The clinical companion

Dose by target AUC using the Calvert formula (dose = AUC x (GFR + 25)); accurate GFR is essential because carboplatin is almost entirely renally cleared. Free (non-protein-bound) carboplatin is dialyzable. In ESKD, individualized reduced AUC targets with chemotherapy timed relative to a hemodialysis session are used; coordinate dosing and HD timing with pharmacy.

Directly nephrotoxic; requires vigorous saline hydration ± mannitol and Mg/K repletion. Reduce dose or avoid with reduced CrCl (commonly substitute carboplatin). Only unbound platinum is removed by dialysis and it binds plasma proteins rapidly, so HD does not reliably rescue toxicity once bound.

Renally eliminated; AKI causes dangerous drug accumulation. Prevent with hydration, urinary alkalinization, and leucovorin rescue. For delayed clearance/AKI, glucarpidase rapidly cleaves plasma methotrexate (>87% reduction) and is preferred; high-flux/high-efficiency hemodialysis removes methotrexate but levels rebound, so it is adjunctive, not first-line.

Predominantly renal elimination; reduce dose with impaired CrCl and use cautiously (limited data) in moderate-to-severe impairment. Pentostatin is removed by hemodialysis — in an ESKD case series HD was given deliberately 1-2 h after each infusion to clear residual drug, allowing cautious dosing. Non-dialysis severe impairment is generally avoided for lack of data.

Substantial renal clearance; reduce dose for moderate renal impairment (commonly halved at low CrCl, e.g., CrCl 20–39 mL/min) per label. Limited dialysis data; HD timing data are sparse, so treat as not reliably removed.

About 40% renally excreted; reduce dose with reduced CrCl (e.g., ~25% reduction at CrCl 15–50 mL/min). Highly protein-bound, so it is not appreciably removed by hemodialysis — no rescue benefit and no need to dose around HD for removal.

Predominantly renally excreted; dose-reduce and extend the interval as CrCl falls. On hemodialysis it is removed, so the dose is given AFTER the HD session on dialysis days. Adjust by CrCl bands per label.

Neither capecitabine nor 5-FU is meaningfully dialyzable; it is the renally cleared catabolites (notably FBAL) that accumulate, and renal impairment does not raise 5-FU exposure itself. Reduce dose at moderate impairment (CrCl 30–50 mL/min). Below CrCl 30 the current label establishes NO DOSAGE rather than contraindicating outright — individualized use at a reduced start is permitted only where no treatment alternative exists, and every patient studied at that clearance had grade 3-4 toxicity. Avoid in dialysis-dependent patients — no dialysis dosing is established and dialysis does not rescue the accumulation.

Large IgG monoclonal antibody cleared by reticuloendothelial/target-mediated routes, not the kidney. No renal dose adjustment and it is NOT removed by dialysis (too large to cross the membrane), so no dose timing around HD is required. Watch for TLS when treating bulky CD20+ disease.

IgG antibodies are not renally cleared and are NOT removed by hemodialysis; no dose adjustment for CrCl or dialysis. Case series report efficacy and acceptable safety in ESKD/dialysis patients. Remain alert for immune-related AKI (most often acute interstitial nephritis) and, in transplant recipients, allograft rejection.

Large proteins not eliminated renally and not dialyzed; no renal dose adjustment. Main onconephrology concern is cytokine-release-syndrome physiology (hemodynamics, AKI) and TLS, not drug accumulation. Limited dedicated ESKD pharmacokinetic data — monitor clinically.

A living cell product — not a renally cleared or dialyzable drug. AKI risk derives from cytokine release syndrome, tumor lysis, and supportive-care exposures rather than the cells themselves. Lymphodepleting chemotherapy (fludarabine/cyclophosphamide) does need renal dose adjustment.

The radioligand is renally excreted and the kidney is the dose-limiting organ, so an anuric patient cannot excrete it — hemodialysis is scheduled deliberately to strip circulating activity and limit marrow dose. One patient on hemodialysis completed all six PSMA-radioligand cycles with HD during each, PSA falling 298 to 7.1 ng/mL at acceptable organ doses. Removal is real but partial, and how much a session takes off differs sharply between reports: postdilution haemodiafiltration begun 5-6 h after a dotatate dose removed 40% and 47% of whole-body activity, while a separate dotatate patient lost 4.9% of total-body radioactivity per session across his course. Blood activity also partly rebounds once the session ends, and whatever has already bound to tumor and organs is beyond reach. Dialysis reduces exposure without normalizing it — marrow dose still ran about twice the non-dialysis literature in a PSMA case given the standard 7.4 GBq. Administered activity is cut in some reported protocols and left standard in others. Dialysate is radioactive waste and can stay above release limits for weeks of later sessions. Requires nuclear-medicine, radiation-safety and nephrology coordination.

General rule: small renally-cleared cytotoxics need CrCl-based dose reduction and some are dialyzable (carboplatin, methotrexate, lenalidomide); large proteins (rituximab, checkpoint inhibitors, bispecifics) and cell therapies (CAR-T) are NOT renally cleared and NOT dialyzed, so they generally need no renal dose change — the kidney risk is downstream (TLS, CRS, immune-related AKI).