In the setting of rapidly improving/worsening renal function, calculations of eGFR are inaccurate, and dosing should be based on estimated renal function instead.
If worsening renal function, actual GFR is likely lower than calculated.
If improving renal function, actual GFR is likely higher than calculated eGFR.
Not On Dialysis (EGFR)
100-200mg IV/PO q24h (400 mg q24h for more aggressive therapy)
400mg IV/PO q24h
Intermittent Dialysis
Give full dose by indication after each HD session
Continuous Dialysis
400mg IV/PO q24h (800 mg IV q24h for more aggressive therapy)