Can drugs that are contraindicated in patients with severe renal impairment be used in individuals with end-stage renal disease (ESRD) who are actively receiving hemodialysis? Will these medications be dialyzed out before negatively affecting the renal system? — Blair Buehler, DNP/FNP-S, Memphis, Tenn.

Patients on dialysis because of ESRD already present with an irreversibly impaired renal system. Since dosing adjustments to protect kidney function are routinely made based on a patient’s renal function, attempting to dose nephrotoxic medications affords negligible benefits to someone already at this stage of kidney failure.

If a patient on dialysis presents with a condition for which he or she could benefit from a nephrotoxic medication, the drug may be given if the benefit outweighs the risk. This scenario would apply in most situations, unless the patient has residual renal function (i.e., making >100 cc of urine per day). Patients receiving medications that fall in this category should be followed for drug levels when appropriate.

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Hemodialysis patients typically receive treatment three times a week. Medications, most of which are eliminated by the kidney, often have longer half-lives and should be dosed and timed accordingly. When in doubt, consult with a nephrologist or a clinical pharmacist.

Some substances are completely contraindicated, including gadolinium (used in MRI exams). — Debra Coplon, DNP, Memphis Internal Medicine and Pediatrics, Memphis, Tenn. (181-3)