Use of Potentially Nephrotoxic Medications by U.S. Adults with Chronic Kidney Disease: NHANES, 2011–2016

  • Shaheen Kurani
  • Molly Moore Jeffery
  • Bjorg Thorsteinsdottir
  • LaTonya J. Hickson
  • Erin F. Barreto
  • Jordan Haag
  • Rachel Giblon
  • Nilay D. Shah
  • Rozalina G. McCoyEmail author
Original Research



People with chronic kidney disease (CKD) are at risk for adverse events and/or CKD progression with use of renally eliminated or nephrotoxic medications.


To examine the prevalence of potentially inappropriate medication (PIM) use by U.S. adults by CKD stage and self-reported CKD awareness.


Cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011–2016


Non-pregnant adults with stages 3a (eGFR 45–59 mL/min/1.73 m2), 3b (eGFR 30–44), or 4–5 (eGFR < 30) CKD, stratified as CKD-aware/unaware.

Main Measures

PIMs were identified on the basis of KDIGO guidelines, label information, and literature review. We calculated proportions using any and individual PIMs, assessing for differences over CKD awareness within each CKD stage. Analyses were adjusted for age, sex, race/ethnicity, education, comorbidities, and insurance type.

Key Results

Adjusted proportions of U.S. adults taking any PIM(s) exceeded 50% for all CKD stages and awareness categories, and were highest among CKD-unaware patients with stages 4–5 CKD: 66.6% (95% CI, 55.5–77.8). Proton pump inhibitors, opioids, metformin, sulfonylureas, and non-steroidal anti-inflammatory drugs (NSAIDs) were all used frequently across CKD stages. NSAIDs were used less frequently when CKD-aware by patients with stage 3a CKD (2.2% [95% CI, − 0.3 to 4.7] vs. 10.7% [95% CI, 7.6 to 13.8]) and stages 4–5 CKD (0.8% [95% CI, − 0.9 to 2.5] vs. 16.5% [95% CI, 4.0 to 29.0]). Metformin was used less frequently when CKD-aware by patients with stage 3b CKD (8.1% [95% CI, 0.3–15.9] vs. 26.5% [95% CI, 17.4–35.7]) and stages 4–5 CKD (none vs. 20.8% [95% CI, 1.8–39.8]). The impact of CKD awareness was statistically significant after correction for multiple comparisons only for NSAIDs in stage 3a CKD.


PIMs are frequently used by people with CKD, with some impact of CKD awareness on NSAID and metformin use. This may lead to adverse outcomes or hasten CKD progression, reinforcing the need for improved medication management among people with CKD.


Authors’ Contributions

Dr. McCoy and Ms. Kurani are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. They affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. Dr. McCoy designed the study, interpreted the data, and drafted the manuscript. Ms. Kurani and Dr. Jeffery analyzed the data and reviewed/edited the manuscript. Dr. Thorsteinsdottir, Dr. Hickson, Ms. Barreto, Mr. Haag, Ms. Giblon, and Dr. Shah contributed to study design, data interpretation, and reviewed/edited the manuscript.

Funding Information

This work was supported by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (K23DK114497 [McCoy] and K23DK109134 [Hickson]), and the National Institute on Aging of the National Institutes of Health (K23AG051679 [Thorsteinsdottir]).

Compliance with Ethical Standards

Conflict of Interest

The authors have no relevant conflicts of interest to declare. In the past 36 months, Dr. McCoy was also supported by the AARP® Quality Measure Innovation Grant through a collaboration with OptumLabs® and the NQF Measure Incubator. Dr. Jeffery has received research support through Mayo Clinic from the National Heart, Lung and Blood Institute (R56HL130496 and R21HL140287), the Agency for Healthcare Research and Quality (R01HS025164), the American Cancer Society (131611-RSGI-17-154-01-CPHPS), the Food and Drug Administration-funded Yale-Mayo CERSI (U01FD 05938), and the National Center for Advancing Translational Sciences (UL1TR 02377; U01TR 02743). In the past 36 months, Dr. Shah has received research support through Mayo Clinic from the Food and Drug Administration to establish Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation (CERSI) program (U01FD005938); the Centers of Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative (TCPI); the Agency for Healthcare Research and Quality (R01HS025164; R01HS025402; R03HS025517); the National Heart, Lung and Blood Institute of the National Institutes of Health (NIH) (R56HL130496; R01HL131535); the National Science Foundation; and the Patient Centered Outcomes Research Institute (PCORI) to develop a Clinical Data Research Network (LHSNet).


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supplementary material

11606_2019_5557_MOESM1_ESM.docx (64 kb)
ESM 1 (DOCX 64 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Shaheen Kurani
    • 1
  • Molly Moore Jeffery
    • 2
  • Bjorg Thorsteinsdottir
    • 3
    • 4
  • LaTonya J. Hickson
    • 3
    • 5
  • Erin F. Barreto
    • 3
    • 6
  • Jordan Haag
    • 6
  • Rachel Giblon
    • 3
  • Nilay D. Shah
    • 2
    • 3
  • Rozalina G. McCoy
    • 2
    • 3
    • 4
    Email author
  1. 1.Mayo Clinic Graduate School of Biomedical SciencesMayo ClinicRochesterUSA
  2. 2.Division of Health Care Policy & Research, Department of Health Sciences ResearchMayo ClinicRochesterUSA
  3. 3.Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterUSA
  4. 4.Division of Community Internal Medicine, Department of Medicine Mayo ClinicRochesterUSA
  5. 5.Division of Nephrology and Hypertension, Department of MedicineMayo ClinicRochesterUSA
  6. 6.Department of PharmacyMayo ClinicRochesterUSA

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