Lamivudine Dosing for eGFR 24 mL/min
For an HIV patient with an eGFR of 24 mL/min (creatinine clearance 15-29 mL/min range), administer lamivudine 150 mg as a loading dose, followed by 100 mg once daily. 1
Dosing Algorithm by Renal Function
The Infectious Diseases Society of America (IDSA) HIV Medicine Association guidelines provide clear stratification for lamivudine dose adjustment based on creatinine clearance 1:
- CrCl ≥50 mL/min: No adjustment needed - standard 150 mg twice daily or 300 mg once daily 1
- CrCl 30-49 mL/min: 150 mg once daily 1
- CrCl 15-29 mL/min (your patient): 150 mg loading dose, then 100 mg once daily 1
- CrCl 5-14 mL/min: 150 mg loading dose, then 50 mg once daily 1
- CrCl <5 mL/min: 50 mg loading dose, then 25 mg once daily 1
- Hemodialysis: 50 mg loading dose, then 25 mg once daily 1
Key Clinical Considerations
Renal function monitoring is essential. Your patient's eGFR of 24 mL/min places them in the moderate-to-severe renal impairment category, requiring dose reduction to prevent drug accumulation 2. Lamivudine clearance decreases proportionally and linearly with declining renal function 2.
Expected improvement in renal function. Patients with baseline creatinine clearance 30-49 mL/min (similar to your patient at 24 mL/min) typically experience substantial increases in mean creatinine clearance (>25 mL/min) after initiating antiretroviral therapy through 96 weeks 3. This improvement is accompanied by substantial increases in CD4+ cell counts (>150 cells/mm³) 3.
Important Pitfalls to Avoid
Do not use combination tablets. Fixed-dose combinations containing lamivudine (such as Combivir or Trizivir) should be administered as separate component medications in patients with creatinine clearance <50 mL/min to allow proper dose adjustment 1.
Hemodialysis considerations. If your patient progresses to requiring hemodialysis, lamivudine is approximately 50% dialyzable, but due to its large volume of distribution (~100 L), a 4-hour hemodialysis session does not significantly affect overall drug exposure 2. The reduced maintenance dose (25 mg daily) accounts for this 1.
Safety profile remains favorable. Patients with creatinine clearance 30-49 mL/min receiving standard lamivudine dosing (300 mg/day) showed comparable Grade 3-4 adverse events and serious adverse events compared to those with normal renal function 3. However, your patient requires dose reduction given the lower eGFR of 24 mL/min.
Monitoring Strategy
Reassess renal function regularly. The 2018 KDIGO guidelines recommend monitoring kidney function 2-4 times per year in patients with or at increased risk of CKD who are receiving antiretroviral therapy 1. More frequent monitoring may be warranted given your patient's baseline severe renal impairment 1.