Can proton pump inhibitors (PPIs) be used in patients with impaired renal function undergoing dialysis?

Use of Proton Pump Inhibitors in Dialysis Patients

Proton pump inhibitors (PPIs) can be used in dialysis patients, but should be prescribed only when clearly indicated and with regular monitoring due to potential adverse effects specific to this population.

Indications for PPI Use in Dialysis Patients

PPIs may be appropriate for dialysis patients in the following situations:

• Patients with high gastrointestinal bleeding risk
• Patients on dual antiplatelet therapy or anticoagulation
• Patients with complicated GERD (severe erosive esophagitis, peptic stricture)
• Patients with Barrett's esophagus or eosinophilic esophagitis 1

Risks and Considerations Specific to Dialysis Patients

Several studies have identified potential risks associated with PPI use in dialysis patients:

• Cardiovascular risk: PPI use is associated with increased risk of cardiovascular events and mortality in hemodialysis patients (HR 2.38,95% CI: 1.02-5.54) 2
• Infection risk: Long-term PPI use (≥6 months) significantly increases infection risk in incident hemodialysis patients (HR 2.88,95% CI: 1.61-5.16) 3
• Hypomagnesemia: PPI use is associated with hypomagnesemia in hemodialysis patients (OR 2.70,95% CI: 1.38-5.27), which may contribute to increased bone fragility 4, 5
• All-cause mortality: PPI exposure has been identified as an independent predictor of all-cause mortality in hemodialysis patients (HR 2.70,95% CI: 1.38-5.27) 4

Prescribing Guidelines for Dialysis Patients

When prescribing PPIs to dialysis patients:

1. Document clear indication: All patients taking a PPI should have a regular review of ongoing indications for use 1
2. Use lowest effective dose: Consider step-down from twice-daily to once-daily dosing when appropriate 1
3. Limit duration: Prescribe for the shortest duration necessary
4. Monitor regularly: Check serum magnesium levels periodically
5. Consider de-prescribing: Regularly reassess the need for continued PPI therapy 1

Special Considerations

• Peritoneal dialysis patients: Evidence regarding the impact of PPIs on peritonitis risk is contradictory 5
• Patients on dual antiplatelet therapy: PPIs are recommended for gastroprotection in dialysis patients on dual antiplatelet therapy 1
• Alternatives to PPIs: Consider H2-receptor antagonists as an alternative when appropriate

Monitoring Recommendations

For dialysis patients on long-term PPI therapy:

• Regular assessment of serum magnesium levels
• Monitoring for signs of infection
• Cardiovascular risk assessment
• Periodic evaluation of continued need for PPI therapy

Conclusion

While PPIs can be used in dialysis patients when indicated, their use should be carefully considered given the potential increased risks of cardiovascular events, infections, hypomagnesemia, and mortality. The decision to prescribe PPIs should be based on a clear indication, with regular reassessment of the risk-benefit ratio and consideration of de-prescribing when appropriate.