Can I give Toradol (ketorolac) to a patient with one kidney and impaired renal function?

Ketorolac (Toradol) Should Not Be Given to Patients with One Kidney and Impaired Renal Function

Ketorolac (Toradol) is contraindicated in patients with a single kidney and impaired renal function due to the high risk of acute kidney injury and potential for irreversible renal damage.

Rationale for Contraindication

Ketorolac is a potent NSAID that carries significant nephrotoxicity risks that are particularly concerning in patients with already compromised renal function:

• The FDA drug label explicitly states that ketorolac is "contraindicated in patients with advanced renal impairment or in patients at risk for renal failure due to volume depletion" 1
• Ketorolac is primarily eliminated by the kidneys, which means patients with reduced creatinine clearance will experience diminished drug clearance and potential accumulation of toxic levels 1
• Having only one kidney represents a significant risk factor, as the patient lacks the compensatory function of a second kidney if injury occurs

Mechanism of Renal Injury

Ketorolac causes renal damage through several mechanisms:

• Inhibits prostaglandin synthesis, which reduces renal blood flow and can precipitate overt renal decompensation 1
• This effect is particularly dangerous in patients with a single kidney, where prostaglandins play a critical compensatory role in maintaining renal perfusion
• Long-term NSAID administration has resulted in renal papillary necrosis and other permanent renal injuries 1

Evidence of Harm

Multiple case reports document acute renal failure associated with ketorolac use:

• Cases of irreversible renal failure have been reported even in patients with normal baseline renal function 2
• Acute renal failure and hyperkalemia have occurred after moderate doses of ketorolac 3
• Even with adequate hydration, patients can develop irreversible renal failure following ketorolac administration 2

Alternative Pain Management Options

For patients with one kidney and impaired renal function, consider these safer alternatives:

• Opioid analgesics are safer and effective alternatives to NSAIDs for patients with renal impairment 4
• For patients with cancer pain and renal impairment, methadone may be appropriate as it is primarily excreted through fecal routes rather than renal elimination 4
• If mild analgesia is needed, acetaminophen (without NSAIDs) may be appropriate with proper dosing

Monitoring If NSAIDs Must Be Used

In the extremely rare circumstance where no alternatives exist and risk-benefit analysis favors short-term NSAID use:

• Monitor blood pressure, BUN, creatinine, and liver function tests at baseline and every 3 months 4
• Discontinue immediately if BUN or creatinine doubles or if hypertension develops or worsens 4
• Limit duration to absolute minimum necessary (ketorolac is generally limited to 5 days maximum use even in healthy patients) 4

Key Takeaway

The risk of acute kidney injury in a patient with one kidney far outweighs any potential analgesic benefit from ketorolac. The FDA label specifically contraindicates its use in patients with advanced renal impairment, and having a single kidney with impaired function clearly meets this criterion. Alternative pain management strategies should be employed instead.