Tranexamic Acid Dosing in Renal Impairment
For adults with impaired renal function, tranexamic acid requires dose reduction based on serum creatinine levels: 10 mg/kg twice daily for creatinine 1.36-2.83 mg/dL, 10 mg/kg once daily for creatinine 2.83-5.66 mg/dL, and 10 mg/kg every 48 hours (or 5 mg/kg every 24 hours) for creatinine >5.66 mg/dL. 1
FDA-Approved Renal Dosing Guidelines
The FDA label provides specific dose adjustments based on serum creatinine rather than creatinine clearance 1:
- Creatinine 1.36-2.83 mg/dL (120-250 micromol/L): 10 mg/kg IV twice daily 1
- Creatinine 2.83-5.66 mg/dL (250-500 micromol/L): 10 mg/kg IV once daily 1
- Creatinine >5.66 mg/dL (>500 micromol/L): 10 mg/kg IV every 48 hours OR 5 mg/kg IV every 24 hours 1
These dose reductions apply to all tranexamic acid administrations, both initial treatment and maintenance therapy. 1
Administration Considerations
- Infusion rate: Administer no faster than 1 mL/minute to prevent hypotension 1
- Standard loading dose: 10 mg/kg IV as a single dose for patients with normal renal function 1
- Maintenance dosing: May continue for 2-8 days at 10 mg/kg three to four times daily in patients with normal renal function 1
Evidence-Based Dosing Strategies for Specific Clinical Scenarios
Cardiac Surgery with Renal Impairment
For cardiopulmonary bypass patients with chronic kidney disease, adjust the maintenance infusion rate based on the percentage reduction in renal clearance to maintain therapeutic plasma concentrations around 100 mg/L while avoiding toxicity. 2 Body weight and creatinine clearance are significant covariates affecting tranexamic acid pharmacokinetics 2.
Major Joint Arthroplasty
Recent pharmacokinetic modeling suggests a bolus of 15 mg/kg over 15 minutes followed by maintenance infusion of 5 mg/kg/hour for 2 hours in patients with poor renal function (eGFR <60 mL/min/1.73 m²), compared to 7.5 mg/kg/hour in those with good renal function. 3 This regimen maintains plasma levels of 50-75 mg/L for approximately 4 hours 3.
Hemodialysis Patients
Administer tranexamic acid after hemodialysis sessions, as dialysis removes approximately 30-40% of the drug. 4 Giving the medication before dialysis leads to subtherapeutic concentrations 4.
Continuous Renal Replacement Therapy (CRRT)
Standard renal adjustment tables do not apply to CRRT patients. 4 CRRT clears 25-50% of tranexamic acid, requiring higher doses of 4 g/0.5 g every 6-8 hours adjusted for residual renal function 4. Residual urine output is critical—patients with residual creatinine clearance >50 mL/min have approximately 5-fold higher drug clearance than those with clearance <10 mL/min 4.
Safety Considerations and Contraindications
- Absolute contraindications: Active venous or arterial thrombosis, allergy to tranexamic acid 5
- Maximum total dose in cardiac surgery: 100 mg/kg, especially in patients over 50 years of age, to avoid neurotoxicity 5
- Pregnancy: Contraindicated due to unknown safety profile 5
Common Pitfalls
- Do not use creatinine clearance estimates alone in critically ill patients, as they underestimate renal function in those with augmented clearance, potentially leading to underdosing 4
- Calculate actual creatinine clearance using urine-based formulas (urine creatinine × urine volume ÷ plasma creatinine) when therapeutic drug monitoring is needed 4
- Avoid mixing with penicillin solutions, as tranexamic acid is a synthetic amino acid incompatible with penicillin 1
- Do not administer before dialysis in hemodialysis patients, as premature drug removal occurs 4