Are you getting side-effects from your drugs for CKD?
On this page we will describe common side-effects of drugs used in CKD patients, and you can see if your symptoms make be linked
The drugs are in alphabetical order.
Alfacalcidol (vitamin D)
- Abdominal pain; headache; hypercalcaemia (high calcium level) – that you will not normally notice.
Note. Other forms of vitamin D include Calcitriol, Doxercalciferol and Paricalcitriol (latter two used alot in the USA).
Allopurinol (gout prevention tablet)
- Rash
- Bone marrow suppression – causing low haemoglobin, white cells and platelets.
Note 1. Dose needs to be reduced in CKD (100 mg once a day, not 300 mg)
Note 2. Do NOT use allopurinol with azathioprine (immunosuppressant drug that is used after transplants; see below). It can lead to fatal bone marrow suppression.
Amlodipine (calcium channel blocker, BP tablet)
- Ankle swelling.
Note 1. Other calcium antagonists include: Felodipine and Lercanidipine
Note 2. Do not use in aortic stenosis (and cautiously in stable chronic heart failure, CHF).
Atorvastatin (HMG-CoA reductase inhibitor, or ‘statin’; high cholesterol)
- Joint and muscle pain
- AKI due to rhabdomyolysis.
Note. Other statins include Simvastatin.
Azathioprine (immunosuppressant used after kidney transplant)
- Gastrointestinal disorders
- Liver dysfunction
- Bone marrow suppression – causing low haemoglobin, white cells and platelets.
Note 1. It is an alternative drug to mycophenolate, with similar side-effects
Note 2. Do NOT use azathioprine with allopurinol. It can lead to fatal bone marrow suppression (see above).
Bendroflumethazide (thiazide diuretic, water tablet)
- Dehydration – shown by dizziness and low blood pressure
- Hyponatraemia, hypokalaemia and hypercalcaemia (low sodium and potassium levels; high calcium level) – that you will not normally notice
- Gout – can cause (or worse) gout.
Note. Other diuretics (e.g. Spironolactone and Amiloride) may give high potassium levels.
Bisoprolol (beta-blocker, BP tablet)
- Bradycardia (low pulse rate)
- Cold fingers and toes.
Note 1. Other beta-blockers include Atenolol and Carvedilol
Note 2. Do NOT use with Diltiazem or Verapamil – can cause rapid reduction in cardiac output.
Calcium acetate (phosphate binder)
- Constipation/diarrhoea
- Hypercalcaemia (high calcium level) – that you will not normally notice.
Note. Other phosphate binders include Calcium carbonate.
Ciclosporin (immunosuppressant used after kidney transplant)
- Diabetes – 10% of patients
- Hair gain (hirsutes = male pattern in a woman)
- Liver dysfunction
- Neurological and/or psychiatric syndromes
- Swollen gums.
Note. Tacrolimus is an alternative drug, with similar side effects though causes hair loss.
Cinacalcet (calcimimetic tablet)
- Appetite decreased; constipation.
Note. It is used to treat hypercalcaemia (high calcium level) secondary t0 secondary/tertiary hyperparathyroidism. This is part of CKD-related renal bone disease. It works by telling the parathyroid glands (in the neck, in front of the thyroid gland) to produce less parathyroid hormone (PTH) in order to decrease the amount of calcium in the blood.
Dapagliflozin (sodium-glucose cotransporter 2 (SGLT-2) inhibitor; diabetes and proteinuric CKD)
- Initial decrease (<10%) in GFR
- UTIs; vulvovaginal disorders; DKA.
Note 1. Its anti-proteinuric effect is augmented if the patient is also on an ACE or ARB.
Note 2. Do NOT use in DM1, or if DM2 patient has had DKA
Note 3. Normal dose (10mg once a day) can be used in CKD
Note 4. Indicated in proteinuric CKD (uACR >25 mg/mmol), and GFR <60 and >25 ml/min (with or without DM). But do not initiate in Stage 5 CKD (GFR < 15 ml/min).
Doxazosin (alpha-blocker, BP tablet)
- Feeling weak; headaches; ankle swelling.
Erythropoietin (EPO) – e.g. Darbepoetin alfa
- Arthralgia; embolism and thrombosis; hypertension; stroke.
Note. Other EPO-like drugs include Roxadustat. This is a tablet. EPO is an injection, usually weekly.
Furosemide (loop diuretic, water tablet)
- Dehydration – shown by dizziness and low blood pressure
- Hyponatraemia, hypokalaemia and hypocalcaemia (low sodium, potassium and calcium levels) – that you will not normally notice
- Blistering rash and deafness – in high dosage.
Note 1. Other loop diuretics include: Bumetanide
Note 2. Can be used to treat hypercalcaemia (high blood calcium)
Note 3. Other diuretics (e.g. Spironolactone and Amiloride) may give high potassium levels.
Gabapentin (gamma aminobutyric acid (GABA) analogue)
Used for itching in CKD; normally used for epilepsy and chronic pain
- Confusion, drowsiness.
Note. In CKD, start low dose, e.g. 100mg alternate nights.
Hydralazine (BP tablet)
- Hypotension (low BP); lupus-like syndrome; tachycardia (fast heart rate).
Linagliptin (dipeptidylpeptidase-4 (DPP4) inhibitor
Diabetes; increases insulin secretion
- Side effects are uncommon.
Note. Normal dose (5mg once a day) can be used in CKD.
Losartan (angiotensin receptor blocker, ARB)
BP tablet; proteinuric CKD; congestive heart failure (CHF)
- Hyperkalaemia (high blood potassium level) – that you will not normally notice
- AKI – mainly in patients with renovascular disease.
Note 1. Other ARBs include Candesartan, Irbesartan, Valsartan, Telmisartan, and Olmesartan
Note 2. Do not use with ACE
Note 3. Do not use in pregnancy.
Mycophenolate (immunosuppressant used after kidney transplant)
- Gastrointestinal disorders
- Liver dysfunction
- Bone marrow suppression – causing low haemoglobin, white cells and platelets.
Note. It is an alternative drug to azathioprine is an alternative drug, with similar side-effects.
Prednisolone (immunosuppressant used after kidney transplant)
- Diabetes; osteoporosis; increased appetite
- Cushing’s syndrome: hypertension; moon face; weight gain and central obesity; proximal muscle weakness
- Adrenal suppression (leading to Addisonian crisis if withdrawn too quickly)
- Thin skin; acne; striae; cataracts
- Altered mood; psychotic illness
- Infections; TB reactivation.
Ramipril (angiotensin-converting-enzyme inhibitor, ACE)
BP tablet; proteinuric CKD; congestive (chronic) heart failure (CHF)
- Cough (dry)
- Hyperkalaemia (high blood potassium level) – that you will not normally notice
- AKI – mainly in patients with renovascular disease.
Note 1. Other ACEs include Lisinopril and Perindopril
Note 2. Do not use with ARB
Note 3. Do not use in pregnancy.
Sodium bicarbonate (alkali tablet)
- Fluid retention
- Hypokalaemia (low blood potassium) – that you will not normally notice.
Note. This is an alkali tablet. Some patients have high levels of acid in their blood and need these tablets will control that. Alkalis are the ‘opposite’ of acids.
Spironolactone (mineralocorticoid receptor antagonist, MRA)
Potassium sparing diuretic (water tablet); chronic liver disease; congestive heart failure (CHF)
- Gynaecomastia (breast enlargement in male); abnormal liver function;
- Hyponatraemia (low blood sodium) – that you will not normally notice
- Hyperkalaemia (high blood potassium) – that you will not normally notice
Note. It is especially likely to cause hyperkalaemia if the patient is on another drug that causes that, e.g. ACE/ARBs.
Tacrolimus (immunosuppressant used after kidney transplant)
- Diabetes – 30% of patients
- Hair loss
- Liver dysfunction
- Neurological and/or psychiatric syndromes.
Note. Ciclosporin is an alternative drug, with similar side effects though causes hair growth (not loss) and swollen gums.
Other drugs used in CKD
- Apixaban
- Gliclazide
- Indapamide
- Insulin (diabetes injection)
Note. As CKD worsens, hypoglycaemia becomes more common. Insulin dose need to be reduced (and in some cases, stopped)
- Metformin
- Metolazone
- Minoxidil
- Rituximab.
Other general points
- Even if you think a drug is giving you a side-effect – please do not stop the drug without discussion with your doctor or pharmacist. They may be an alternative
- If the side-effect described above is not well known – it does not mean its not real. People are different in how they react to drugs. You may be the first person to get that side-effect with that drug.
Summary
We have described the side-effects of CKD drugs. We hope it has been useful.
Other resources
CKD patient information (CKD Explained’s 30+ core articles about CKD)
These are useful review articles:
Whittaker, 2018
Perazella, 2020
Laville, 2020
This study (summarised in diagram below) showed the CKD patients were taking a large number of drugs (8 on average) with side-effects more common with decreasing kidney function (shown by increasing GFR). Doctors and patients need to be more observant as GFR declines (especially with blood thinning drugs).
Dahl, 2022 (points out that polypharmacy associated with poor nutritional status)
Shougair, 2022
Last Reviewed on 16 May 2024