Medication considerations for different kidney disorders

The way medicines are handled by the body can be affected to different extents, depending on the kidney disorder and degree of impairment. We provide advice on the considerations needed when optimising medicines. This is to ensure the safe use of medicines in the context of preserving kidney function, where possible.

Ensure you have all the relevant background information by following the advice in our article: Questions to ask when giving advice on medicines in renal impairment.

Acute Kidney Injury (AKI)

AKI is a reversible state characterised by a rapid decline in kidney function over hours or days. It can result in failure to maintain fluid, electrolytes, and acid-base balance.

Management aims include preservation and optimisation of kidney function and minimisation of secondary organ damage (e.g arrthymias, pulmonary oedema, CKD).

Medication review

All people who develop AKI should have a medication review to:

• eliminate any potential causes or contributory factors for AKI, e.g. nephrotoxic medicines
• avoid inappropriate combinations of medications in the context of AKI
• check that doses are appropriate for the level of kidney function
• decide when to safely restart any medicines stopped temporarily

Medicines that may be stopped temporarily during AKI include angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), non-steroidal anti-inflammatory drugs (NSAIDs), and diuretics.

See our SPS page on information resources that assist with managing medicines in renal impairment for further advice.

Chronic Kidney Disease (CKD)

CKD is an irreversible and gradual loss of renal function over time.

It is defined as abnormalities in kidney structure or function present for greater than 3 months. There are different stages of CKD.

Medication review

All people who develop CKD should have a medication review to:

• routinely check for dose reductions and kidney function changes
• offer lipid lowering therapy with a statin for primary or secondary prevention of cardiovascular disease (CVD)
• offer an antiplatelet for secondary prevention of CVD
• offer immunisations for the influenza and pneumococcal viruses
• monitor the effects of newly started medicines

Medicines started and managed by a renal specialist do not usually need regular review in primary care as they will be managed by the specialist team.

The UK Renal Pharmacy Group advise on how to prevent CKD complications such as anaemia, bone disease and osteoporosis, and metabolic acidosis. They also advise on how to manage complications such as oedema and uraemia.

See our SPS page on information resources that assist with managing medicines in renal impairment for further advice.

Acute on Chronic kidney disease

People with pre-existing CKD can experience a sudden decline in kidney function, known as Acute on Chronic kidney disease.

Management aims include identification and treatment of the underlying cause of AKI (e.g infection, medicines, or dehydration).

This requires rapid assessment to prevent any irreversible loss of kidney function.

Medication review

Review all medicines during an episode of Acute on Chronic kidney disease and reintroduced/re-titrated medicines as appropriate once the AKI has resolved.

Renal Replacement Therapy (RRT)

The main types of RRT are peritoneal dialysis (PD), haemodialysis (HD), haemofiltration and haemodiafiltration. Some of these may be continuous or intermittent.

RRT is indicated in the end stages of CKD when kidney function is so poor that the kidneys are barely operational.

RRT may also be used in the management of severe AKI to remove toxins, excess fluid, and correct biochemical disturbances.

Medication review

When dosing medicines for people on RRT, consider:

• medicine factors (e.g highly protein bound drugs or very large molecules are less likely to be removed by RRT)
• person factors (e.g do not under dose antibiotics in a person with a severe infection)
• the type of RRT and membrane used as different membranes can affect the medicine factors
• reviewing all medicines for suitability especially any newly started medicines

Medicines started and managed during RRT by a renal specialist do not usually need regular review in primary care as they will be managed by the specialist team.

Any new medicines started in primary care in a person receiving RRT should be checked for correct dosing and interactions with other medications.

Kidney transplant

Transplantation is a form of RRT that is typically offered to end stage CKD patients and is a surgical procedure. During the surgery, a healthy kidney from one person is placed into another whose kidneys have stopped working.

Management aims include effective immunosuppression and optimising kidney function.

Medication review

People post-kidney transplant are usually prescribed long-term immunosuppressants to reduce kidney rejection risk. Medicines include tacrolimus, sirolimus, ciclosporin, mycophenolate, azathioprine or prednisolone.

All people who have had a kidney transplant should have a medication review to:

• ensure the correct immunosuppressant has been prescribed. Brand prescribe tacrolimus and ciclosporin to reduce rejection risk from fluctuations in drug levels
• check for drug-drug interactions
• check any new medicine doses are appropriate for kidney function
• avoid any medicines that cause renal impairment (e.g NSAIDs)