Can buprenorphine cause Acute Kidney Injury (AKI)?

From the Guidelines

Buprenorphine is unlikely to cause acute kidney injury (AKI) in most patients, but it may contribute to AKI in certain circumstances, such as dehydration, pre-existing kidney disease, or concomitant use of nephrotoxic medications. The risk of buprenorphine-induced AKI is higher in patients with renal impairment, and healthcare providers should exercise caution when prescribing buprenorphine to these patients 1. Buprenorphine-induced AKI may occur through several mechanisms, including rhabdomyolysis, hemodynamic changes that reduce kidney perfusion, or rarely through direct nephrotoxicity.

Mechanisms of Buprenorphine-Induced AKI

• Rhabdomyolysis (muscle breakdown) in cases of overdose or prolonged immobility
• Hemodynamic changes that reduce kidney perfusion
• Rarely through direct nephrotoxicity

Patient Monitoring and Prevention

Patients on buprenorphine who develop symptoms such as decreased urination, swelling, fatigue, nausea, or confusion should seek medical attention promptly. To minimize risk, patients should:

• Maintain adequate hydration
• Avoid combining buprenorphine with other potentially nephrotoxic substances
• Undergo regular kidney function monitoring if they have risk factors for kidney disease

Clinical Guidelines and Recommendations

Healthcare providers typically prescribe buprenorphine at appropriate doses (usually 2-24 mg daily for sublingual formulations) and monitor kidney function in high-risk patients to prevent complications 1. The CDC clinical practice guideline for prescribing opioids for pain recommends starting opioids at the lowest possible effective dosage and using caution when increasing opioid dosages 1.

Key Considerations

• Buprenorphine is a partial mu-agonist and may be especially appropriate for treating cancer pain in patients with renal impairment 1
• The dose conversion from other opioids to buprenorphine can be complex, and healthcare providers should consider a pain specialty consultation for complex cases 1
• Patients with renal impairment should be closely monitored for signs of AKI, and healthcare providers should adjust the buprenorphine dose accordingly 1

From the FDA Drug Label

Buprenorphine is known to be substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

Buprenorphine may increase the risk of Adverse Renal Reactions, including Acute Kidney Injury (AKI), particularly in patients with pre-existing renal impairment.

• Key Considerations:
  • Monitor renal function in patients taking buprenorphine, especially the elderly.
  • Use caution when selecting a dosage for patients with impaired renal function.
  • Titrate the dosage of buprenorphine slowly in patients with renal impairment 2

From the Research

Buprenorphine and Acute Kidney Injury (AKI)

• Buprenorphine is a semi-synthetic opioid derivative commonly used in the treatment of heroin addiction 3.
• There is evidence to suggest that buprenorphine can cause liver and kidney failure in susceptible individuals, possibly through direct mitochondrial toxicity 3.
• A case study reported a patient with previously latent hepatitis C virus chronic infection who developed acute liver and kidney failure after taking recommended doses of buprenorphine 3.
• The study found that causality criteria fulfillment indicates a high probability of buprenorphine-induced liver toxicity, and no signs of pre-existing kidney impairment or pre- or post-renal causes were observed 3.

Opioids and AKI

• Opioid use and misuse have been linked to an increased risk of acute kidney injury (AKI) 4, 5.
• A review of the literature on the effect of opioids on kidney function found that opioid use can lead to AKI, particularly in at-risk populations such as those with pre-existing kidney disease 4.
• Another study found that evidence suggests a link between opioid use and kidney disease, including acute and chronic kidney injury 5.

Buprenorphine in Patients with Renal Impairment

• Buprenorphine can be administered at normal doses in patients with renal dysfunction because it is mainly excreted through the liver 6.
• In patients undergoing regular haemodialysis treatment, the pharmacokinetics of buprenorphine are unchanged, which means that there is no need for dose-reduction with this drug 6.
• Buprenorphine appears to be a safe choice when opioid treatment is initiated in patients with reduced renal function, chronic renal insufficiency, and haemodialysis 6.