What are the recommendations for using Proton Pump Inhibitors (PPIs) in patients with Chronic Kidney Disease (CKD)?

PPI Use in Chronic Kidney Disease: Recommendations and Considerations

Proton pump inhibitors (PPIs) should be used with caution in patients with CKD, with clear documentation of appropriate indications, regular reassessment for continued need, and consideration for de-prescribing when possible to minimize potential adverse renal effects. 1

Indications and Risks in CKD Patients

Appropriate Indications for PPI Use

• Definitely indicated for long-term use (>8 weeks):

  • Barrett's esophagus
  • Clinically significant (LA Classification grade C/D) erosive esophagitis
  • Gastroprotection in high-risk patients using ASA/NSAIDs 1

• Conditionally indicated for long-term use:

  • PPI-responsive endoscopy-negative reflux disease with recurrence on PPI cessation
  • Esophageal strictures from GERD (peptic strictures) 1

Inappropriate Long-term Use

• Symptoms of nonerosive reflux disease with no sustained response to high-dose PPI therapy
• Empiric treatment of laryngopharyngeal symptomatology
• Acute undifferentiated abdominal pain 1

Renal Risks Associated with PPIs

PPIs have been associated with:

• Acute tubulointerstitial nephritis (TIN) that may occur at any point during therapy 2
• Increased risk of chronic kidney disease progression 3, 4
• Higher risk of end-stage renal disease compared to H2-receptor antagonists 4

The risk appears to be:

• Dose-dependent (higher with high doses) 5
• Duration-dependent (risk increases after 3 months of exposure) 5
• Present even without intervening acute kidney injury 6

Recommendations for PPI Management in CKD

Assessment and Monitoring

1. Document clear indication for PPI therapy in all CKD patients 1
2. Monitor renal function regularly in CKD patients on PPIs
3. Watch for signs of acute kidney injury or worsening of CKD

De-prescribing Considerations

1. Consider de-prescribing in all patients without a definitive indication for chronic PPI use 1

2. Step-down approach:

   • For patients on twice-daily dosing, consider step-down to once-daily PPI 1
   • Consider on-demand therapy for appropriate patients
   • Consider H2-receptor antagonists as alternatives when appropriate

3. Do not discontinue in patients with:

   • Complicated GERD (severe erosive esophagitis, esophageal ulcer, peptic stricture) 1
   • High risk for GI bleeding on antithrombotics or anticoagulants 1

Special Considerations for CKD Patients

1. Gastroprotection: Consider PPI use in CKD patients on:

   • Multiple antithrombotics
   • Anticoagulants plus aspirin
   • NSAIDs with additional risk factors 1

2. Warn patients about potential rebound acid hypersecretion upon discontinuation 1

3. Monitor for drug interactions as CKD patients are often on multiple medications

Common Pitfalls to Avoid

1. Inappropriate continuation without reassessment of ongoing need
2. Failure to recognize PPI-associated nephrotoxicity - be vigilant for unexplained decline in renal function
3. Overlooking non-pharmacological approaches to GERD management
4. Abrupt discontinuation without tapering or patient education about rebound symptoms
5. Missing appropriate indications for gastroprotection in high-risk CKD patients

Algorithm for PPI Management in CKD

1. Assess indication:

   • Is there a definite indication for long-term use? (Barrett's, severe erosive esophagitis, etc.)
   • Is gastroprotection needed due to high bleeding risk?

2. If yes to either:

   • Use lowest effective dose
   • Monitor renal function regularly
   • Reassess need periodically

3. If no clear indication:

   • Consider de-prescribing
   • Taper dose to prevent rebound symptoms
   • Consider H2-blocker alternative if acid suppression still needed

4. For all CKD patients on PPIs:

   • Monitor for signs of worsening kidney function
   • Educate about potential renal risks
   • Consider discontinuation if renal function deteriorates without other explanation

By following these recommendations, clinicians can balance the benefits of PPI therapy against potential renal risks in patients with CKD, optimizing both gastrointestinal and kidney outcomes.