From the Guidelines
Buprenorphine is generally considered safer for kidney function compared to other opioids, with no specific dose adjustments typically required for patients with existing kidney disease. For patients with renal impairment, buprenorphine may be a suitable option due to its primary metabolism in the liver rather than the kidneys 1. However, it's essential to monitor patients with severe kidney disease for signs of opioid toxicity, including excessive sedation, respiratory depression, or confusion, as these can indirectly affect kidney function. According to the most recent guideline, patients with renal impairment should be carefully managed, and opioids primarily eliminated in urine should be avoided or used with caution 1. Additionally, more frequent clinical observation and opioid dose adjustment are recommended for patients with renal or hepatic impairment 1. While buprenorphine can cause urinary retention in some patients, which might indirectly impact kidney function, the medication itself is rarely the primary cause of declining renal function.
Some key points to consider when using buprenorphine in patients with kidney disease include:
- Buprenorphine's pharmacokinetics make it a suitable option for patients with renal impairment 1
- No specific dose adjustments are typically required for buprenorphine in patients with existing kidney disease
- Patients with severe kidney disease should be monitored for signs of opioid toxicity
- Other causes should be investigated if kidney function worsens while on buprenorphine, as the medication itself is rarely the primary culprit of declining renal function
- Buprenorphine is a safer alternative compared to other opioids such as morphine, meperidine, codeine, and tramadol, which should be avoided in patients with renal impairment 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 worsen kidney function, particularly in patients with impaired renal function. It is recommended to monitor renal function and take care in dose selection, especially in elderly patients who are more likely to have decreased renal function 2.
From the Research
Buprenorphine and Kidney Function
- Buprenorphine can be administered at normal doses in patients with renal dysfunction because it is mainly excreted through the liver 3.
- The pharmacokinetics of buprenorphine are unchanged in haemodialysis patients, which means that there is no need for dose-reduction with this drug 3.
- However, there is a case report of acute liver and kidney failure in a patient with previously latent hepatitis C virus chronic infection following recommended doses of buprenorphine 4.
- Buprenorphine appears to be a promising and safer option for pain management in patients with kidney disease due to its partial agonism at the mu opioid receptor 5.
Safety and Efficacy of Buprenorphine in Kidney Disease
- There is limited and low-quality evidence to inform the safety and analgesic effect of opioid use, including buprenorphine, in reduced renal function 6.
- Buprenorphine is considered a lipophilic opioid that may be beneficial for patients with chronic kidney disease (CKD) as a first-line treatment option 7.
- However, opioid prescription in CKD patients requires careful consideration of potential risks and benefits, and dosage adjustments may be necessary to avoid adverse effects 7.
Comparison with Other Opioids
- Morphine and codeine metabolites may accumulate in patients with renal dysfunction, resulting in neurotoxic side effects 3, 7.
- Hydromorphone and oxycodone are considered safe to administer in patients with CKD, but require careful adjustments in dosage 7.
- Fentanyl is inappropriate for patients undergoing hemodialysis 7.