | Standard dosing; may accumulate metabolites |
| **Clopidogrel (Plavix)** | No dosage change | Standard dosing; metabolized hepatically |
| **Prasugrel** | Caution | Increased bleeding risk in CKD; use lower loading/maintenance dose if eGFR \<30 |
| **Ticagrelor** | Caution | Monitor for bradycardia, blocks adenosine uptake; dosing unchanged but increased AE risk |

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## Part 4: Antihypertensives and Cardiac Drugs

### ACE Inhibitors and Angiotensin Receptor Blockers

**No dosage adjustment** based on eGFR; however, monitor SCr and K carefully.

**Caution thresholds:** - Hold if Cr rise \>30% from baseline within 4 weeks of initiation - Hold if K \>6.0 mEq/L (hyperkalemia)

### Beta-Blockers

| Agent           | eGFR \<30 | Normal Dose     | Adjusted Dose           |
|-----------------|-----------|-----------------|-------------------------|
| **Metoprolol**  | Safe      | 25–50 mg BID    | 25 mg daily (start low) |
| **Atenolol**    | Caution   | 25–50 mg daily  | 12.5–25 mg daily        |
| **Propranolol** | Safe      | 10–20 mg Q6–8h  | No change (hepatic)     |
| **Carvedilol**  | Safe      | 3.125–25 mg BID | No change (hepatic)     |

**Monitoring:** Heart rate, blood pressure, fatigue, bradycardia in advanced CKD.

### Calcium Channel Blockers

**No significant renal adjustment** (hepatically metabolized).

| Agent | eGFR \<30 | Normal Dose | Note |
|----|----|----|----|
| **Amlodipine** | Safe | 2.5–10 mg daily | Hepatic metabolism; no dose change |
| **Diltiazem** | Safe | 120–240 mg daily | Hepatic; no change needed |
| **Verapamil** | Safe | 120–240 mg daily | Hepatic; caution with constipation in CKD |

### Diuretics

| Agent | eGFR \<30 | Dosing Adjustment |
|----|----|----|
| **Furosemide** | Decreased efficacy | Higher doses needed; eGFR \<30 may need 40–80 mg BID to TID |
| **Hydrochlorothiazide** | Reduced efficacy | May add loop diuretic if eGFR \<30 |
| **Spironolactone** | CAUTION | Higher hyperkalemia risk; eGFR \<30 generally avoid; if use, monitor K closely Q2–4 weeks |
| **Potassium-sparing (amiloride, triamterene)** | AVOID | High hyperkalemia risk; contraindicated eGFR \<30 |

### Digoxin (Cardiac Glycoside)

**Principle:** Entirely renally eliminated; significant accumulation risk.

**Dosing:** - **eGFR \>50:** 0.25–0.5 mg daily - **eGFR 30–50:** 0.25 mg daily or Q48h - **eGFR 10–30:** 0.125 mg daily or Q48h - **eGFR \<10:** 0.125 mg Q48–72h or avoid

**Monitoring:** Serum digoxin level (target 0.5–1.5 ng/mL); toxicity more common in CKD due to hypokalemia and hypermagnesemia interactions.

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## Part 5: Antidiabetic Medications

### Metformin

**CONTRAINDICATION: eGFR \<30 mL/min/1.73 m²**

**Rationale:** Lactic acidosis risk from accumulation.

**Dosing:** - **eGFR ≥60:** Standard dosing (500–1000 mg BID–TID) - **eGFR 45–60:** Use standard dosing; monitor closely - **eGFR 30–45:** Reduce to 500 mg BID; caution - **eGFR \<30:** CONTRAINDICATED; discontinue

**Hold metformin in acute situations:** Surgery, acute illness, contrast administration.

### Sulfonylureas (Glyburide, Glipizide, Glimepiride)

**Significant renal clearance; hypoglycemia risk in CKD.**

| Agent | eGFR \<30 | Normal Dose | Adjusted Dose |
|----|----|----|----|
| **Glyburide** | Caution | 5–10 mg daily–BID | Avoid; use alternatives |
| **Glipizide** | Safer | 5–10 mg daily–BID | 2.5–5 mg daily (metabolized hepatically) |
| **Glimepiride** | Caution | 1–4 mg daily | 0.5–1 mg daily; increase gradually |

**Monitoring:** Glucose monitoring; risk of hypoglycemia increases as eGFR declines.

### GLP-1 Receptor Agonists

**Generally safe; some dosing considerations:**

| Agent | eGFR \<30 | Normal Dose | Adjusted Dose |
|----|----|----|----|
| **Liraglutide** | Safe | 1.8 mg daily SQ | No change |
| **Semaglutide** | Safe | 1 mg weekly SQ | No change |
| **Dulaglutide** | Safe | 0.75–1.5 mg weekly SQ | No change |
| **Exenatide** | Caution | 10 μg BID or 2 mg weekly | eGFR \<30: avoid immediate-release; use extended-release carefully |

### SGLT2 Inhibitors

**Safe in CKD; continue even as eGFR declines** (per KDIGO 2024).

| Agent | eGFR \<45 | eGFR \<20 | Note |
|----|----|----|----|
| **Dapagliflozin** | 10 mg daily | Continue if eGFR ≥20 | No change; approved for eGFR ≥20 |
| **Empagliflozin** | 10 mg daily | Continue if eGFR ≥20 | No change; beneficial even at G5 |
| **Canagliflozin** | 100 mg daily | Caution; limit to 100 mg if eGFR \<30 | No change but limit max dose |

### DPP-4 Inhibitors

**Generally safe; some renal clearance.**

| Agent | eGFR \<30 | Normal Dose | Adjusted Dose |
|----|----|----|----|
| **Sitagliptin** | Reduce dose | 100 mg daily | 50 mg daily (eGFR 30–50); 25 mg daily (eGFR \<30) |
| **Saxagliptin** | Reduce dose | 5 mg daily | 2.5 mg daily if eGFR \<50 |
| **Linagliptin** | Safe | 5 mg daily | No change (hepatic metabolism) |
| **Alogliptin** | Reduce dose | 25 mg daily | 12.5–25 mg daily if eGFR \<30 |

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## Part 6: Analgesics and NSAIDs (CONTRAINDICATED in CKD)

### NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

**GENERAL CONTRAINDICATION: eGFR \<60 mL/min/1.73 m² (especially \<30)**

**Mechanism:** Inhibit prostaglandin-mediated renal vasodilation; cause acute kidney injury; increase cardiovascular risk.

**Absolute avoidance:** eGFR \<30, acute decompensation, polyuric renal disease, volume depletion.

**Caution if used in eGFR 30–60:** Shorter duration (\<7 days preferred); adequate hydration; avoid in acute illness.

**Safer alternatives:** - **Acetaminophen:** Up to 3 g/day (eGFR \>30) - **Tramadol:** 50–100 mg Q4–6h (reduce to 50–100 mg Q12h if eGFR \<30) - **Opioids:** Morphine, hydromorphone (see below)

### Opioid Analgesics (Dose by Renal Function)

| Agent | Normal Dose | eGFR 30–50 | eGFR \<30 | Avoidance |
|----|----|----|----|----|
| **Morphine** | 10–30 mg PO Q4–6h | 50% dose reduction | 50% dose reduction + longer interval | Metabolite accumulation |
| **Hydromorphone** | 2–4 mg PO Q4–6h | 50% reduction | 50% reduction | M6G metabolite toxic |
| **Codeine** | 15–60 mg Q4–6h | Reduce 25–50% | Avoid (codeine-6-glucuronide accumulation) | Neurotoxicity risk |
| **Tramadol** | 50–100 mg Q4–6h | 50–100 mg Q12h | 50–100 mg Q24h or avoid | Seizure risk; accumulation |
| **Fentanyl** | Variable (patch, lozenge) | Safe (hepatic) | Safe (hepatic) | No renal adjustment |
| **Oxycodone** | 5–10 mg Q4–6h | 50% reduction | 50% reduction + longer interval | Noroxycodone accumulation |

**Key principle:** Opioid metabolites accumulate in renal failure; use long-acting opioids (fentanyl) or non-accumulating agents (hydromorphone with caution).

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## Part 7: Drugs to AVOID or Use with EXTREME CAUTION in CKD

### Absolute Contraindications

| Drug | Reason | Threshold |
|----|----|----|
| **Metformin** | Lactic acidosis | eGFR \<30 |
| **NSAIDs** | Acute kidney injury; GI bleed risk | eGFR \<60 (avoid); \<30 contraindicated |
| **ACE-I/ARB in acute setting** | Can precipitate acute renal failure | Use only if chronic HTN indication; monitor Cr closely |
| **Potassium-sparing diuretics** | Hyperkalemia | eGFR \<30 |
| **Lithium** | Accumulates; neurotoxicity; kidney damage | eGFR \<60 (avoid most); requires therapeutic drug monitoring |
| **Gadolinium (contrast agent)** | Nephrogenic systemic fibrosis (NSF) | eGFR \<30 (use only if essential; avoid gadolinium-based) |
| **Iodinated contrast agents** | Contrast-induced nephropathy (CIN) | eGFR \<30 (use iso/low-osmolar; hydrate; hold metformin) |

### Relative Contraindications (Use with Caution)

| Drug | Reason | Adjustment |
|----|----|----|
| **Aminoglycosides** | Nephrotoxicity; ototoxicity | eGFR \<20: avoid or extended-interval dosing |
| **Vancomycin** | Accumulation | Individualize dose; use indication-appropriate drug-level monitoring |
| **NSAIDs (if eGFR 30–60)** | Renal injury risk | Use lowest dose, shortest duration; ensure hydration |
| **Codeine** | Metabolite accumulation | Reduce dose or avoid eGFR \<30 |
| **Thiazolidinediones (pioglitazone)** | Fluid retention; heart failure exacerbation | Use cautiously in advanced CKD; monitor for edema |
| **Finasteride, dutasteride** | Renal clearance; accumulation risk | eGFR \<30: consider dose reduction |

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## Part 8: Dialysis-Specific Dosing

### Hemodialysis (HD)

**Principles:** - **Removed by HD:** Small water-soluble molecules (urea, creatinine, small MW drugs) - **NOT removed:** Protein-bound drugs, large molecules, highly lipophilic agents - **Timing:** Dose AFTER HD if drug significantly removed

### Peritoneal Dialysis (PD)

**Generally:** Less drug clearance than HD; similar dosing principles as nondialyzed CKD patients.

### Specific Drug Adjustments for Dialysis

| Drug | HD Removal | Dosing Strategy | Timing |
|----|----|----|----|
| **Gentamicin** | Significant (70–90%) | Extended-interval dosing; usual dose Q36–48h | Dose after HD |
| **Vancomycin** | Minimal (\<10%) | 10–15 mg/kg per HD session (NOT post-HD redose; allow level to drop 10–15 μg/mL/day) | Dose after HD or per serum level |
| **Penicillins/cephalosporins** | Significant | Standard dosing; Q8–12h dosing in nondialyzed; Q12–24h in HD | Dose after HD |
| **Warfarin** | Minimal | No change; monitor INR | Standard |
| **DOAC** | Variable (apixaban 25%, dabigatran 80%) | Standard dosing; redose after HD if timing convenient | Post-HD redose |
| **Digoxin** | Minimal | No change; maintain low level (avoid toxicity) | Standard |
| **Metoprolol** | Minimal | 25–50 mg post-HD | Post-HD |
| **Acetaminophen** | Significant | Standard dosing | Standard |

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## Part 9: Special Considerations

### Contrast-Induced Nephropathy (CIN) Prevention

**Risk factors:** - eGFR \<30 mL/min/1.73 m² - Diabetes - Volume depletion - Repeated contrast exposure

**Contrast-associated AKI prevention:** Assess kidney function, clinical indication, and volume status. IV isotonic saline prophylaxis is considered for patients with AKI or eGFR below 30 mL/min/1.73 m² who are not on maintenance dialysis, unless contraindicated; tailor the regimen to heart failure and fluid-overload risk. Avoid unnecessary nephrotoxins. Metformin management depends on kidney function, AKI, and the contrast procedure; it is not itself a nephrotoxin. **N-acetylcysteine is not recommended for prophylaxis.** Follow-up creatinine testing is individualized to risk. See the [ACR–NKF consensus](https://pubmed.ncbi.nlm.nih.gov/31961246/) and [PRESERVE trial](https://pubmed.ncbi.nlm.nih.gov/29130810/).

### Drug-Drug Interactions in CKD

**Common problematic interactions:**

| Combination | Problem | Management |
|----|----|----|
| **ACE-I/ARB + NSAID + diuretic** | “Triple whammy” → acute renal failure | Avoid; use SGLT2i instead of NSAID |
| **ACE-I/ARB + potassium-sparing diuretic** | Hyperkalemia | Monitor K; reduce diuretic dose |
| **Digoxin + diuretics (loop, thiazide)** | Hypokalemia → digoxin toxicity | Ensure K \>3.5 mEq/L; add K-sparing diuretic |
| **NSAIDs + ACE-I/ARB** | Acute renal failure | Avoid; separate if possible; monitor Cr |
| **Metformin + iodinated contrast** | Lactic acidosis (contrast-induced AKI) | Hold metformin; restart 48 hours post-contrast if Cr normal |

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## Part 10: Key Warnings

### Warning 1: Metformin Accumulation Lactic Acidosis

Metformin is cleared renally; at eGFR \<30, accumulation increases lactate production and acidosis risk. **Absolute contraindication: eGFR \<30**. Hold in acute illness, dehydration, sepsis, or before contrast administration.

### Warning 2: NSAIDs Cause “Silent” Renal Failure

NSAIDs rarely cause obvious symptoms; patient may not realize declining renal function. Especially dangerous in elderly, diabetic, or volume-depleted patients. **Educate patients to avoid OTC NSAIDs; recommend acetaminophen or tramadol.**

### Warning 3: Opioid Metabolite Neurotoxicity

Morphine-6-glucuronide, codeine-6-glucuronide, and other opioid metabolites accumulate in renal failure and cause sedation, confusion, myoclonus, and seizures. **Prefer fentanyl (hepatically metabolized) or non-accumulating opioids in advanced CKD.**

### Warning 4: Hyperkalemia from Drug Combinations

ACE-I/ARB + SGLT2i + NSAIDs + potassium-sparing diuretics = dangerous hyperkalemia (K \>6.0 mEq/L with arrythmias). **Monitor K closely; educate on low-K diet; remove one agent if K trending up.**

### Warning 5: Vancomycin Dosing by Level, Not By eGFR

Vancomycin requires individualized therapeutic drug monitoring. For serious MRSA infection use the AUC-guided approach above. Dialysis patients need a regimen and sampling schedule matched to the dialysis modality and local pharmacy protocol.

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## Related Resources

- ← Back to CKD Management Hub
- ← Back to Nephrology Hub
- Back to Medical Education Dashboard

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## References

Matzke GR, Aronoff GR, Atkinson AJ, et al. Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80(11):1122. [PubMed](https://pubmed.ncbi.nlm.nih.gov/21918498/)

\[2\] Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. *Am J Health Syst Pharm*. 2020. [PubMed PMID 32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)

Ashley C, Dunleavy A. The Renal Drug Handbook. 5th ed. CRC Press; 2019. [Publisher](https://www.routledge.com/The-Renal-Drug-Handbook-The-Ultimate-Prescribing-Guide-for-Renal-Practitioners/Ashley-Dunleavy/p/book/9781138624511).

\[4\] Perazella MA, Rosner MH. Drug-Induced Acute Kidney Injury. *Clin J Am Soc Nephrol*. 2022. [PubMed PMID 35273009](https://pubmed.ncbi.nlm.nih.gov/35273009/)

\[5\] Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. *Ann Intern Med*. 2009;150:604–612. [PubMed](https://pubmed.ncbi.nlm.nih.gov/19414839/)

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*Last updated: 2026-02-28* *Board-review quality curriculum for nephrology education.*


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