HCP Covid Treatment Update 2025

COVID-19 Treatment Options for Patients with CKD

The Bigger Picture

People with CKD, especially those with stage 3–5 CKD or a kidney transplant (KT), have a higher risk of serious illness from COVID-19.

Hospitalization and ICU Admission

CV Complications

Long COVID

Mortality

Many factors contribute to this increased risk:

Higher incidence of comorbidities

Increased time in dialysis centers & healthcare settings

Chronic immunosuppression (KT recipients)

Impaired immune response leading to reduced vaccine efficacy

Lowering Risks Associated with COVID-19

COVID-19 Treatment Options for People with CKD

Treatment is recommended for patients with CKD or KT recipients and mild/moderate COVID-19 - started as soon as possible, with the goal of reducing progression to hospitalization and death.

Paxlovid (nirmatrelvir/ritonavir)

Oral option for adults (and children ≥12 years old and ≥40 kg under EUA) within 5 days of symptom onset. Dosage depends on eGFR.

eGFR ≥60 mL/min

eGFR<30 mL/min or HD

eGFR≥30 to <60 mL/min

Side Effects

Drug Interactions

Patient Education

Veklury (remdesivir)

IV option for adults and pediatric patients ≥1.5 kg within 7 days of symptom onset. Must be administered in a healthcare setting.

Pertinent Information

Outpatient Dosing

Inpatient Dosing

Lagevrio (molnupiravir)

Oral option for adults within 5 days of symptom onset if options above cannot be used or are unavailable; available under Emergency Use Authorization.

Pertinent Information

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References

Supported by an educational grant from Pfizer.

Information contained in this NKF educational resource is based on data available at the time of publication. It is intended to help clinicians stay informed about new scientific findings and developments. This resource is not intended to establish a preferred standard of care and should not be interpreted as prescribing an exclusive course of management.

References

• United States Renal Data System (USRDS). Chronic Kidney Disease – Chapter 3: Morbidity and Mortality in Patients with CKD. In: USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD, 2024. Accessed October 22, 2025. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/3-morbidity-and-mortality-in-patients-with-ckd

• Vecchio LD, Balafa O, Dounousi E, et al. COVID-19 and cardiovascular disease in patients with chronic kidney disease. Nephrol Dial Transplant. 2024;39(2):177-189. Doi: 10.1093/ndt/gfad170

• United States Centers for Disease Control and Prevention. COVID-19 treatment clinical care for outpatients. June 11, 2025. Accessed October 22, 2025. https://www.cdc.gov/covid/hcp/clinical-care/outpatient-treatment.html

• Infectious Diseases Society of America (IDSA). IDSA guidelines on the treatment and management of patients with COVID-19. October 14, 2025. Accessed October 22, 2025. https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/

• Paxlovid [prescribing information]. Pfizer Labs; 2025. Accessed October 22, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/217188s010lbl.pdf

• Veklury [prescribing information]. Gilead Sciences, Inc; 2025. Accessed October 22, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/214787s032lbl.pdf

• Lagevrio [prescribing information]. Merck & Co., Inc.; 2025. Accessed October 22, 2025. https://www.merck.com/eua/molnupiravir-hcp-fact-sheet.pdf

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Drug Interactions

Paxlovid (nirmatrelvir/ritonavir) has multiple drug interactions (including herbal supplements and OTC products) via CYP3A4. This is especially critical for kidney transplant recipients. For specific assistance, consult a reliable reference such as the Liverpool COVID-19 Interaction Checker.

Standard Dose Pack

• Nirmatrelvir 150 mg tablets & ritonavir 100 mg tablets
• 2 nirmatrelvir (300 mg) and 1 ritonavir taken together twice daily x 5 days
• Take at morning and bedtime, approximately same time each day, with or without food.

Pertinent Information

• Must be administered in a healthcare setting with access to anaphylaxis medications and ability to activate the emergency medical system, as necessary.

• Prior to initiation, check liver function and prothrombin time as clinically appropriate.
• The most common side effects from clinical trials are nausea, abdominal pain, diarrhea and elevated transaminases. Rare but serious reactions include anaphylaxis & hypersensitivity reactions, generalized seizure, and rash.
• Reports during the Emergency Use Authorization (EUA) period have also included extravasation and infusion-related reactions.

Patient Education

• Advise patients to administer all tablets within each blister pack together and swallow tablets whole
• For a missed dose, take as soon as you remember only if <8 hours have passed from the time it was supposed to be taken. Otherwise, skip the dose and take next one as regularly scheduled. Do not double-up doses.
• Complete the full 5-day course as prescribed – do not stop early.

Side Effects

• The most common side effects from clinical trials are dysgeusia (altered taste) and diarrhea.
• Reports during the Emergency Use Authorization (EUA) period have also included anaphylaxis & hypersensitivity reactions, headache, hypertension, abdominal pain, and malaise.

Pertinent Information

• Dosage is 800mg by mouth every 12 hours for 5 days, with or without food.
• No dosage adjustment needed for eGFR ≥ 30; same recommendation applies for eGFR < 30 or dialysis, though not studied in these populations.
• Women who can become pregnant and their partners should use birth control. Avoid in pregnant women due to risk of embryo-fetal toxicity.
• For a missed dose, take as soon as you remember only if <10 hours have passed from the time it was supposed to be taken. Otherwise, skip the dose and take next one as at regularly scheduled. Do not double-up doses.
• Complete the full 5-day course as prescribed – do not stop early.
• The most common side effects from clinical trials are diarrhea, nausea, and dizziness. Reports during the Emergency Use Authorization (EUA) period have also included anaphylaxis & hypersensitivity reactions, vomiting, erythema, pruritic, rash, and urticaria.

Inpatient Dosing

• Adults and pediatric patients ≥ 40 kg:
• 200 mg IV on Day 1
• 100 mg IV once daily from Day 2
• At least 28 days old and 3 kg to <40 kg:
• 5 mg/kg IV on Day 1
• 2.5 mg/kg IV once daily from Day 2
• Infants <28 days and ≥ 1.5 kg, or ≥ 28 days and 1.5 to < 3kg:
• 2.5 mg/kg IV on Day 1
• 1.25 mg/kg IV once daily from Day 2

• Recommended treatment duration for hospitalized patients not requiring invasive mechanical ventilation and/or ECMO is 5 days. If a patient does not demonstrate clinical improvement, treatment may be extended for up to 5 additional days for a total treatment duration of up to 10 days.
• Recommended total treatment duration for patients requiring invasive mechanical ventilation and/or ECMO is 10 days.

Outpatient Dosing

• Adults and pediatric patients ≥ 40 kg:
• 200 mg IV on Day 1
• 100 mg IV once daily on Days 2-3
• At least 28 days old and 3 kg to <40 kg:
• 5 mg/kg IV on Day 1
• 2.5 mg/kg IV once daily on Days 2-3
• Infacnts <28 days and ≥ 1.5 kg, or ≥ 28 days and 1.5 < 3 kg:
• 2.5 mg/kg IV on Day 1
• 1.25 mg/kg IV once daily on Days 2-3

Severe Renal Impairment Dose Pack

• Nirmatrelvir 150 mg tablets & ritonavir 100 mg tablets
• Day 1: 2 nirmatrelvir (300 mg) and 1 ritonavir taken together once
• Days 2-5: 1 nirmatrelvir and 1 ritonavir taken together once daily x 4 days
• Take at approximately same time each day, with or without food.
• On hemodialysis days, administer AFTER hemodialysis

Reduced Dose Pack

• Nirmatrelvir 150 mg tablets & ritonavir 100 mg tablets
• 1 nirmatrelvir and 1 ritonavir taken together twice daily x 5 days
• Take at morning and bedtime, approximately same time each day, with or without food.