Society of Diabetic Nephropathy Prevention Journal of Nephropathology 2251-8363 16 1 2027 01 01 Radiopharmaceutical administration in chronic kidney disease; pharmacokinetic challenges, dosimetry, and safety considerations e28741 e28741 10.34172/jnp.28741 EN Narges Mostafaloo https://orcid.org/0009-0004-6875-8632 Gaffarov Usmon https://orcid.org/0009-0009-7559-4046 Mamajonova Oygul https://orcid.org/0009-0005-4056-5721 Sagdiana Buranova https://orcid.org/0000-0002-7626-9546 Parpiyeva Umida https://orcid.org/0009-0007-5135-1192 Nodirbek Komilov https://orcid.org/0009-0009-9174-1843 Samadov Bakhodirjon https://orcid.org/0000-0003-4593-6569 Azima Bakhramova https://orcid.org/0009-0003-8150-7259 Boretskaya Alisa https://orcid.org/0009-0004-9931-4567 Ali Darabi https://orcid.org/0009-0009-8840-7000 Journal Article 10.34172/jnp.28741 2026 06 19 2026 08 10 Chronic kidney disease (CKD) significantly alters the pharmacokinetics of radiopharmaceuticals, primarily through reduced renal clearance that prolongs systemic circulation and modification of biodistribution patterns. This condition impaired excretion elevates plasma concentrations of both diagnostic and therapeutic radiotracers, potentially increasing radiation exposure to non-target tissues while compromising image quality or therapeutic efficacy. Dosimetry becomes particularly complex in CKD patients, as standard models assuming normal renal function underestimate radiation doses to kidneys and other organs. One of them is 177Lu-PSMA [lutetium-177-(prostate-specific membrane antigen)], which demonstrated higher healthy tissue doses in patients with reduced glomerular filtration rates. The kidneys themselves face dual risks; as the clearance organs, they receive elevated radiation doses from retained radiopharmaceuticals, since pre-existing renal impairment may lower tolerance thresholds below the conventional 23 Gy limit established for peptide receptor radionuclide therapy. Furthermore, safety considerations necessitate individualized approaches, though evidence-based dosing guidelines remain scarce and inconsistent across radiopharmaceuticals. Patients on dialysis present additional challenges, as extracorporeal clearance may incompletely remove radiotracers while creating radiation safety concerns for healthcare staff and equipment contamination. Notably, certain agents exhibit nephrotoxic potential beyond radiation effects, particularly those with inherent renal retention properties. Despite these complexities, most diagnostic nuclear medicine procedures maintain favorable safety profiles in CKD when appropriately managed. Still critical knowledge gaps persist regarding optimal dose adjustments across CKD stages, long-term renal functional impacts of therapeutic radiopharmaceuticals, and standardized protocols for dialysis timing relative to administration, therefore future studies should prioritize prospective dosimetry studies and develop consensus guidelines to ensure safe, effective radiopharmaceutical use across the spectrum of renal impairment while balancing diagnostic/therapeutic benefits against cumulative radiation risks.