Reviewing medicines use in renal impairment

Medicines use in kidney disorders

Kidney disorders and the degree of renal impairment can alter how medicines are handled by the body. This article outlines key considerations to optimise medicines use whilst preserving kidney function where possible.

Before giving advice on medicines use in renal impairment, read Questions to ask when giving medicines advice in renal impairment (SPS page).

Renal impairment: resources to support clinical decisions (SPS page) should help you in assessing the use of medicines in renal impairment.

If the recommended resources do not provide information or if the clinical scenario is complex, contact our SPS medicines advice service (SPS page). This service is available for healthcare professionals working in NHS primary care, including community pharmacy, in England.

If you work in secondary care then you can contact your local medicines information service or specialist pharmacist for further advice.

Acute kidney injury (AKI)

AKI is 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.

People with pre-existing chronic kidney disease (CKD) can also experience a sudden decline in kidney function, known as acute on chronic kidney disease.

Risk factors for AKI include:

• aged 65 years or over
• a history of AKI
• dehydration
• chronic conditions such as heart failure or diabetes

Prevention measures for individuals at risk include regular monitoring of serum creatinine and the provision of clear guidance on seeking medical advice when acutely unwell.

The NICE Clinical Knowledge Summary (CKS) Management of AKI guidance aims to preserve and optimise kidney function, and minimise the risks of complications such as pulmonary oedema or CKD.

Medication review

Undertake a medication review for all people who develop AKI, or individuals at increased risk during certain times such as intercurrent illness. It may be appropriate to temporarily withhold certain medicines after a full risk assessment.

Medicines that may be stopped temporarily include:

• angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs)
• non-steroidal anti-inflammatory drugs (NSAIDs)
• diuretics
• sodium-glucose co transporter-2 (SGLT-2) inhibitors

Check that the doses and frequencies of continued medicines are appropriate in relation to the cause of AKI and the level of kidney function.

Reassess kidney function regularly, the frequency may depend on the clinical status of the individual and the setting where they are being managed.

Decide when to safely restart any medicines stopped temporarily or readjust any changed dosage regimens. Ensure the individual is counselled about any medicine changes made during this time.

Chronic kidney disease (CKD)

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

It is defined as abnormalities in kidney structure or function present for greater than 3 months. The UK Kidney Association (UKKA) describe the different stages of CKD.

Medication review

Undertake routine medication reviews for individuals who develop CKD to check for kidney function changes and any required dosage regimen adjustments. The effects of any newly started medicines should be monitored.

Recommendations from NICE include advice on factors to help determine an appropriate frequency for monitoring, such as the underlying cause of CKD.

Consult the NICE CKS guidance on the Management of CKD to optimise treatment for people with CKD. Considerations should be made to offer certain medicines where appropriate, which may include:

• lipid lowering therapy with a statin for primary or secondary prevention of cardiovascular disease (CVD)
• an antiplatelet for secondary prevention of CVD
• a SGLT-2 inhibitor, such as dapagliflozin
• appropriate immunisations, such as for the influenza virus and pneumococcal disease

It is important to know what medicines an individual is taking to check for potential drug interactions with anything prescribed in primary care.

Check if a person is taking any over the counter or complementary products to assess their impact on kidney function. Read Managing complementary products and conventional medicines (SPS page) to help with this.

Some medicines may be started or advised by a renal specialist and then prescribed or continued in primary care, for example alfacalcidol. Refer to local guidelines or protocols where necessary.

The UK Renal Pharmacy Group (RPG) advise on how to prevent and manage CKD complications such as anaemia, osteoporosis, cardiovascular disease and metabolic acidosis.

Renal replacement therapy (RRT)

The main types of RRT for people with established renal failure are:

• peritoneal dialysis
• haemodialysis
• haemodiafiltration
• transplant

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.

Dialysis

The UK RPG has a handy guide to dialysis. Different types of dialysis may be continuous or intermittent.

Medication review

When dosing medicines for people on RRT, consider:

• the type of RRT
• the length of the RRT sessions and how frequently they occur
• the type of dialysis membrane used
• person factors, for example do not under dose antibiotics in a person with a severe infection
• medicine factors, for example highly protein bound drugs or very large molecules are less likely to be removed by RRT

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. You must be aware of any changes to medicines the individual is taking, and ensure their records are kept up to date in all settings.

Check the UK RPG guidance on drug dosing in renal impairment and dialysis for general advice on dose adjustments. Review Renal impairment: resources to support clinical decisions (SPS page) for other resources which may provide guidance on appropriate dosing of medicines initiated in primary care for individuals on RRT. Check for any interactions between new medicines started for an individual receiving RRT and those prescribed in primary care.

Kidney transplant

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

Check the UK RPG guidance on medicines optimisation in kidney transplantation. Management aims include effective immunosuppression and optimisation of 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. The article Example medicines to prescribe by brand name (SPS page) includes tacrolimus and ciclosporin as examples of medicines which must be prescribed by brand name.

When reviewing medicines or prescribing for people who have had a kidney transplant:

• be aware of any changes to medicines made by their specialist, and make sure the record of their medicines list is kept up to date
• check for drug-drug interactions, in particular with immunosuppressants such as tacrolimus
• do not assume that the individual has normal kidney function, and refer to guidance on Calculating kidney function (SPS page) as usual to guide medicine dosing
• check any new medicine doses and frequencies are appropriate for their kidney function
• avoid any nephrotoxic medicines where possible, for example NSAIDs

Update history