How do you adjust the loading and maintenance doses for Keppra when treating status epilepticus in patients with ESRD, patients on HD, or patients on CVVH?

Ideally, if you have a patient with status epilepticus and known ESRD, then Keppra may not be an ideal first option. You should be reaching for your other status anti-seizure meds that aren’t exclusively renally excreted and are readily available in most hospitals; Depakote (40 mg/kg loading dose) or fosphenytoin (20 mg of phenytoin equivalent/kg loading dose).

In the acute sense, I agree with Dr. @Dr. First Last. Unless the patient has absolute contraindications to IV valproic acid, fosphenytoin, lacosamide, Versed, propofol, and phenobarbital, you should probably not be using Keppra.

Once the patient is no longer in status epilepticus and a change to Keppra is desired, it can be used but consider whether the patient might fare better on an alternative (e.g., carbamazepine).

For true ESRD not on dialysis, you are unlikely to require more than 1000 mg per day to maintain a therapeutic level. As should always be the case, target the lowest effective dose and pay attention to clinical signs of toxicity; do NOT rely on a lab test that may not be performed in-house to make judgments.

On dialysis, while it is common to perform once-daily dosing with a 50% post-dialysis correction, I usually will request BID/Q12H with a post-dialysis correction dosing due to this article by Shiue et al., PMID 28582998. Admittedly, the study is small but I would welcome the results of a more robust study if I could find one.

On CRRT/CVVH, you basically have a patient with a device that behaves like a normal kidney; regimens of 500-1000 mg BID/Q12H are reasonable but do make a contingency plan.