Inappropriate Prescribing in Chronic Kidney Disease (CKD): Risks, Patterns and Prevention

Chronic Kidney Disease (CKD) affects approximately 10–15% of the world's population, and is associated with significant morbidity, mortality and health care utilization. Patients with CKD have a higher risk of drug accumulation, toxicity, and adverse drug reactions as a result of impaired renal clearance. This population is plagued by inappropriate prescribing including contraindicated medications, inappropriate dose adjustments based on glomerular filtration rate (GFR), polypharmacy, and a myriad of other unrecognized issues. In fact, systematic reviews and international audits suggest that 50 - 80% of CKD patients will receive at least one renally inappropriate medication during their treatment. These inappropriate prescribing practices lead to stomaching hospitalization, accelerating decline in kidney function and poor patient outcomes. This review uses current literature about the extent, frequency, and implications of inappropriate prescribing (IP) in CKD. We discuss important pharmacokinetic changes related to renal impairment, high-risk drug categories (e.g., NSAIDs, please note aminoglycosides, and metformin) and clinical implications of misuse. We also examine system and clinician-related factors leading to prescribing errors, including clinical inertia, weak electronic alerts, and lack of CKD-specific prescribing education. Ultimately, we summarize evidence-based interventions to prevent these errors, including pharmacist-led medication reviews, clinical decision support tools, guideline-based prescribing, and interdisciplinary care. While systemic policy changes and enhanced prescriber education are both strategies to change, shared goals should address prescribing safety in CKD to achieve nephroprotection, reduction of preventable harm, improvement of quality-of-life, and maximization of treatment efficacy in one of the highest-risk patient demographics.