Use of NSAIDs on nocturnal with no kidney function

Ask Our Experts Dr. John Agar, Nephrologist
1

Hello Dr. Agar,

I have been on dialysis for almost 20 years now, no urine output, Hep C positive (initial stages of liver fibrosis), on daily nocturnal home hemo (6 nights a week, 7-8 hours each night).

For the last couple of months, I have been having pain in my left knee (more at the back of the knee). X Rays showed Grade 1 Osteoarthritis. An MRI revealed a Baker’s cyst an inflammation in the area with fluid collecting there. I was asked to take Indomethacin 25 mg twice daily. The pain subsided to a large extent. After about 3 weeks, I stopped taking this medicine 2 days back. Within 2 days, the pain was back to becoming unbearable.

My doctor has advised to continue Indomethacin long term (a few more weeks).

On the internet I read that NSAIDs are harmful but my doctor says that since I have zero kidney function, it would be ok for me to take. Are there any other side-effects for someone on Daily nocturnal that I need to be careful about? Maybe the liver? Or would this drug be effectively cleaned out during my dialysis (high flux).

Thanks so much!

  • Kamal
2

I fully agree with your doctor, Kamal. As you will have no residual renal function to fight for, nor to preserve, there is no contraindication to indomethacin here - beyond the usual cautioning that should accompany all NSAID use = take with food, and not on an empty tummy … and to be alert to any dyspepsia that might signal upper GI erosive side-effects. I wouldn’t be expecting any liver issues. So … if it works, use it.

3

Thanks so much Dr. Agar for the quick response. It is a relief to know that I can use it.

4

Dr. Agar,

Is osteoarthritis common among long term dialysis patients? Out of my almost 20 years on dialysis now, I have been on daily nocturnal home hemo for more than 10 years. Shouldn’t that reduce the extent of co-morbidities?

  • Kamal
5

As I hobble to my keyboard - just as common in dialysis patients as the rest of us. And, yes, nocturnal does lessen the severity of many of the blights of dialysis, but nothing prevents the march of years.

6

In the 4 years I have been on Dialysis my Primary Dr at the VA has changed, reduced, or quit some of medications because I am a ‘Renal Patient’. I have under 4% Residual Function.

This leads me to ask at what point do we determine if I may return to using some of these meds that are now ‘restricted use’. I too had been using indosin for 30+ years, now reliant on pain meds including Tramadol which the dosage has been cut by half. Chantix worked well before, currently only allowed at half dose it does nothing.

How can I convince my Primary Dr, my Neph agrees with me but will not go on record contrary to my Primary.

7

In the 4 years I have been on Dialysis my Primary Dr at the VA has changed, reduced, or quit some of medications because I am a ‘Renal Patient’. I have under 4% Residual Function.

This leads me to ask at what point do we determine if I may return to using some of these meds that are now ‘restricted use’. I too had been using indosin for 30+ years, now reliant on pain meds including Tramadol which the dosage has been cut by half. Chantix worked well before, currently only allowed at half dose it does nothing.

How can I convince my Primary Dr, my Neph agrees with me but will not go on record contrary to my Primary.

8

Dear CharlieB

It is quite true that a good many medications need to be stopped or reduced either in actual dose or in dosage frequency … the reasons for this are that many (if not the majority) of medicines are excreted by the kidneys in the urine, and if kidney function is diminished, the active drug may remain in your system longer and thus the dose or its frequency needs to be reduced to avoid side effects or other damage.

As I am not your physician - nor do I know your medication list - and it would be wrong to try to advise without knowing your circumstances, I can only talk in generalities. That said, drugs like the NSAID group … among which are drugs like indomethacin … can do significant damage to kidneys and are always avoided in people with impaired kidney function. But, once residual kidney function is lost, and there is no kidney function left to ‘preserve’, it is feasible to consider use them again, always while weighing up any other contraindications or potential complications against the potential benefit they may bring.

In Kamal’s case … see the thread above … I have been aware - from past discussions with him - that he has been on dialysis for many, many years and has no residual kidney function at all to try to preserve. In that event, the use (or not) of NSAIDs becomesa trade off against any other potential issues - like irritation or ulceration of his upper gut - rather than a concern re what might happen to his now non-existent kidneys.

You, on the other hand, state you still have some residual function … limited though it may be … and the preservation of this may actually be useful to you, especially if you still pass a reasonable volume of urine. your stated level of 4% residual function can be a very useful/important additive to the clearance provided by dialysis, especially in patients who are on peritoneal dialysis - perhaps more-so than in those on haemodialysis.

But … over and above the additional clearance that even a small amount of residual function (eGFR) provides, there is even a greater advantage … for residual function usually means a preserved urine volume.

Most long term dialysis patients will eventually lose their urine output, but while there is a urine flow (as might be expected with an eGFR of 4), there is also the greater freedom of fluid intake that urine volume brings. This means that even 4% is worth preserving and fighting for … and any drug that is likely to negatively impact urine volume is still a drug to shy away from, if possible.

NSAID use is almost certain to fairly quickly dry up your urine volume … permanently … and this would mean less flexibility with your fluid intake and greater thirst. This is the crux of the problem. It boils down to a toss up between thirst versus joint improvement - if indeed that does occur.

There is no right answer here - and as in all things in life, it comes down to a trade-off. It seems likely your primary doctor has come down on one side of the trade-off, your nephrologist on the other … and both are likely right - or wrong - depending on your interpretation of what matters most, to you.

I am not sure if I explained that well … but I think you will get my meaning.

9

Dear CharlieB

It is quite true that a good many medications need to be stopped or reduced either in actual dose or in dosage frequency … the reasons for this are that many (if not the majority) of medicines are excreted by the kidneys in the urine, and if kidney function is diminished, the active drug may remain in your system longer and thus the dose or its frequency needs to be reduced to avoid side effects or other damage.

In addition, as the drug(s) are excreted by the kidneys, the mechanism by which the kidneys concentrate the urine during the process of urine formation means that the concentration(s) of the drug (or drugs) is increased many fold as the forming urine passes down the tubular structures within the kidneys … thus exposing the kidney tissue to concentrations of drug many times those that are safe. This can lead to the kidneys ‘poisoning themselves’ as it attempts to excrete the active drug.

As I am not your physician - nor do I know your medication list - and it would be wrong to try to advise without knowing your circumstances, I can only talk in generalities. That said, drugs like the NSAID group … among which are drugs like indomethacin … can do significant damage to kidneys and are always avoided in people with impaired kidney function. But, once residual kidney function is lost, and there is no kidney function left to ‘preserve’, it is feasible to consider use them again, always while weighing up any other contraindications or potential complications against the potential benefit they may bring.

In Kamal’s case … see the thread above … I have been aware - from past discussions with him - that he has been on dialysis for many, many years and has no residual kidney function at all to try to preserve. In that event, the use (or not) of NSAIDs becomesa trade off against any other potential issues - like irritation or ulceration of his upper gut - rather than a concern re what might happen to his now non-existent kidneys.

You, on the other hand, state you still have some residual function … limited though it may be … and the preservation of this may actually be useful to you, especially if you still pass a reasonable volume of urine. your stated level of 4% residual function can be a very useful/important additive to the clearance provided by dialysis, especially in patients who are on peritoneal dialysis - perhaps more-so than in those on haemodialysis.

But … over and above the additional clearance that even a small amount of residual function (eGFR) provides, there is even a greater advantage … for residual function usually means a preserved urine volume.

Most long term dialysis patients will eventually lose their urine output, but while there is a urine flow (as might be expected with an eGFR of 4), there is also the greater freedom of fluid intake that urine volume brings. This means that even 4% is worth preserving and fighting for … and any drug that is likely to negatively impact urine volume is still a drug to shy away from, if possible.

NSAID use is almost certain to fairly quickly dry up your urine volume … permanently … and this would mean less flexibility with your fluid intake and greater thirst. This is the crux of the problem. It boils down to a toss up between thirst versus joint improvement - if indeed that does occur.

There is no right answer here - and as in all things in life, it comes down to a trade-off. It seems likely your primary doctor has come down on one side of the trade-off, your nephrologist on the other … and both are likely right - or wrong - depending on your interpretation of what matters most, to you.

I am not sure if I explained that well … but I think you will get my meaning.

10

Thank you for such a quick reply. I had no idea how well these forums were monitored as many threads are somewhat dated.

Residual Kidney Function is a very valid reason for exercising care.

I think a better question may be how dialysis ‘clears’ medications, if, or how well, Hemo/PD work in clearing medications from the system.

I expect depending on molecule size of the med may be a factor in clearance rate. There may also be significant difference clearance rates between the dializer filter used with Hemo vs the body membranes used in PD.

Medication, depending on clearance rates can/may/will need adjustment. This may require study into medications commonly prescribed as to molecule sizes that have not yet been considered/investigated.

Just as we do not want to ‘over’ medicate, we do not want to ‘under’ medicate as well. This can be difficult to determine with the current system of only monthly labs when med changes are ordered.

We still have so much yet to learn.

11

Thank you for such a quick reply. I had no idea how well these forums were monitored as many threads are somewhat dated.

Residual Kidney Function is a very valid reason for exercising care.

I think a better question may be how dialysis ‘clears’ medications, if, or how well, Hemo/PD work in clearing medications from the system.

I expect depending on molecule size of the med may be a factor in clearance rate. There may also be significant difference clearance rates between the dializer filter used with Hemo vs the body membranes used in PD.

Medication, depending on clearance rates can/may/will need adjustment. This may require study into medications commonly prescribed as to molecule sizes that have not yet been considered/investigated.

Just as we do not want to ‘over’ medicate, we do not want to ‘under’ medicate as well. This can be difficult to determine with the current system of only monthly labs when med changes are ordered.

We still have so much yet to learn.

12

Thanks Dr Agar,

I am a medical student lurking in this forum to learn from first hand experiences the information here is quite useful

You are doing a great job

13

Thanks Betsy … that is very kind of you.

There are a great many ‘threads’ - as you will see if you scroll back through the many pages over many years … threads that are still current in the information they contain and the messages they convey. Sadly - in my view - the use of this message board format has dwindled since HDC moved its flagship forum to the social media platform of FaceBook. Again, in my view, FaceBook provides a poor education platform as anything written on FB is immediately swamped by all and any subsequent messaging and is thus effectively ‘gone for good’ with little hope of retrieval.

I have tried to encourage serious dialysis knowledge-seekers to keep using this platform … but few do. There is a permanent ‘pinned’ note at the start of the HDC FaceBook platform that refers to this site and that new members are MEANT to read - but I suspect (like the small print instructions that we ‘accept’ when we download new internet sites and apps) that no-one ever reads it. Meantime, I occasionally dip a toe in the conversation water at HDC’s FaceBook site - but always against my better judgement and always understanding the effernescent nature of that site.

I am thrilled to see that at least one reader comes back here from time to time. More strength to your bow!

14

Thanks Betsy … that is very kind of you.

There are a great many ‘threads’ - as you will see if you scroll back through the many pages over many years … threads that are still current in the information they contain and the messages they convey. Sadly - in my view - the use of this message board format has dwindled since HDC moved its flagship forum to the social media platform of FaceBook. Again, in my view, FaceBook provides a poor education platform as anything written on FB is immediately swamped by all and any subsequent messaging and is thus effectively ‘gone for good’ with little hope of retrieval.

I have tried to encourage serious dialysis knowledge-seekers to keep using this platform … but few do. There is a permanent ‘pinned’ note at the start of the HDC FaceBook platform that refers to this site and that new members are MEANT to read - but I suspect (like the small print instructions that we ‘accept’ when we download new internet sites and apps) that no-one ever reads it. Meantime, I occasionally dip a toe in the conversation water at HDC’s FaceBook site - but always against my better judgement and always understanding the effernescent nature of that site.

I am thrilled to see that at least one reader comes back here from time to time. More strength to your bow!