Safe Prescribing in Patients with Kidney and Hepatic Diseases

Safe prescribing in kidney disease, particularly chronic kidney disease (CKD), requires careful monitoring of the use of nephrotoxic medications and dosage adjustments for those that are predominantly cleared by the kidneys. Generally, to minimize the risk of adverse effects and toxicity, medication selection in people with CKD should consider a host of factors, such as medications’ route of clearance, nephrotoxicity potential, therapeutic window, and their adverse effect profile. For medications that are predominantly cleared by the kidneys, dosage adjustment decisions are made based on residual kidney function, which is typically determined using equations that provide an estimated glomerular filtration rate. The hepatic system also plays a crucial role in the metabolism of many medications by converting them into active and inactive metabolites as well as elimination of exogenous substances. Rates of hepatic elimination and therapeutic window of medications are important aspects to consider in people with reduced hepatic function. The Child–Pugh score and the Model for End-stage Liver Disease are some of the tools used to assess and score levels of hepatic impairment, with implication for medication choice and dosing. In summary, prescribing decisions in people with kidney or hepatic diseases should be made based on several clinical and patient factors, as well as considering functional and biochemical markers.