What is the recommended dose of Augmentin (amoxicillin/clavulanate) for a patient with End-Stage Renal Disease (ESRD)?

Augmentin Dosing in ESRD

For patients with end-stage renal disease (ESRD), Augmentin (amoxicillin/clavulanate) requires significant dose reduction, with specific adjustments based on whether the patient is on hemodialysis or peritoneal dialysis.

Hemodialysis Patients

Administer Augmentin after each dialysis session to prevent premature drug removal, as both amoxicillin and clavulanic acid are substantially cleared during hemodialysis. 1

Pharmacokinetic Rationale

• During a 4-hour hemodialysis session, approximately 64% of amoxicillin and 65% of clavulanic acid are removed from the body 1
• Dialysis clearance for amoxicillin is 77.1 mL/min and for clavulanic acid is 92.8 mL/min, representing significant drug removal 1
• The half-life of amoxicillin during dialysis drops from 13.6 hours (non-dialysis day) to 2.3 hours, while clavulanic acid decreases from 3.05 hours to 1.19 hours 1

Dosing Strategy

• Reduce the standard dose and administer post-dialysis to facilitate directly observed therapy and prevent premature clearance 2
• On non-dialysis days, both components have markedly prolonged half-lives (amoxicillin: 13.6 hours; clavulanic acid: 3.05 hours) compared to patients with normal renal function 1
• Total serum clearance on non-dialysis days is substantially lower than in normal subjects for both components, suggesting some degree of hepatic impairment in ESRD patients 1

Peritoneal Dialysis Patients

Peritoneal dialysis removes substantially less drug than hemodialysis, so supplemental dosing is generally not necessary. 3

Key Considerations

• The cumulative removal of renally excretable drugs is higher in continuous ambulatory peritoneal dialysis (CAPD) patients than in hemodialysis patients between sessions, but still lower overall 3
• Apply dosing regimens designed for pre-ESRD patients (CrCl <10 mL/min) to CAPD patients 3
• Drug clearance is enhanced in automated peritoneal dialysis compared to CAPD, requiring careful individualization 3
• Patients with residual urine output will have higher drug clearance than anuric patients 3

Critical Monitoring

Close clinical and pharmacological monitoring is essential in ESRD patients who often take multiple interacting medications. 2

Common Pitfalls to Avoid

• Never administer hemodialysis patients their dose before dialysis, as this results in immediate drug removal and therapeutic failure 1
• Do not assume peritoneal dialysis patients need the same supplemental dosing as hemodialysis patients—they do not 3
• Recognize that non-renal clearance is impaired in ESRD patients, affecting both amoxicillin and clavulanic acid elimination 1
• Be aware that residual renal function significantly impacts drug clearance in peritoneal dialysis patients 3

Practical Algorithm

1. Determine dialysis modality (hemodialysis vs. peritoneal dialysis)
2. For hemodialysis: Reduce dose, give post-dialysis on dialysis days 1
3. For peritoneal dialysis: Use pre-ESRD dosing (CrCl <10 mL/min) without supplementation 3
4. Assess for residual urine output in peritoneal dialysis patients, as this increases clearance 3
5. Monitor for therapeutic response and adverse effects given altered pharmacokinetics 2, 1