Table 1.

Cautionary notes for prescribing in people with CKD

MedicationComments
Narrow therapeutic index drugs
 AminoglycosidesNephrotoxic (acute tubular necrosis, AKI). Ototoxic. Therapeutic drug monitoring recommended.
 DigoxinIncreased for digoxin toxicity including arrhythmias. Therapeutic drug monitoring recommended.
 LithiumDiabetes insipidus, interstitial disease. Avoid concomitant use of thiazide diuretics and NSAIDs, maintain hydration. Therapeutic drug monitoring recommended.
 PhenytoinLow albumin will affect bound concentration. Monitor free phenytoin level.
 TacrolimusVasoconstriction, nephrotoxicity. Avoid concomitant use of CYP 3A4 inhibitors. Therapeutic drug monitoring recommended.
 WarfarinIncreased risk of bleeding. Close INR monitoring recommended.
Analgesics
 NSAIDsHemodynamically mediated kidney injury, sodium and/or potassium retention, interstitial nephropathy. Avoid with concomitant use of diuretics or RAAS inhibitors, maintain hydration, consider alternate analgesic.
 MeperidineActive metabolite, normeperidine, increases risk of seizure. Avoid.
 MorphineActive metabolites, increased drug effect.
Contrast agents
 Iodinated contrast mediaNephrotoxic. Use lowest dose, maintain hydration with saline, can consider N-acetylcysteine or sodium bicarbonate, avoid concomitant nephrotoxins, avoid use of high-osmolarity agents, avoid use of gadolinium-containing contrast media.
Bowel preparation
 Phosphate-containing bowel preparationIncreased risk for phosphate nephropathy and electrolyte disturbances. Avoid phosphate-based preparations.
Herbals
 LicoriceIncreased risk of sodium and water retention, hypokalemia, hypertension. Avoid use.
 Noni juiceIncreased risk of hyperkalemia. Avoid use.
 St. John’s wortCYP inducer. Increased risk of drug interactions. Avoid use.
Ginkgo bilobaIncreased risk of bleeding. Avoid use.
 Ephedra alkaloids (ma huang)May potentiate hypertension. Avoid use.
  • Excerpted from the 2012 Kidney Disease Improving Global Outcomes Guidelines on the management of CKD (77). NSAIDs, nonsteroidal anti-inflammatory drugs; CYP 3A4, cytochrome p450 3A4; INR, International Normalized Ratio; RAAS, renin-angiotensin-aldosterone system; CYP, cytochrome p450.