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Renal impairment may be acute or chronic - both of which can result in problems with
medications. Renal impairment may be the result of a variety of renal or systemic diseases,
such as diabetic nephropathy or systemic lupus erythematosus. Normal ageing results in a
decline in renal function due to loss of nephrons. When prescribing for elderly patients, it
should therefore be assumed that some degree of renal impairment exists[1, 2].If even mild
renal impairment is considered likely, renal function should be checked before prescribing any
drug which requires dose modification. Reasons for problems with medications in renal
impairment include:
Computerised alerts are likely to become more important in reducing errors of prescribing in
patients with renal impairment[3, 4].
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Prescribing any drug that increases potassium levels is potentially very dangerous - eg,
potassium supplements and potassium-sparing diuretics. Other products that contain
potassium include ispaghula husk laxatives.
Products with a high sodium content (eg, some antacids) may cause sodium and water
retention in patients with renal impairment.
Excessive vitamin D replacement therapy can cause hypercalcaemia that may precipitate
or exacerbate renal impairment. Many patients with chronic kidney disease (CKD) are
prescribed alfacalcidol; therapy should therefore be closely monitored.
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Nephrotoxic drugs
Drugs causing prerenal damage
Drugs that cause excessive gastrointestinal losses, either through diarrhoea or vomiting,
also cause volume depletion and may precipitate acute kidney injury (AKI).
NSAIDs, even in short courses, can cause AKI as a result of renal underperfusion.
Angiotensin-converting enzyme (ACE) inhibitors can also cause a deterioration in renal
function. However, this is a problem only in patients with compromised renal perfusion,
particularly those with renal artery stenosis.
Care should be taken when an ACE inhibitor and NSAID are prescribed together, as this
combination may precipitate an acute deterioration in renal function.
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Intrarenal damage may result in a direct toxic effect on the kidneys or hypersensitivity
reactions.
Most drugs that cause damage within the kidneys do so as a result of hypersensitivity
reactions, which involve either glomerular or interstitial damage.
Drugs that have been reported to cause glomerulonephritis include penicillamine, gold,
captopril, phenytoin and some antibiotics, including penicillins, sulfonamides and
rifampicin.
Drugs that may cause interstitial nephritis include penicillins, cephalosporins,
sulfonamides, thiazide diuretics, furosemide, NSAIDs and rifampicin.
There are a number of drugs that cause direct toxicity to the renal tubules (acute tubular
necrosis) - eg, aminoglycosides, amphotericin and ciclosporin.
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1. Bell JS, Blacker N, Leblanc VT, et al; Prescribing for older people with chronic renal
impairment. Aust Fam Physician. 2013 Jan-Feb;42(1-2):24-8.
2. Jones SA, Bhandari S; The prevalence of potentially inappropriate medication prescribing
in elderly patients with chronic kidney disease. Postgrad Med J. 2013 Feb 16.
3. Joosten H, Drion I, Boogerd KJ, et al; Optimising drug prescribing and dispensing in
subjects at risk for drug errors due to renal impairment: improving drug safety in
primary healthcare by low eGFR alerts. BMJ Open. 2013 Jan 24;3(1). pii: e002068. doi:
10.1136/bmjopen-2012-002068. Print 2013.
4. Erler A, Beyer M, Petersen JJ, et al; How to improve drug dosing for patients with renal
impairment in primary care - a cluster-randomized controlled trial. BMC Fam Pract. 2012
Sep 6;13:91. doi: 10.1186/1471-2296-13-91.
5. Continuing good CKD management; The Renal Association
Disclaimer: This article is for information only and should not be used for the diagnosis or
treatment of medical conditions. EMIS has used all reasonable care in compiling the
information but make no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions. For details see our conditions.
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