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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2026/02/09/securite-medicaments-insuffisance-renale

Interprofessional and systemic considerations

By Jason Cohen
February 9, 2026

I recently had a near miss with a nursing student who almost administered a prescribed non-steroidal anti-inflammatory drug (NSAID) to a patient with a very low estimated glomerular filtration rate (eGFR). It made me wonder to what extent direct-care nurses consider renal function before routine medication administration.

While searching the literature for an answer to this question, it became apparent to me that my close call was symptomatic of a long-standing issue that extends beyond the nursing profession. The issue concerns the prescription and administration of excessively dosed, or entirely inappropriate, medications in the context of renal impairment.

Following a brief summary of the issue, I will discuss some of the potential interventions that could be implemented at the prescriptive and administrative levels of medication management.

The persistence and prevalence of the issue

Unfortunately, inappropriate medication prescription and administration, in the context of renal impairment, is not a new issue, nor is it limited to any type of care setting or geographic region. Nash et al. (2005) noted that approximately 20% of administered medications on three nursing units were excessively dosed, given the renal impairment of the patients who received them. In 2016, in a study of 2,470 prescribed drugs for 362 inpatients, Hammad et al. discovered that “more than half of the medications that [needed] dosing adjustment [for chronic kidney disease (CKD)] were not adjusted” (p. 39). In 2022, Bosi et al. concluded that 20% of outpatients with chronic kidney disease, in two different health systems, received nephrotoxic medications. In their scoping review, Wilson et al. (2024) found the prevalence of inappropriate prescribing to outpatients with chronic kidney disease to be as high as 60%.

Renally relevant drugs

Hammad et al. (2016) found that antibiotics constituted the majority of the medications needing dose adjustment for chronic kidney disease. Bosi et al. (2022) found NSAIDs to be the most common nephrotoxic class of medications prescribed for renally compromised patients. Table 1 lists some common medications requiring replacement or dosage adjustment for renal impairment.

Table 1. Some common medications requiring replacement or dosage adjustment for renal impairment

Source: Vallerand & Sanoski (2025).

What is needed in the health-care system?

In this section, I summarize three systemic interventions that could facilitate the prescription and administration of appropriate medication dosages for patients experiencing some degree of renal impairment. These interventions include the performance of routine kidney function tests, the prescribing of administration parameters within medication orders, and the use of automated tracking, feedback and alerts.

1. Routine tests of kidney function

The findings of Nash et al. (2005), Hammad et al. (2016), Bosi et al. (2022), and Wilson et al. (2024) suggest that the potential existence, or progression, of kidney disease within some patient populations is not being systematically considered within community or inpatient settings. A greater systematization of renal function screening will enable more informed prescriptive decision making (Bosi et al., 2022), thereby enabling medication doses to be adjusted accordingly (Hammad et al., 2016).  Routine kidney function tests should be performed for any individual receiving potentially nephrotoxic, or renally relevant, medications.

Many adverse drug reactions could be avoided with the consideration of renal function tests such as eGFR in the decision-making process (Wilson et al., 2024). Generally, avoidance or dosage reduction of nephrotoxic medications should be considered for individuals with an eGFR of less than 60 mL/min/1.73 m2 (Bosi et al., 2022; Wilson et al., 2024). Table 2 lists some of the routine blood work associated with the evaluation of kidney function.

Table 2. Routine blood work associated with the evaluation of kidney function

Source: National Kidney Foundation (2018).

2. Prescribed administration parameters within medication orders

When I have worked with patients receiving antihypertensives on an as needed basis (PRN), the prescription has necessarily included the parameter of systolic blood pressure (SBP). This has been the contingency factor determining whether or not the medication would be administered (e.g., “give if SBP > 160”). I have often wondered why I have observed a scarcity of similar prescribing parameters to guide the administration of scheduled antihypertensives (e.g., “hold if BP < 90”).

A similar approach to prescribed administration parameters could also be applied to scheduled or PRN medications that are renally relevant (e.g., “hold if eGFR < 45”). When nurses consult prescribers in this context, it is often to determine whether assessment data or diagnostic results warrant holding the medication or not. It would save a lot of time if the administrative parameters were already prescribed within the original order. Moreover, some nurses may not have the clinical judgment to reach out to the prescriber in the first place; this makes the presence of prescribed parameters even more essential in avoiding potential adverse drug reactions.

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3. Automated tracking, feedback and alerts

Bosi et al. (2022) endorsed the use of automated decision support systems that provide alerts based on patient data such as eGFRs. I believe such alerts would be beneficial during the prescriptive and administrative phases of medication management. That is, the work of prescribing physicians and direct-care nurses could benefit from such alerts. Devin et al. (2020) suggested involving prescribers in the development of such automated alert systems. I would suggest also involving nursing throughout the process.

Nash et al. (2005) implemented an automated tracking system that provides feedback to nurses, pharmacists and prescribers regarding the administration of excessive dosages of medication to patients who were renally compromised. This feedback yielded a 6% decrease in the incidence of the administration of excessively dosed medications.

The role of nursing in mitigating patient risks

In this section, I summarize four strategies that nurses could implement to minimize the risk of inappropriate medication administration in the context of renal impairment. These strategies include reading the entire medication order text, referring to medication monographs, reviewing renal blood work results, and consulting with the prescriber or pharmacist before medication administration.

1. Reading the entire medication order text

At first glance, the nurse may not observe all of the prescribed parameters associated with a particular medication on the electronic medication administration record (MAR). Often, the nurse needs to hover the mouse above each order to read the entire text associated with the prescription. Therefore, while many of the essential rights of a medication check can often be viewed at a glance, nurses should make the additional effort to hover the mouse over the item in order to read any prescribed administration parameters that might appear lower down in the associated text.

2. Referencing medication monographs

Nursing schools often train students to use pharmacologic monographs using publications, such as Davis’s Drug Guide for Nurses (Vallerand & Sanoski, 2025). This drug guide contains a section on contraindications/precautions near the top of each drug monograph, where any renal considerations would be listed. After reviewing the drug monographs to identify renally relevant medications, alongside renal panel results to identify suboptimal kidney function, the nurse should consult with the pharmacist to discuss any necessary medication replacements or dose adjustments. In community health-care settings, where renal blood work is not conducted frequently (Bosi et al., 2022), the identification of renally relevant drugs through the use of monographs might prompt the nurse to advocate for kidney performance testing.

3. Reviewing renal blood work results

As discussed above, the nurse should review available blood work to identify patients who may be in the midst of chronic or acute kidney failure. Table 2 lists some of the routine blood work associated with the evaluation of kidney function.

4. Consulting with the prescriber or pharmacist before medication administration

It is not within the scope of most direct-care nurses to unilaterally decide which medications should be held for patients with compromised kidney function. Sometimes nephrotoxic medications “may be indicated if the benefit from using them surpasses the potential harm in the kidney” (Bosi et al., 2022, p. 444). The finely nuanced knowledge that is foundational to prescriptive decision-making typically falls within the scope of physicians and pharmacists, who may decide to change a medication dosage or avoid it altogether (Wilson et al., 2024). Therefore, in the absence of prescribed medication administration parameters (discussed above), the nurse should consult the prescriber or pharmacist to consider the extent of prescriptive alternatives to, or omissions of, renally relevant drugs when kidney function test results are suboptimal (Wilson et al., 2024).

Closing summary

Inappropriate medication prescription, relative to kidney performance, is a persistent issue in diverse community and inpatient settings. In this article, I have suggested systemic interventions, such as the performance of routine kidney function tests, the prescribing of administration parameters within medication orders, and the use of automated tracking, feedback and alerts. I have also suggested that nurses intervene to mitigate patient risks by way of reading the entire medication order text, referring to medication monographs, reviewing renal blood work results, and consulting with the prescriber or pharmacist before medication administration.

Implications for further research

The questions below could be the basis of future research related to the issue of medication administration in the context of renal impairment.

• Are nursing programs approaching this topic, in terms of theory and practice, in a systematic manner, or is it only covered on an ad-hoc basis in the practicum setting?
• Are adverse medication reactions decreased in settings where prescribed administration parameters are used?
• Are adverse medication reactions decreased in settings that use automated alert systems?

References

Bosi, A., Xu, Y., Gasparini, A., Wettermark, B., Barany, P., Bellocco, R., Inker, L. A., Chang, A. R., McAdams-DeMarco, M., Grams, M. E., Shin, J.-I., & Carrero, J. J. (2022). Use of nephrotoxic medications in adults with chronic kidney disease in Swedish and US routine care. Clinical Kidney Journal, 15(3), 442–451. https://doi-org.ezproxy.vcc.ca/10.1093/ckj/sfab210

Devin, J., Cleary, B. J., & Cullinan, S. (2020). The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis. Systematic Reviews, 9(275), 1–17. https://doi.org/10.1186/s13643-020-01510-7

Hammad, M. A., Khamis, A. A., Al-Akhali, K. M., Elsayed, T. M., Alasmri, A. M., Al-Ahmari, E. M., Mossa, E. M., Al-Gahtani, N. M., & El-Sobky, Y. (2016). Evaluation of drug dosing in renal failure. Journal of Pharmacy and Biological Sciences, 11(5), 39–50. https://iosrjournals.org/iosr-jpbs/papers/Vol11-issue5/Version-3/H1105033950.pdf

Nash I. S., Rojas M., Hebert P., Marrone S. R., Colgan C., Fisher L. A., Caliendo G., & Chassin M. R. (2005). Reducing excessive medication administration in hospitalized adults with renal dysfunction. American Journal of Medical Quality, 20(2), 64–109. https://journals.sagepub.com/doi/10.1177/1062860604273752

National Kidney Foundation. (2018, March 2). What is the difference between sCr, eGFR, ACR, and BUN? Retrieved from https://www.kidney.org/news-stories/what-difference-between-scr-egfr-acr-and-bun

Vallerand, A. H., & Sanoski, C. A. (2025). Davis's drug guide for nurses (19th ed.). F.A. Davis Company.

Wilson, J., Ratajczak, N., Halliday, K., Battistella, M., Naylor, H., Sheffield, M., Marin, J. G., Pitman, J., Kennie-Kaulbach, N., Trenaman, S., & Gillis, L. (2024). Medications for community pharmacists to dose adjust or avoid to enhance prescribing safety in individuals with advanced chronic kidney disease: A scoping review and modified Delphi. BMC Nephrology, 25, Article 386. https://doi.org/10.1186/s12882-024-03829-y

Jason Cohen, RN, MN, is a nursing instructor at Vancouver Community College.

#analysis
#adverse-events
#chronic-conditions
#clinical-practice
#intra-professional-collaboration
#nursing-practice
#patient-care
#patient-safety