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16th May 2025
Medication dosing in renal impairment
Many drugs are eliminated via the kidneys and in chronic kidney disease (CKD) or acute kidney injury (AKI) these medications can accumulate increasing the risk of adverse drug reactions. If CKD or AKI is suspected a review of medications is indicated. Medications that cause or can exacerbate renal impairment should be avoided, examples of these can be found in table 2. If changes are needed to the total daily dose of a medication can be altered by reducing individual doses or by increasing the time interval between doses. Information regarding the use of medications in renal impairment can be found in the appropriate drug monograph in the BNF or in a manufacturers summary of product characteristics (SPC).
| Medication | Effect on the kidney | Action during AKI |
|---|---|---|
| NSAIDs | Altered haemodynamics within the kidney leading to hypoperfusions | Avoid |
| Aminoglycosides | Tubular cell toxicity | Avoid if possible. If use is unavoidable, reduce dose &/or increase dosing interval |
| Glycopeptides | Acute interstitial nephritis | Reduce dose / increase dose interval |
| ACE inhibitors/ARBs | Altered haemodynamics. Can impair kidney’s ability to maintain GFR when perfusion is compromised | Avoid unless in certain circumstances where they may be beneficial. |
| Thiazide and loop diuretics | Over diuresis leading to hypoperfusion of the kidneys can cause or exacerbate AKI. | Loop diuretics preferred as thiazides less effective if GFR < 25ml/min. Higher doses may be needed to achieve a diuresis in patients with fluid overload. |
| Methotrexate | Crystal nephropathy | Use with caution, avoid in severe impairment |
| IV bisphosphonates | Can cause impaired renal function – especially when given in high doses and short duration infusions | Reduce dose and infuse at correct rate |
| Table 2: Nephrotoxic medications | ||
In patients with CKD or AKI some medications may accumulate increasing the risk of toxicity and adverse side effects. Product literature should be consulted, and doses should be adjusted, or the medications should be temporarily held. Examples of these are highlighted in table 3.
| Medication | Effect on medication during renal impairment | Action during AKI |
|---|---|---|
| Opioid analgesics | Risk of accumulation leading to toxicity | Reduce dose or consider alternatives that are not renally excreted e.g. oxycodone, fentanyl |
| Metformin | Increased risk of lactic acidosis | Avoid if GFR <30mL/min |
| Methotrexate | Risk of accumulation leading to toxicity | Use with caution, avoid in severe impairment |
| Digoxin | Risk of accumulation leading to bradycardia and toxicity | Consider reducing dose and monitoring digoxin level |
| Lipid lowering agents | Possible increased risk of rhabdomyolysis | Monitor for unexplained/persistent muscle pain. Stop if AKI due to rhabdomyolysis. |
| Lithium | Risk of accumulation leading to toxicity | Avoid where possible Monitor lithium levels Seek advice for alternative |
| Low molecular weight heparins | Risk of accumulation which can increase bleeding risk | Consider reducing dose or switching to alternative medication as per hospital guidance |
| Warfarin | Acute rise in urea may displace warfarin from binding site causing a rise in INR | Monitor INR and consider adjusting dosage |
| Table 3: Medications requiring adjustment in AKI | ||
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