What is the recommended dosing of ceftriaxone (Ceftriaxone) for patients with End-Stage Renal Disease (ESRD)?

Ceftriaxone Dosing in End-Stage Renal Disease (ESRD)

No dosage adjustment is required for ceftriaxone in patients with ESRD, and the standard dose of 1-2 grams daily can be maintained. 1

Pharmacokinetics of Ceftriaxone in ESRD

Ceftriaxone has unique pharmacokinetic properties that differentiate it from many other antibiotics when considering dosing in renal impairment:

• Ceftriaxone is excreted via both biliary (40-65%) and renal (33-67%) routes 1
• Despite ESRD, ceftriaxone maintains adequate therapeutic levels due to its dual elimination pathway
• The FDA label specifically states: "Patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered" 1

Evidence Supporting Standard Dosing in ESRD

Research studies confirm the appropriateness of standard dosing in ESRD:

• In patients with ESRD, the half-life of ceftriaxone is moderately increased to approximately 15.6-16.6 hours (compared to 8 hours in normal renal function) 2, 3
• Despite this prolongation, plasma concentrations remain well above the minimum inhibitory concentration (MIC) for most susceptible organisms 4
• A study of 104 ESRD patients demonstrated efficacy and safety using 1 gram of ceftriaxone daily without dose adjustment 4

Hemodialysis Considerations

• Ceftriaxone is partially removed during hemodialysis, with approximately 41% reduction in plasma levels during a 4-hour session 2
• However, even after hemodialysis, plasma concentrations remain within therapeutic range 2
• No supplemental dosing is required after hemodialysis 1

Dosing Recommendations

For adult patients with ESRD:

• Standard dose: 1-2 grams IV once daily (or divided twice daily) 1
• Maximum daily dose: 4 grams 1
• Duration: Generally 4-14 days depending on infection type and severity 1
• For surgical prophylaxis: Single 1 gram dose 30-120 minutes before procedure 1

Special Considerations

Hepatic Impairment

• In patients with both severe renal and hepatic dysfunction, close clinical monitoring is advised, and the ceftriaxone dosage should not exceed 2 grams daily 1

Administration

• Administer intravenously by infusion over 30 minutes 1
• For intramuscular administration, inject well within the body of a relatively large muscle 1

Potential Adverse Effects to Monitor

• Urolithiasis: Ceftriaxone-calcium precipitates can form in the urinary tract; ensure adequate hydration 1
• Gallbladder pseudolithiasis: Monitor for signs of gallbladder disease 1
• Prothrombin time alterations: Monitor in patients with impaired vitamin K synthesis or low vitamin K stores 1

Conclusion

Unlike many other antibiotics, ceftriaxone does not require dose adjustment in ESRD due to its dual elimination pathway. The standard dosing regimen of 1-2 grams daily provides adequate therapeutic levels while maintaining an acceptable safety profile in this population.