Medicines for chronic kidney disease
The general goal of treatment for chronic kidney disease (CKD) is to reduce the progression of the disease and reduce cardiovascular risk. Typically, this involves the use of medicines that treat comorbidities and risk factors, and can offer protection against further kidney damage in the early stages of the disease. Managing existing conditions like diabetes, high blood pressure and cardiovascular disease before kidney disease develops and in the early stages of CKD is critical in protecting the kidneys in the long-term.
The cause of CKD is important in determining the most appropriate treatment and management strategies, as these usually depend on the underlying condition.
In 2021, 37% of kidney failure cases in those who started dialysis or received a transplant were attributable to diabetes (ANZDATA 2022). Controlling blood sugar in diabetes is important to reduce the risk of CKD.
Methods of controlling blood sugar include medication and engaging in healthy lifestyle practices, including physical activity and eating a healthy diet.
Medications often prescribed for type 2 diabetes are:
- sodium-glucose transporter 2 (SGLT2) inhibitors
- DPP-4 inhibitors
- glucagon-like-peptide-1 receptor agonists/analogues.
Sodium-glucose transporter 2 inhibitors
SGLT2 inhibitors are a class of glucose-lowering drugs used in managing type 2 diabetes. They work by reducing the amount of glucose that is reabsorbed in the kidneys, promoting its excretion in the urine.
Multiple clinical trials have shown SGLT2 inhibitors to be effective in delaying the progression of CKD in people with and without type 2 diabetes (Heerspink et al. 2020, Li et al. 2021, Neal et al. 2017, Perkovic et al. 2019).
In September 2021, the Therapeutic Goods Administration approved dapagliflozin for treatment of CKD to reduce the risk of progressive decline in kidney function in adults with proteinuric CKD (stage 2, 3 or 4 and urine ACR≥ 30 mg/g) (TGA 2021). In September 2022, treatment of CKD was added to the Pharmaceutical Benefits Scheme listing for dapagliflozin (PBS 2022).
For more information, see Diabetes medicines.
Managing cardiovascular disease
High blood pressure
High blood pressure was the primary cause of 12% of kidney failure cases in people newly diagnosed with kidney failure in Australia in 2021 (ANZDATA 2022). High blood pressure can cause CKD; however, CKD both perpetuates and exacerbates high blood pressure.
Medications that may be prescribed to control high blood pressure, include:
- ACE inhibitors
- beta blockers
As with all medication in people with CKD, these need to be carefully monitored and adjusted or ceased depending on a person’s individual circumstances and their level of kidney function.
Statins are a first line treatment for managing high cholesterol; however, some research has indicated that the use of statins in people receiving dialysis shows limited benefits and can potentially be harmful (Kennard and Singer 2017). For people with CKD not on dialysis, combining statin therapy with ezetimibe has been shown to reduce the risk of adverse kidney events compared with statin use alone (Bae et al. 2020, CARI Living Guideline Lipid Work Group 2021).
For more information, see Medicines for cardiovascular disease.
Managing medications in chronic kidney disease
In stages 3–5 CKD, medicine use must be carefully managed. This is because medicines that are excreted through the kidneys have the potential to build up in the body and be toxic to the kidneys or other organs (Hartmann et al. 2010). To avoid this, clinical assessment and management of medication are important components of treating and managing later stages of CKD.
Management should be tailored to each individual and may involve stopping or lowering the dosage of certain medications or, when available, using alternatives that are not eliminated from the body through the kidneys (Faull and Lee 2007, Hartman et al. 2010, KHA 2020).
Because CKD is typically caused by another health condition, comorbidity and multimorbidity are common. This means that many people with CKD are prescribed complex medication regimens, which need to be monitored and adjusted to achieve the best outcomes.
Australians with CKD were prescribed an average of 8.4 medications between January 2013 and June 2016 (Castelino et al. 2020).
The use of multiple medications to manage underlying chronic conditions increases the chances of drug interactions, as well as adverse outcomes such as hospitalisation, falls, and mortality (Manski-Nankervis et al. 2021). In Australia, medication reviews are subsidised under Medicare and may be beneficial for people with CKD to simplify their medication regimen.
Potentially inappropriate medication use in clinical management of chronic kidney disease
Inappropriate prescribing in CKD involves the prescription of medications that are filtered or excreted through the kidneys and may potentially harm those taking them. As such, the types and dosages of medicines prescribed to people with CKD should be carefully monitored.
A potentially inappropriate prescription can include a contraindicated medicine, or too high a dose for a persons’ level of kidney function.
In Australia, between 1.5% and 2.6% of people with CKD were potentially inappropriately prescribed the combination of an ACE inhibitor, diuretic and non-steroidal anti-inflammatory drug (NSAID) (the ‘triple whammy’), according to estimates from 2016 and 2019 (Bezahbe et al. 2020, NPS MedicineWise 2020). Kidney Health Australia advises against using this combination of medicines in people with CKD, due to the increased risk of acute kidney injury.
Castelino and colleagues (2020) found that 35% of all Australians with CKD were given at least one potentially inappropriate prescription. The rate of potentially inappropriate prescribing increased with the stage of CKD, with 69% of people with stages 4–5 CKD receiving at least one potentially inappropriate prescription.
ANZDATA (Australia and New Zealand Dialysis and Transplant Registry) (2022) ANZDATA 45th Annual Report 2022, ANZDATA, Adelaide, accessed 15 March 2023.
Bae J, Hong N, Lee B, Kang E, Cha B and Lee Y (2020) Comparison of renal effects of ezetimibe-statin combination versus statin monotherapy: a propensity-score-matched analysis, Journal of Clinical Medicine, 9(3):798, doi:10.3390/jcm9030798.
Bezabhe W, Kitsos A, Saunder T, Peterson G, Bereznicki L, Wimmer B et al. (2020) Medication prescribing quality in Australian primary care patients with chronic kidney disease, Journal of Clinical Medicine, 9(3):783, doi:10.3390/jcm9030783.
Caring for Australians and New Zealanders with Kidney Impairment (CARI) Living Guideline Lipid Work Group (2021) Management of cholesterol-lowering therapy for people with chronic kidney disease, CARI, Sydney, accessed 13 July 2022.
Castelino RL, Saunder T, Kitsos A, Peterson GM, Jose M, Wimmer B et al. (2020) Quality use of medicines in patients with chronic kidney disease, BMC Nephrology, 21:216, doi:10.1186/s12882-020-01862-1.
Faull R and Lee L (2007) Prescribing in renal disease, Australian Prescriber, 30(1):17–20, doi:10.18773/austprescr.2007.008.
Hartmann B, Czock D and Keller F (2010) Drug therapy in patients with chronic renal failure, Deutsches Arzteblatt International, 107(37):647–655, doi:10.3238/arztebl.2010.0647.
Heerspink HLJ, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou F et al. (2020) Dapagliflozin in patients with chronic kidney disease, New England Journal of Medicine, 383:1436–1446, doi:10.1056/NEJMoa2024816.
Kennard A and Singer R (2017) Lipid lowering in renal disease, Australian Prescriber, 40(4):141–146, doi: 10.18773/austprescr.2017.047.
Kidney Health Australia (KHA) (2020) Chronic kidney disease (CKD) management in primary care, 4th edn, KHA, Melbourne, accessed 11 April 2022.
Li N, Lv D, Wei P, Gui Y, Liu S, Zhou E et al. (2021) Effects of SGLT2 inhibitors on renal outcomes in patients with chronic kidney disease: a meta-analysis, Frontiers in Medicine, 8:728089, doi:10.3389/fmed.2021.728089.
Manski-Nankervis J, McMorrow R, Nelson C, Jesudason S and Sluggett J (2021) Prescribing and deprescribing in chronic kidney disease, Australian Journal of General Practice, 50(4), doi:10.31128/AJGP-11-20-5752.
Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N et al. (2017) Canagliflozin and cardiovascular and renal events in type 2 diabetes, New England Journal of Medicine, 377:644–657, doi:10.1056/NEJMoa1611925.
NPS MedicineWise (2020) Clinical review, testing and management of renally cleared medicines among MedicineInsight patients with chronic kidney disease in 2018–2019, Sydney: NPS MedicineWise, accessed 11 April 2022.
Perkovic V, Jardine MJ, Neal B, Bompoint S, Heerspink HLJ, Charytan DM et al. (2019) Canagliflozin and renal outcomes in type 2 diabetes and nephropathy, New England Journal of Medicine, 380:2295–2306, doi:10.1056/NEJMoa1811744.
PBS (Pharmaceutical Benefits Scheme) (2022) PBS Schedule: Summary of Changes (September 2022), Canberra: Australian Government Department of Health and Aged Care, accessed 5 October 2022.
TGA (Therapeutic Goods Administration) (2021) Prescription medicines: new or extended uses, or new combinations of registered medicines, 2021, TGA, Australian Government, accessed 29 June 2022.