Current practice and guideline adherence in renal dose adjustment for patients with chronic kidney disease: A systematic review and meta-analysis.

AIMS: To quantify prescribing adherence to renal dosing recommendations in adults with chronic kidney disease (CKD; Stage 3 and above) and to evaluate the clinical consequences of non-adherence.

METHODS

This systematic review and meta-analysis was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO (CRD42025620883). Eight electronic databases were searched from inception to 31 December 2025. Quantitative studies assessing renal dose adjustment practices in adults with advanced CKD were included in the review. Two reviewers independently performed study selection, data extraction and quality assessment. Random-effects meta-analyses (REML) were used to pool adherence proportions at prescription/order and patient levels.

RESULTS

Thirty studies were included in the review. The observational studies were of moderate to high quality, while the two interventional studies had moderate risk of bias due to confounding. Prescribing adherence to renal dosing guidelines ranged from 33% to 87.7%. Pooled prescription/order-level guideline adherence (n = 16) was 0.48 (95% CI 0.42-0.55; I2 ≈ 98%). Conversely, the pooled patient-level guideline adherence (n = 7) was higher at 0.7 (95% CI 0.57-0.83; I2 ≈ 99.9%). The study results suggest that the prevalence of prescribing non-adherence to renal dosing guidelines was high and may be associated with various adverse drug events.

CONCLUSIONS

The available evidence suggests that adherence to renal dosing recommendations in adults with advanced CKD is variable and may be suboptimal. The pooled estimate suggests a potential safety gap, although substantial heterogeneity limits interpretation. Furthermore, non-adherence to renal dosing recommendations was associated with adverse clinical consequences and increased healthcare utilization. High-quality studies are needed to inform effective strategies aimed at improving prescribing practices and medication safety.