In the setting of rapidly improving/worsening renal function, calculations of eGFR are inaccurate, and dosing should be based on estimated renal function instead.
If worsening renal function, actual GFR is likely lower than calculated.
If improving renal function, actual GFR is likely higher than calculated eGFR.
Not on Dialysis
150 mg IV q36h, or if less than 60 kg, 1.5-2.5 mg/kg IV q36h
150 mg IV q24h, or if less than 60 kg, 2.5 mg/kg IV q24h
150 mg IV q12h, , or if less than 60 kg, 2.5 mg/kg IV q12h
Intermittent Dialysis
On days with no HD, give 52.5 mg IV q12h; on dialysis days, give 75 mg IV during last hour of dialysis and 75 mg 12 hours later
Continuous Dialysis
150 mg IV q24h, or if less than 60 kg, 2.5 mg/kg IV q24h
