Ceftriaxone Dosing in Dialysis Patients
For patients on dialysis, ceftriaxone requires no dose adjustment and should be administered at standard doses of 1-2 grams once daily for most infections, with no supplemental dosing needed after dialysis sessions. 1
Standard Dosing Principles for Dialysis Patients
Ceftriaxone is NOT removed by hemodialysis or peritoneal dialysis, eliminating the need for supplemental post-dialysis dosing 1
The FDA label explicitly states: "Ceftriaxone is not removed by peritoneal- or hemodialysis. In patients undergoing dialysis no additional supplementary dosing is required following the dialysis" 1
Standard dosing of 1-2 grams every 24 hours is appropriate for isolated renal impairment, including dialysis patients 2, 3
The elimination half-life is prolonged to approximately 14.7-15.7 hours in hemodialysis patients (compared to 5.8-8.7 hours in healthy subjects), but this does not necessitate dose reduction 1, 4, 5
Infection-Specific Dosing Adjustments
While standard doses don't require adjustment for renal function, infection severity dictates total daily dose:
For meningitis: Use 2 grams IV every 12 hours (4 grams total daily) regardless of renal function to achieve adequate CSF penetration 2, 6
For endocarditis: Use 2 grams IV/IM once daily for 4 weeks without adjustment 2, 6
For standard infections (pneumonia, UTI, skin/soft tissue): Use 1-2 grams once daily 2, 3
Critical Monitoring Considerations
In patients with BOTH severe renal AND hepatic dysfunction, the maximum dose should not exceed 2 grams daily, and close clinical monitoring is required 1
A small percentage of dialysis patients (6 of 26 in one study) showed markedly reduced elimination rates, suggesting plasma concentration monitoring may be warranted in select cases 1, 7
Ceftriaxone is excreted via both biliary (33-67%) and renal (33-67%) routes, providing dual elimination pathways that minimize accumulation risk 1
Pharmacokinetic Rationale
The lack of dose adjustment is supported by robust pharmacokinetic data:
Plasma clearance decreases by less than 50% in dialysis patients (mean 0.65 L/hour vs 0.58-1.45 L/hour in healthy subjects) 1, 5
Volume of distribution remains relatively unchanged (13.7 L in hemodialysis patients vs 5.8-13.5 L in healthy subjects) 1
The moderate twofold increase in half-life does not result in clinically significant accumulation at standard doses up to 2 grams daily 8, 5
Important Caveats
Avoid exceeding 2 grams daily in dialysis patients with concurrent severe hepatic dysfunction 1
Monitor for gallbladder pseudolithiasis and urolithiasis, which can occur with ceftriaxone use regardless of renal function 1
Ensure adequate hydration to minimize risk of ceftriaxone-calcium precipitates in the urinary tract 1