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Renal disease alters the effects of many drugs. Drug doses of certain drugs have to be appropriately adjusted depending upon the degree of renal impairment. Drug dosing errors in patients with renal impairment are common and can lead to accumulation and toxicity leading to adverse effects and poor outcomes. A case of a 72 years old male patient with chronic renal failure with other co morbid disease states like systemic hypertension, diabetes mellitus, osteoporosis and peripheral artery disease has been discussed. Laboratory data revealed both elevated serum creatinine and urea levels. On the day of admission the patient was in end stage renal disease as his calculated GFR was 12ml/min. Modified Diet for Renal Disease equation was used to calculate the GFR and dose adjustments were made accordingly. Drugs prescribed to the patients included ceftriaxone 1 g, Pentoxifylline 400 mg, Tapendadol 50 mg, Levocarnitine 500 mg, Alprazolam 0.5 mg, Alpha calcidiol 0.25 mg, Atorvastatin 20 mg, Cilostazol 50 mg, Tramadol 50 mg, Esomeprazole 40mg, Calcium 250 mg, A systematic medication chart review revealed that pentoxyfylline is the drug of choice with altered dosing recommendations in this patient. Therapeutic duplication in the form of using pentoxyfylline and cilostazole to treat peripheral vascular disease was also noted. Alprazolam was started at a higher dose for the geriatric patient.