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If a dose is missed, patients should take it as soon as remembered on the same day

This is the manufacturer telling you that beyond 21 days outside refrigeration, they cannot guarantee what you are injecting will work as intended

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Cyanocobalamin, the most commonly used form of B12 supplementation therapy, is indeed metabolized to active methylcobalamin, releasing small amounts of cyanide whose clearance is reduced in CKD [34]

In fact, since B12 deficiencies can lead to mood changes, proper supplementation often helps improve mood-related issues

They also suggest that a person with CKD should take vitamin B12 supplements if necessary to help improve their clinical outcomes