Appendix 12. Dose adjustments in renal insufficiency

12.1 Normal values for the creatinine clearance

Men: 97 to 137 ml/min
Women: 88 to 128 ml/min

12.2 Calculation of creatinine clearance

   
    Weight (kg) x (140 – age) x (constant)
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          Serum creatinine (μmol/L)

The constant = 1.23 for men and 1.04 for women

Example:

A female patient under capreomycin (Cm), weight 50 kg, age 46, has a serum creatinine = 212 μmol/L:

Step 1: Calculate the creatinine clearance
50 x (140 – 46) x (1.04) / 212 = 23.0 ml/min

Step 2: As creatinine clearance is < 30, administer 12 to 15 mg/kg of Cm 3 times weekly (ie. 600 to 750 mg of Cm per dose 3 times weekly).
If the creatinine continues to increase, consider suspension of the injectable agent.

Step 3: Adjust every drug in the regimen as necessary according to the following table.

12.3 Adjustment of anti-TB drugs in renal insufficiency

Dosing of anti-TB drugs in renal insufficiency6,7

Drugs

Dose and frequency if creatinine clearance < 30 ml/min

H

No change

R

No change

Z

25 mg/kg 3 times per week (not daily)

E

15-25 mg/kg 3 times per week (not daily)

Rfb

2.5-5 mg/kg per day

Sa

12-15 mg/kg 2 or 3 times per week (not daily)

Kma

12-15 mg/kg 2 or 3 times per week (not daily)

Amka

12-15 mg/kg 2 or 3 times per week (not daily)

Cma

12-15 mg/kg 2 or 3 times per week (not daily)

Lfx

750-1000 mg 3 times per week (not daily)

Mfx

No change

Ofx

600-800 mg 3 times per week (not daily)

Eto/Pto

250-500 mg per day

Csb

250 mg once daily or 500 mg 3 times per week

PASc

8 g per day in 2 divided doses

Cfz

No change

Amx/Clv

1000 mg per day in 2 divided doses

Lzd

No change

Ipm/Cln

500 mg every 8 hours for creatinine clearance 20-40 ml/min
500 mg every 12 hours for creatinine clearance < 20 ml/min

a. Use injectable agents with caution in patients with impaired renal function (increased risk of ototoxicity and nephrotoxicity).
b. Monitor carefully for signs of neurotoxicity.
c. Sodium salt formulations of PAS may result in excessive sodium load and should be avoided in patients with kidney disease.