Can a one-time dose of Toradol (ketorolac) intramuscularly (IM) be given to someone with one kidney and normal kidney function, as indicated by a glomerular filtration rate (GFR) of 69?

Ketorolac (Toradol) Administration in a Patient with One Kidney

A single dose of intramuscular Toradol (ketorolac) should not be administered to a patient with one kidney, even with a GFR of 69, due to the significant risk of acute kidney injury in a patient with reduced renal reserve.

Risk Assessment for NSAIDs in Patients with Single Kidney

Patients with a solitary kidney represent a special population with reduced renal reserve, making them particularly vulnerable to nephrotoxic medications. While the GFR of 69 indicates relatively preserved function in the remaining kidney, this patient lacks the compensatory capacity of a second kidney if acute injury occurs.

Nephrotoxicity Risk of Ketorolac

Ketorolac is a potent NSAID with significant nephrotoxic potential:

• Even a single dose of ketorolac can cause acute kidney injury, as documented in case reports 1
• The risk of irreversible renal failure has been reported even in patients with normal baseline renal function 2
• Young adults with normal preoperative renal function have developed AKI after short courses of ketorolac 3

Guidelines on NSAID Use in Kidney Disease

The KDIGO guidelines recommend temporary discontinuation of potentially nephrotoxic drugs in people with increased risk of AKI, specifically mentioning NSAIDs 4. While this recommendation primarily addresses patients with GFR <60 ml/min/1.73m², the principle applies to patients with reduced renal reserve from anatomical causes (single kidney).

Alternative Pain Management Options

Instead of ketorolac, consider these safer alternatives:

1. Opioid analgesics: These are safer alternatives to NSAIDs for patients with kidney concerns 4
2. Acetaminophen: A safer non-NSAID alternative for pain management
3. Local anesthetic techniques: When appropriate for the clinical situation

Special Considerations for Single Kidney Patients

The risk-benefit analysis for nephrotoxic medications differs significantly in patients with a solitary kidney:

• While a GFR of 69 would normally be considered mild kidney dysfunction, the absence of a second kidney eliminates the safety margin
• Any acute injury to the remaining kidney could lead to severe consequences including dialysis dependence
• Research has shown that even when used for less than 5 days, ketorolac can still pose risks in vulnerable populations 5

Monitoring if NSAID Use is Unavoidable

If pain management absolutely requires an NSAID despite the risks (which is not recommended):

• Use the lowest possible effective dose
• Limit to a single dose only
• Ensure adequate hydration before and after administration
• Monitor renal function closely after administration
• Watch for warning signs including decreased urine output, flank pain, or edema
• Discontinue immediately if any signs of renal dysfunction appear

Common Pitfalls to Avoid

• Assuming normal GFR means safety: Even with a GFR of 69, a patient with one kidney lacks the compensatory capacity of a second kidney
• Underestimating short-term risk: Evidence shows that even brief NSAID exposure can cause AKI 6
• Relying on monitoring alone: By the time laboratory values show kidney injury, significant damage may have already occurred

The risk of acute kidney injury from even a single dose of ketorolac in a patient with one kidney outweighs the potential analgesic benefit, especially when safer alternatives are available.