Ketorolac Use in Patients with a Single Kidney
Ketorolac should be avoided in patients with a single kidney due to the high risk of acute kidney injury and potential for irreversible renal failure, as these patients have no renal reserve and depend entirely on prostaglandin-mediated renal perfusion. 1, 2
Critical Contraindications in Single Kidney Patients
The FDA drug label explicitly states that ketorolac is contraindicated in patients with advanced renal impairment and should be used with extreme caution in patients with impaired renal function or history of kidney disease, as it is a potent inhibitor of prostaglandin synthesis 2
Patients with a single kidney have no functional reserve—any acute kidney injury to their remaining kidney could result in complete renal failure requiring dialysis 1
The kidneys depend on prostaglandins to maintain adequate renal perfusion through vasodilation, and ketorolac blocks COX-1 and COX-2 enzymes, eliminating this protective effect and causing renal vasoconstriction with decreased renal blood flow 1
Evidence of Ketorolac-Induced Renal Toxicity
Multiple case reports document acute renal failure following ketorolac administration, with one particularly concerning case of a 17-year-old sickle cell patient with normal baseline renal function who developed irreversible renal failure after ketorolac use despite adequate hydration 3
Short-term ketorolac administration has been associated with reversible oliguric renal insufficiency, with serum creatinine increasing from baseline 106 μmol/L (1.2 mg/dL) to peak values of 256 μmol/L (2.9 mg/dL) in documented cases 4
Recovery of renal function typically occurred after 2-3 days following ketorolac discontinuation in patients with two functioning kidneys, but this recovery may not occur in single-kidney patients who lack renal reserve 4, 5
High-Risk Scenarios That Amplify Nephrotoxicity Risk
The "triple whammy" combination of ketorolac + ACE inhibitors/ARBs + diuretics is absolutely contraindicated, as this eliminates both prostaglandin-mediated vasodilation and angiotensin II-mediated pressure maintenance, dramatically increasing acute kidney injury risk 1, 6
Volume depletion significantly increases nephrotoxicity risk—postoperative patients with third-spacing of fluids are at particularly high risk 7
Concurrent use with other nephrotoxic medications (aminoglycosides, contrast dye, other NSAIDs) must be avoided 1
Patients with cardiovascular disease, heart failure, or cirrhosis have compromised renal perfusion and are at greatest risk 2, 8
Guideline-Based Recommendations for Single Kidney Patients
The Kidney Disease Outcomes Quality Initiative (KDOQI) specifically states that NSAIDs should be avoided in patients with GFR < 30 mL/min/1.73 m² and prolonged NSAID therapy is not recommended for GFR < 60 mL/min/1.73 m² 1
The Acute Disease Quality Initiative (ADQI) consensus recommends avoiding NSAIDs in elderly patients with creatinine clearance < 30 mL/min 1
If ketorolac must be used in a patient with marginal kidney function, care should be taken as it can be associated with acute kidney injury, and the FDA label mandates dose reduction and close monitoring 9, 2
Safer Alternative Analgesics
Acetaminophen is the preferred first-line analgesic for patients with renal impairment, with a recommended dose of up to 3 grams daily in chronic settings 1
For severe pain, low-dose opioids without active metabolites (methadone, buprenorphine, or fentanyl) are preferred over NSAIDs in patients with renal dysfunction 1
Short courses of oral or intra-articular corticosteroids can be considered for acute inflammatory pain 1
Monitoring Requirements If Ketorolac Cannot Be Avoided
The FDA label requires that ketorolac be used for the shortest duration possible (maximum 5 days combined IV/IM and oral therapy), with dose reduction to 10 mg every 4-6 hours (maximum 40 mg/day) in patients with renal impairment 2
Monitor serum creatinine and GFR at baseline and 48-96 hours after administration 1
Monitor renal function weekly for the first 3 weeks in high-risk patients 1
Ensure adequate hydration status, as volume depletion dramatically increases nephrotoxicity risk 1
Discontinue immediately if any deterioration in renal function occurs 2
Common Pitfalls to Avoid
Do not assume that short-term use is safe—acute renal failure has been documented after just 3 doses of ketorolac in susceptible patients 5
Do not use ketorolac in postoperative single-kidney patients who may have third-spacing and relative volume depletion 7
Never combine ketorolac with ACE inhibitors, ARBs, or diuretics in single-kidney patients 1, 6
The analgesic potency of ketorolac may lead to indiscriminate use in place of narcotic analgesics—this should be avoided in high-risk patients 4