Does Suboxone Affect the Kidneys?
Suboxone (buprenorphine/naloxone) does not significantly impair kidney function and is considered safe for use in patients with renal impairment, including those on dialysis, because buprenorphine is primarily metabolized by the liver rather than excreted by the kidneys. 1
Renal Safety Profile
Buprenorphine is one of the safest opioids for patients with kidney disease because it undergoes hepatic metabolism via CYP3A4 rather than renal elimination. 2, 3
Key Pharmacokinetic Advantages:
- Hepatic metabolism predominates: Approximately 70-90% of buprenorphine is eliminated through feces, with only 10-30% excreted in urine 2
- No dose adjustment needed: The FDA label states that buprenorphine dosage does not require significant adjustment in patients with renal impairment 1
- Safe in dialysis patients: Pharmacokinetics remain unchanged in hemodialysis patients, with no need for dose reduction between dialysis sessions 3, 4
Metabolite Accumulation Considerations
While the parent compound (buprenorphine) is safe, metabolites can accumulate in renal failure but are not clinically significant:
- Norbuprenorphine levels increase approximately 4-fold in renal failure 4
- Buprenorphine-3-glucuronide (B3G) levels increase approximately 15-fold in renal failure 4
- These metabolite accumulations do not cause toxicity or require dose adjustments because they have minimal pharmacological activity 3, 4
Comparison to Other Opioids
Buprenorphine is superior to most other opioids in renal impairment:
- Avoid: Morphine and codeine (active metabolites accumulate and cause toxicity) 5
- Use with extreme caution: Tramadol, hydromorphone, oxycodone (require dose reduction and close monitoring) 5
- Safe alternatives: Transdermal buprenorphine, methadone, fentanyl/sufentanil 5
Rare Hepatorenal Toxicity
One case report documented acute liver and kidney failure with therapeutic-dose buprenorphine in a patient with latent hepatitis C, but this is extremely rare and resolved upon drug discontinuation. 6 This appears to be an idiosyncratic reaction rather than a direct nephrotoxic effect.
Clinical Implications:
- The FDA label advises caution in patients with "severe impairment of renal function" but does not contraindicate use 1
- Monitor renal function if hepatic impairment coexists, as the drug label notes buprenorphine is "substantially excreted by the kidney" (referring to metabolites, not parent drug) 1
Practical Recommendations
For patients with any degree of renal impairment (including ESRD on dialysis):
- Start at standard doses—no initial adjustment required 1, 3
- Monitor for excessive sedation or respiratory depression (standard opioid precautions) 1
- No need to time doses around dialysis sessions 4
- Avoid combining with other CNS depressants that could compound respiratory depression 1
The risk of adverse renal effects is negligible compared to the substantial benefits of opioid use disorder treatment, making buprenorphine an excellent choice even in advanced kidney disease. 3, 5