Rifampicin Dosing in Chronic Kidney Disease
No dose adjustment of rifampicin is required for patients with chronic kidney disease or impaired renal function, regardless of the severity of renal impairment. 1
Standard Dosing Recommendations
The standard adult dose of rifampicin remains 600 mg once daily (or 10 mg/kg body weight) in patients with CKD, including those with end-stage renal disease. 1
Serum concentrations of rifampicin do not differ in patients with renal failure at the studied dose of 300 mg, and consequently, no dosage adjustment is required. 1
Less than 30% of the rifampicin dose is excreted in the urine as rifampicin or metabolites, with the majority eliminated through biliary excretion and enterohepatic circulation. 1
Pharmacokinetic Rationale
Rifampicin is primarily eliminated through hepatic metabolism and biliary excretion rather than renal clearance, which explains why renal impairment does not significantly affect drug levels. 1, 2
Rifampicin undergoes progressive enterohepatic circulation and deacetylation to 25-desacetyl-rifampin, with almost equal excretion in bile and urine. 1, 2
Research confirms that rifampicin excretion with urine decreases with progression of renal insufficiency but has no effect on plasma levels, and the drug does not accumulate in patients with renal insufficiency. 3
Important Clinical Considerations
Fixed-dose combination products containing rifampicin (Rifamate®) may be used in persons with renal insufficiency without adjustment. 4
Using rifampicin in doses less than 10 mg/kg body weight in patients with chronic renal insufficiency is not advisable, as standard dosing maintains therapeutic efficacy. 3
Patients with end-stage renal disease on hemodialysis should receive the standard dose without supplemental dosing after dialysis, as rifampicin is highly protein-bound (80%) and not significantly removed by dialysis. 1
Monitoring Considerations
While dose adjustment is not needed, patients with both hepatic and renal impairment require closer monitoring, as elimination may be slower than in those with isolated renal dysfunction. 2
The absence of rifampicin in urine specimens does not indicate drug accumulation but rather reflects the predominant non-renal elimination pathway. 3