Can tranexamic acid be given to patients with chronic kidney disease, and how should the dose be adjusted based on eGFR and dialysis status?

Can Tranexamic Acid Be Given in CKD?

Yes, tranexamic acid can be given to patients with chronic kidney disease, but dose reduction is mandatory based on renal function because approximately 90% of the drug is excreted unchanged in the urine within 24 hours. 1

Dose Adjustment Algorithm Based on Renal Function

For Patients with eGFR ≥60 mL/min/1.73 m²

• Use standard dosing without adjustment 1
• For surgical procedures: 15 mg/kg bolus over 15 minutes followed by 7.5 mg/kg/h maintenance infusion for 2 hours 2

For Patients with eGFR 30-59 mL/min/1.73 m² (Moderate CKD)

• Reduce the maintenance infusion rate proportionally to the reduction in renal clearance 2, 3
• For surgical procedures: 15 mg/kg bolus over 15 minutes followed by 5 mg/kg/h maintenance infusion for 2 hours 2
• The FDA label mandates dose reduction in this population to prevent drug accumulation 1

For Patients with eGFR 15-29 mL/min/1.73 m² (Severe CKD)

• Further dose reduction is required 1
• Pharmacokinetic modeling demonstrates significantly higher plasma concentrations in this population with standard dosing 3
• Monitor closely for adverse effects including seizures and thromboembolic events 1

For Patients with eGFR <15 mL/min/1.73 m² or on Dialysis

• Use with extreme caution 1
• The drug is known to be substantially excreted by the kidney, and the risk of toxic reactions is greater in patients with impaired renal function 1
• Consider alternative hemostatic strategies when possible 4

Clinical Context and Evidence Quality

The strongest evidence comes from the FDA drug label, which explicitly states that dose reduction is necessary in renal impairment 1. This is supported by recent pharmacokinetic studies demonstrating that plasma tranexamic acid concentrations remain elevated for prolonged periods in CKD patients receiving standard doses 2, 3.

A 2025 prospective pharmacokinetic study in arthroplasty patients with CKD demonstrated that patients with eGFR <60 mL/min/1.73 m² had significantly higher plasma concentrations and reduced clearance compared to those with normal renal function 2. The study used population pharmacokinetic modeling to derive the specific dosing recommendations above, targeting therapeutic plasma levels of 50-75 mg/L while avoiding excessive accumulation 2.

Special Clinical Situations

Gross Hematuria in ADPKD

• Tranexamic acid has been used successfully in autosomal dominant polycystic kidney disease patients with severe hematuria, including those with chronic renal impairment 5
• In a prospective case series, massive bleeding stopped within 2-5 days in all 8 patients treated, with no thromboembolic events reported 5
• Dose adjustment for renal impairment remains critical even in this indication 5

Cirrhosis Patients with Concurrent CKD

• The 2022 EASL guidelines discourage routine use of tranexamic acid to decrease procedure-related bleeding in cirrhosis patients undergoing invasive procedures 4
• Renal clearance is the major mechanism of excretion, and reduced doses are indicated in patients with chronic or acute renal failure 4
• The combination of cirrhosis and CKD creates particularly high risk for neurotoxicity and ocular toxicity 4

Critical Safety Considerations

Monitoring Requirements

• Calculate creatinine clearance using the Cockcroft-Gault equation before initiating therapy 1
• Monitor renal function regularly during treatment, especially in elderly patients who are more likely to have decreased renal function 1
• Watch for signs of drug accumulation including seizures (a known complication of excessive tranexamic acid levels) 1, 3

Contraindications and Warnings

• Avoid concomitant use with hormonal contraceptives due to increased thromboembolic risk 1
• The risk of toxic reactions is substantially greater in patients with impaired renal function 1
• Elderly patients require particular attention to dose selection and renal function monitoring 1

Common Pitfalls to Avoid

• Do not use standard dosing in patients with any degree of renal impairment - this is the most common error and can lead to drug accumulation and toxicity 1, 6
• Do not rely solely on serum creatinine - calculate creatinine clearance or eGFR using validated equations 6
• Do not forget to adjust maintenance infusion rates - both bolus and maintenance dosing require modification in CKD 2, 3
• Do not assume the drug is contraindicated in CKD - with appropriate dose adjustment, it can be used safely even in severe renal impairment 5