What are the considerations for using prednisone (a corticosteroid) in a patient with end-stage renal disease (ESRD) requiring dialysis?

From the Guidelines

Prednisone can be used in patients with end-stage renal disease (ESRD) requiring dialysis, but it is essential to use it with caution, as recommended by the British Thoracic Society guidelines 1. When considering the use of prednisone in ESRD patients, it is crucial to weigh the potential benefits against the risks, particularly given the patient's compromised renal function and potential for multiple comorbidities.

• The primary concern is the potential for prednisone to exacerbate existing conditions, such as fluid retention, hypertension, and hyperglycemia, which are common in ESRD patients.
• Additionally, ESRD patients may be more susceptible to the adverse effects of prednisone due to their impaired renal function and potential for electrolyte imbalances.
• However, the most recent and highest quality study, published in 2021, suggests that low-dose prednisone may be maintained in patients with a failed allograft and returned to dialysis, as part of a comprehensive immunosuppression management strategy 1.
• In terms of dosing, standard prednisone dosing can typically be used in patients on dialysis, with starting doses of 5-60 mg daily, depending on the condition being treated.
• Careful monitoring is essential to mitigate the risks associated with prednisone use in ESRD patients, including regular checks for electrolyte imbalances, blood pressure changes, and glucose control.
• The timing of prednisone administration relative to dialysis sessions is generally not critical, as the drug is not significantly removed during hemodialysis, and standard dosing applies to peritoneal dialysis patients.
• It is also important to provide appropriate prophylaxis for complications like osteoporosis and gastrointestinal issues, which are common in patients taking prednisone, particularly in those with ESRD.

From the FDA Drug Label

Cardio-Renal As sodium retention with resultant edema and potassium loss may occur in patients receiving corticosteroids, these agents should be used with caution in patients with congestive heart failure, hypertension, or renal insufficiency.

The use of prednisone in a patient with end-stage renal disease (ESRD) requiring dialysis should be done with caution due to the potential for:

• Sodium retention and resultant edema
• Potassium loss Considerations for use include:
• Monitoring for signs of fluid overload and electrolyte imbalances
• Adjusting the dose and duration of treatment based on the patient's individual response and clinical status
• Weighing the benefits and risks of treatment with prednisone in the context of the patient's underlying renal disease and dialysis requirements 2

From the Research

Considerations for Using Prednisone in ESRD Patients Requiring Dialysis

• The pharmacokinetics of prednisone may be altered in patients with renal impairment who require dialysis 3
• The drug's clearance and therapeutic index determine if a dose adjustment is needed, and a lower dose or less frequent dosing may be required 3
• Consult a reference source or the patient's nephrologist before prescribing, and start at a low dose and increase gradually 3
• If possible, give once-daily drugs after dialysis 3

Dosing Considerations for Patients on Peritoneal Dialysis

• The quantity of drugs removed during peritoneal dialysis is substantially lower than that during hemodialysis, and thus, the supplemental administration of drugs is not necessary in patients receiving continuous ambulatory peritoneal dialysis (CAPD) 4
• However, the cumulative removal of renally excretable drugs is higher in CAPD patients than in hemodialysis patients between sessions, and an appropriate dosage regimen based on drug clearance should be determined 4

Potential Side Effects and Interactions

• Careful consideration should be exercised in cases where drugs that have adverse effects on renal function are being administered, such as drugs that exert nephrotoxic effects and cause renal ischemia in CAPD patients 4
• High doses of corticosteroids, such as prednisone, can be effective in treating acute allograft rejection, but may also be accompanied by a high risk of steroid-related complications 5
• Methylprednisolone pulse therapy has been used to treat rapidly progressive glomerulonephritis, with minimal adverse reactions 6