What is the appropriate dosing of Tranexamic Acid (TXA) in patients with impaired renal function?

From the Guidelines

Tranexamic Acid (TXA) dosing in patients with impaired renal function should be reduced.

Rationale

• The elimination of intravenous TXA is exponential, with approximately 90% cumulative excretion of the drug in urine in a time span of 24 hours 1.
• Renal clearance is the major mechanism of excretion, and impaired renal function correlates with an increased incidence of complications, such as neurotoxicity and ocular toxicity 1.
• Therefore, reduced doses of TXA are indicated in patients with chronic or acute renal failure, and it should be used with caution in this setting 1.
• The exact reduced dose is not specified in the provided evidence, but it is implied that a dose adjustment is necessary to avoid potential complications in patients with impaired renal function 1.
• As a result, TXA should be used with caution and at a reduced dose in patients with impaired renal function.

From the FDA Drug Label

For patients with moderate to severe impaired renal function, the following dosages are recommended: Table 1. Recommended Dosage in Patients with Varying Degrees of Renal Impairment Serum Creatinine (mg/dL) Tranexamic acid IntravenousDosage 1.36 to 2.83 (120 to 250 micromol/L) 10 mg/kg twice daily 2.83 to 5. 66 (250 to 500 micromol/L) 10 mg/kg daily

5.66 (>500 micromol/L) 10 mg/kg every 48 hours or 5 mg/kg every 24 hours

• Dose reduction is recommended for all doses, both before and after tooth extraction.

The appropriate dosing of Tranexamic Acid (TXA) in patients with impaired renal function is as follows:

• For patients with serum creatinine levels between 1.36 and 2.83 mg/dL, the recommended dose is 10 mg/kg twice daily.
• For patients with serum creatinine levels between 2.83 and 5.66 mg/dL, the recommended dose is 10 mg/kg daily.
• For patients with serum creatinine levels greater than 5.66 mg/dL, the recommended dose is 10 mg/kg every 48 hours or 5 mg/kg every 24 hours. Dose reduction is recommended for all doses, both before and after tooth extraction 2, 2, 2.

From the Research

Appropriate Dosing of Tranexamic Acid (TXA) in Patients with Impaired Renal Function

The dosing of Tranexamic Acid (TXA) in patients with impaired renal function is crucial to avoid excessive drug accumulation and potential toxicity. Several studies have investigated the pharmacokinetics of TXA in patients with renal impairment and proposed dosing adjustments.

• A study published in 2015 3 used pharmacokinetic modeling to recommend a new dosing adjustment based on the BART dosing regimen for cardiopulmonary bypass patients with chronic renal dysfunction (CRD).
• Another study published in 2025 4 proposed a new dosing regimen for major joint arthroplasty in adult patients with chronic kidney disease, which includes a bolus dose of 15 mg/kg over 15 min and a maintenance infusion of 7.5 mg/kg/h or 5 mg/kg/h for 2 hours for patients with good and poor renal function, respectively.
• A study published in 2018 5 measured plasma TXA concentrations in cardiac surgical patients with chronic renal dysfunction and proposed a simple new TXA dosing regimen that optimizes maximal antifibrinolysis and avoids excessive drug dosing.
• The importance of dose adjustment in patients with chronic kidney dysfunction is also highlighted in a review article published in 2020 6, which recommends decreased dosing regimens in patients with chronic kidney dysfunction secondary to reduced clearance and drug accumulation.

Key Considerations for Dosing Adjustments

When adjusting the dose of TXA in patients with impaired renal function, the following factors should be considered:

• The degree of renal impairment, as measured by creatinine clearance or estimated glomerular filtration rate (eGFR) 3, 4, 5
• The type of surgery being performed, as different procedures may require different dosing regimens 4, 5
• The patient's body weight, as this can affect the volume of distribution and clearance of TXA 3, 4
• The risk of postoperative seizures, which may be increased in patients with high TXA doses, advanced age, underlying neurologic disease, or chronic kidney disease 6

Proposed Dosing Regimens

Based on the available evidence, the following dosing regimens have been proposed for patients with impaired renal function:

• For cardiopulmonary bypass patients with chronic renal dysfunction, a dosing adjustment based on the BART dosing regimen, with consideration of renal function, has been proposed 3
• For major joint arthroplasty in adult patients with chronic kidney disease, a bolus dose of 15 mg/kg over 15 min and a maintenance infusion of 7.5 mg/kg/h or 5 mg/kg/h for 2 hours for patients with good and poor renal function, respectively, has been proposed 4
• For cardiac surgical patients with chronic renal dysfunction, a simple new TXA dosing regimen that optimizes maximal antifibrinolysis and avoids excessive drug dosing has been proposed 5