NSAIDs in CKD: Are They Safe?

Am J Kidney Dis. 2020 Oct;76(4):546-557. doi: 10.1053/j.ajkd.2020.03.023. Epub 2020 May 30.


The management of pain in patients with chronic kidney disease (CKD) is challenging for many reasons. These patients have increased susceptibility to adverse drug effects due to altered drug metabolism and excretion, and there are limited safety data for use in this population despite a high pain burden. Nonsteroidal anti-inflammatory drugs (NSAIDs) have long been regarded as dangerous for use in patients with CKD because of their risk for nephrotoxicity and thus alternative classes of analgesics, including opioids, have become more commonly used for pain control in this population. Given the well-established risks that opioids and other analgesics pose, further characterization of the risk posed by NSAIDs in patients with CKD is warranted. NSAID use has been associated with acute kidney injury, progressive loss of glomerular filtration rate in CKD, electrolyte derangements, and hypervolemia with worsening of heart failure and hypertension. The risk for these nephrotoxicity syndromes is modified by many comorbid conditions, risk factors, and characteristics of use, and in patients with CKD, the risk differs between levels of glomerular filtration rate. In this review, we offer recommendations for the cautious use of NSAIDs in the CKD population after careful consideration of these risk factors on an individualized basis.

Keywords: CKD progression; Nonsteroidal anti-inflammatory drugs (NSAIDs); acute kidney injury (AKI); adverse effects; analgesic; chronic kidney disease (CKD); chronic pain; drug safety; hyperkalemia; hypervolemia; hyponatremia; nephrotoxicity; pain management; renal dysfunction; review.

Publication types

  • Review

MeSH terms

  • Anti-Inflammatory Agents, Non-Steroidal / adverse effects*
  • Humans
  • Kidney Diseases / chemically induced
  • Pain / drug therapy*
  • Pain / etiology*
  • Renal Insufficiency, Chronic / complications*


  • Anti-Inflammatory Agents, Non-Steroidal