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

Aims To quantify adherence to renal dosing recommendations in adults with advanced chronic kidney disease (CKD; stages 3–5, including dialysis) and to evaluate the clinical consequences of non-adherence. Methods This systematic review and meta-analysis was conducted in accordance with PRISMA 2020 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. Two reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle–Ottawa Scale and ROBINS-I. Random-effects meta-analyses (REML) were used to pool adherence proportions at prescription/order and patient levels. Results Thirty studies were included. Observational studies were of moderate to high quality (NOS 6–9/9), while two interventional studies had moderate risk of bias due to confounding. Adherence ranged from 33% to 83%. Pooled prescription/order-level adherence (n=16) was 48% (95% CI 0.42–0.55; I 2 ≈98%). Patient-level adherence (n=7) was higher at 70% (95% CI 0.57–0.83; I 2 ≈99.9%). Non-adherence was associated with adverse drug events, including hypoglycemia and nephrotoxicity, and with increased emergency department visits, hospitalizations, and mortality. Conclusions Adherence to renal dosing recommendations in advanced CKD is suboptimal and highly variable across settings. Interventions targeting prescribing systems, including clinical decision support tools, are warranted to improve guideline adherence and medication safety in this high-risk population.