Remdesivir and Kidney

Q: A 67-year-old male with renal insufficiency with a baseline Glomerular Filtration Rate (GFR) of 34 is admitted to the ICU with COVID-19 during the 2025 flu season. Remdesivir is contraindicated in this patient due to acute-on-chronic renal failure.

A) True

B) False

Answer: B

Remdesivir can be safely used in patients with acute kidney injury (AKI) and chronic kidney disease (CKD) without fear of worsening kidney function, including those on dialysis. There is no need to adjust the dose. Previously, it was suggested that the cyclodextrin vehicle of this drug can accumulate in renal failure, but concern seems to be unfounded, at least clinically. 

Also, Remdesivir can be relatively safely used in decompensated liver disease. Care should be taken to check baseline Liver Function Tests (LFTs) and to monitor them while remdesivir is in use. It can be safely used till alanine aminotransferase (ALT) elevation is below >10 times the upper limit of normal.

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References:

1. Thakare S, Gandhi C, Modi T, et al. Safety of Remdesivir in Patients With Acute Kidney Injury or CKD. Kidney Int Rep 2021; 6:206.

2. Seethapathy R, Wang Q, Zhao S, et al. Effect of remdesivir on adverse kidney outcomes in hospitalized patients with COVID-19 and impaired kidney function. PLoS One 2023; 18:e0279765.

3. Sise ME, Santos JR, Goldman JD, et al. Efficacy and Safety of Remdesivir in People With Impaired Kidney Function Hospitalized for COVID-19 Pneumonia: A Randomized Clinical Trial. Clin Infect Dis 2024; 79:1172.

4. Sabers AJ, Williams AL, Farley TM. Use of remdesivir in the presence of elevated LFTs for the treatment of severe COVID-19 infection. BMJ Case Rep. 2020 Oct 31;13(10):e239210. doi: 10.1136/bcr-2020-239210. PMID: 33130588; PMCID: PMC10577715.

5. Shah S, Ackley TW, Topal JE. Renal and Hepatic Toxicity Analysis of Remdesivir Formulations: Does What Is on the Inside Really Count? Antimicrob Agents Chemother. 2021 Sep 17;65(10):e0104521. doi: 10.1128/AAC.01045-21. Epub 2021 Jul 26. PMID: 34310212; PMCID: PMC8448111.