Agents that need specific renal dosing
The 65 anti-cancer agents in the atlas that need renal attention — 61 with a specific dose change (by CrCl band, GFR formula, or a hard cutoff) plus a few with only a general caution — grouped by what to do. Each links to its full profile; see the renal-dosing reference for the CrCl bands and dialyzability.
Reduce dose by kidney function
47Start lower or step the dose down at defined CrCl / eGFR thresholds.
No change for mild-moderate; for severe impairment (eGFR 15-29) start reduced 30 mg once daily and titrate as tolerated
Reduce initial dose ~30-40% in severe renal (or hepatic) impairment or documented impaired drug clearance
No baseline change; reduce next cycle 50% if unexplained bicarbonate <20 or BUN/creatinine rise, resume after recovery
Reduce ~25% for CrCl 40-50; up to ~50-60% for CrCl 10-40; dose conservatively in ESKD.
Reduce starting dose: 400 mg if CrCl 30-50; 300 mg if CrCl <30 (resistant/intolerant setting).
Reduce maintenance dose ~50% for severe impairment (eGFR <30); no change for mild-moderate.
No change CrCl 51-80; reduce to 75% starting dose for CrCl 30-50; contraindicated if CrCl <30
Reduce ~25% for CrCl 46-60 and ~50% for CrCl 30-45; avoid/withhold if CrCl <50-60
Start at reduced dose for CrCl 30-60; not recommended (avoid) if CrCl <30
No change for CrCl >=30; reduce to 250 mg once daily for severe impairment (CrCl <30, not on dialysis)
Attenuate dose (~25% reduction) for severe impairment (CrCl <10-25); maintain aggressive hydration with high IV doses.
Standard-dose needs little change; reduce HIGH-dose cytarabine as CrCl worsens to limit cerebellar neurotoxicity.
Reduce starting dose to 300 mg BID in severe renal impairment (increased exposure); 600 mg BID otherwise.
Reduce to 1.1 mg/m2 for CrCl 30-50; use caution/limited data below CrCl 30
Give ~75% dose for CrCl 15-50; consider further reduction below CrCl 15
Reduce ~20% for CrCl 30-70; avoid if CrCl <30
Renally cleared; halve starting dose when CrCl <60, marked reduction/avoid in ESKD, dose after HD; titrate to counts
No change if CrCl >=30; not recommended/caution if <30; reduce and slow-infuse oncology IV dose; withhold for acute decline
Consider dose reduction in renal impairment (e.g. serum creatinine >2 mg/dL); no precise CrCl algorithm.
Individualize; many reduce or avoid when CrCl <30-50 mL/min given toxic metabolite accumulation.
Reduce starting dose ~50% for severe impairment (CrCl <20); caution with moderate impairment.
Peginterferon-alfa: reduce or avoid if CrCl <50; alfa-2b not recommended in ESKD.
No change if CrCl >=30; reduce from 4 mg to 3 mg for severe impairment (CrCl <30) or ESRD/dialysis
Reduced starting dose (e.g., 60 mg) in moderate-severe renal impairment for certain indications; exposure rises with impairment
CrCl 30-60: 10 mg daily; CrCl <30 not on HD: 15 mg QOD; on dialysis: 5 mg daily post-HD (myeloma)
No change for mild-moderate; reduce starting dose for severe renal impairment (CrCl <30)
No change for mild-moderate; for severe impairment (eGFR <30, not on dialysis) reduce 100 mg to 75 mg once daily
High-dose conditioning: reduce to 140 mg/m2 in significant renal impairment/dialysis dependence and AL amyloidosis
Reduce to 30 mg for moderate impairment (eGFR 30 to <45); ~20 mg studied in severe; recalculate eGFR before dosing
Reduce dose and extend interval for baseline renal impairment; monitor free-platinum AUC and avoid cumulative platinum stacking
No change for mild-moderate; in severe impairment/dialysis use lower or less frequent dosing with closer monitoring
No change for CrCl 51-80; reduce to 200 mg BID for CrCl 31-50; not recommended if CrCl <30
Standard 85 mg/m2 down to CrCl ~30; reduce to 65 mg/m2 if CrCl <30
CrCl>60: 4 mg/m2; 41-60: 3 mg/m2; 21-40: 2 mg/m2; avoid if CrCl <20-30
Reduce starting dose for moderate-severe renal impairment (CrCl 15-59 mL/min)
No change for mild-moderate; reduce dose in severe impairment (eGFR 15-29)
Reduce dose (~15 mg/m2) in severe renal impairment/ESRD; standard with monitoring for mild-moderate
Full dose CrCl>=65; reduce dose + lengthen interval (q4wk) for CrCl 25-65; not recommended <25
No change for mild-moderate; reduced starting dose (200 mg) for severe renal impairment
Reduced starting dose in moderate-severe impairment (CrCl 15-29) and ESKD; in HD give single reduced dose after dialysis
Reduce dose and lengthen interval in renal impairment; hold for new/worsening proteinuria or rising creatinine
CrCl 60-89 no change; CrCl 30-59 reduce to 0.75 mg daily; CrCl 15-29 reduce to 0.5 mg daily; not studied <15/dialysis
IV: no change if CrCl >=40; reduce dose for CrCl 20-39 mL/min. Oral: reduce in moderate-severe impairment. <20 insufficient data.
Full dose CrCl>=60; reduce starting dose for CrCl 30-59; further reduce (20 mg/m2 BID) for CrCl 15-29; avoid ESKD
Reduce starting dose to 200 mg when CrCl <50 mL/min; titrate with ECG and electrolyte monitoring
320 mg/m2 if CrCl >=60; 280 for CrCl 40-<60; 250 for CrCl 20-<40 mL/min
CrCl-banded: 3.5 mg (50-60), 3.3 mg (40-49), 3.0 mg (30-39); avoid if CrCl <30
Avoid or contraindicated in impairment
13Do not initiate — or hold / stop — below a kidney-function threshold.
Use with caution/consider dose reduction if CrCl <40; not recommended in severe renal impairment (limited data).
No change for mild-moderate; avoid in severe impairment (CrCl <30) due to increased MMAE exposure/toxicity.
Reduce or avoid in baseline renal impairment; cap cumulative lifetime dose; hold courses for sustained creatinine rise
Do not initiate with significant baseline renal impairment; withhold doses for rising creatinine (>4-4.5)/oliguria.
Reduce dose or avoid in baseline renal impairment; cap lifetime cumulative nitrosourea dose and hold for sustained creatinine rise
Baseline CrCl <30 is a contraindication/caution; reduce or omit cycles for grade >=2-3 renal toxicity; activity capped by renal radiation dose
High-dose MTX contraindicated or sharply dose-reduced when CrCl/eGFR low; withhold until prior AKI resolves; titrate leucovorin to MTX levels
Avoid/use cautiously when serum creatinine >~1.7 mg/dL; cap cumulative dose to limit TMA risk
Do not initiate if CrCl <30 mL/min; discontinue for HUS/recurrent severe CLS
Avoid in severe renal impairment; hold next dose if renal function deteriorates; cap at 90 mg over >=2-4 h
Do not initiate if CrCl <45 (contraindicated); no reduced-dose regimen below threshold; hold NSAIDs peri-dose
Avoid/contraindicated in significant renal impairment; nephrotoxicity is dose-related and cumulative
Caution/relative contraindication in significant renal impairment; reduced clearance raises retained activity and marrow exposure
Dose calculated from GFR
1The dose itself is a function of measured kidney function.
Caution — no defined threshold
4Renally handled agents with no validated nomogram: consider reducing and monitor closely.
Renally excreted; dose reduction and intensified QT/exposure monitoring advised in significant renal impairment
No validated nomogram; consider dose reduction in significant impairment (renally eliminated 5-FU metabolites)
Renally eliminated; consider dose reduction/every-other-week spacing in significant/severe CKD with close monitoring
Consider caution/dose reduction in significant renal impairment (renal clearance component; renally eliminated 5-FU metabolites)
Dosing rules are concise paraphrases of each agent's label/PK guidance, verified against FDA labels — confirm the exact thresholds on the drug page and against current local protocols before use. Medical-education content only — not medical advice.