Nephrology
Canadian Society of Nephrology
Last updated: November 2025
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Administering ESAs to CKD patients with the goal of normalizing hemoglobin levels has not demonstrated survival or cardiovascular disease benefit, and may be harmful in comparison to a treatment regimen that delays ESA administration or sets relatively conservative targets (90–110 g/L).
Sources:
Drüeke T, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med. 2006 Nov 16;355(20):2071-84. PMID: 17108342.
Moist LM, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013 Nov;62(5):860-73. PMID: 24054466.
Pfeffer MA, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009 Nov 19;361(21):2019-32. PMID: 19880844.
Singh AK, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006 Nov 16;355(20):2085-98. PMID: 17108343.
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The use of NSAIDS, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function in these individuals. Other medication prescribed by a healthcare professional may be safer than and as effective as NSAIDs.
Sources:
Gooch K, et al. NSAID use and progression of chronic kidney disease. Am J Med. 2007 Mar;120(3):280.e1-7. PMID: 17349452.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 S1):S1-266. PMID: 11904577.
Scottish Intercollegiate Guidelines Network (sponsored by NHS Quality Improvement Scotland). Management of chronic heart failure: A national clinical guideline. Edinburgh (UK): Scottish Intercollegiate Guidelines Network (SIGN). [Internet]. 2007 Feb [cited 2014 Sept 23].
US Department of Health and Human Services. National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [Internet]. 2004 Aug [cited 2014 Sept 23].
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When used in combination ACE inhibitors and ARBs are associated with an increased risk of symptomatic hypotension, acute renal failure and hyperkalemia and may increase mortality.
Sources:
Fried LF, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013 Nov 14;369(20):1892-903. PMID: 24206457.
Heran BS, et al. Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD003040. PMID: 22513909.
Mann JF, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008 Aug 16;372(9638):547-53. PMID: 18707986.
Phillips CO, et al. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med. 2007 Oct 8;167(18):1930-6. PMID: 17923591.
Yusuf S, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008 Apr 10;358(15):1547-59. PMID: 18378520.
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The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process between patients, their families, and their nephrology health care team. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefits and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively.
Sources:
Chandna SM, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011 May;26(5):1608-14. PMID: 21098012.
Jassal SV, et al. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ. 2007 Oct 23;177(9):1033-8. PMID: 17954892.
Kurella M, et al. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007 Feb 6;146(3):177-83. PMID: 17283348.
Kurella Tamura M, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009 Oct 15;361(16):1539-47. PMID: 19828531.
Murtagh FE, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007 Jul;22(7):1955-62. PMID: 17412702.
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Initiating chronic dialysis before the appearance of uremic symptoms or other clinical indication is associated with significant burden and inconvenience for the patient without any clinical benefit. Recent guidelines from the Canadian Society of Nephrology recommend that patients with an estimated glomerular filtration rate (eGFR) less than 15 mls/min should be closely followed by their nephrologist and dialysis deferred until symptoms of uremia, volume overload, hyperkalemia or acidosis become an issue or the eGFR drops below 6 mls/min.
Sources:
Cooper BA, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
Nesrallah GE, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
Susantitaphong P, et al. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis. 2012 Jun;59(6):829-40. PMID: 22465328.
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As CKD progresses, increased use of medications to manage symptoms and complications of CKD increases the risk of drug interactions, adverse events, dosing errors, and decreased adherence in this population. As kidney function declines, the ability to excrete some drugs and their metabolites also declines, increasing the risk of drug accumulation and toxicity. Thus, comprehensive medication reviews and deprescribing strategies should be implemented to mitigate risks of polypharmacy.
Sources:
Adjeroh L, et al. The association between polypharmacy and health-related quality of life among non-dialysis chronic kidney disease patients. PLoS ONE. 2023;18(11): e0293912. PMID: 37956162.
Hall RK, et al. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol. 2024; 20(6):386-401. PMID: 38491222.
McIntyre C, et al. Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy. Am J Kidney Dis. 2017;70(5): 611-618. PMID: 28416321.
Sommer J, et al. Adverse Drug Events in Patients with Chronic Kidney Disease Associated with Multiple Drug Interactions and Polypharmacy. Drugs Aging. 2020; 37(5):359-372. PMID: 32056163.
Van Oosten MJM, et al. Polypharmacy and medication use in patients with chronic kidney disease with and without kidney replacement therapy compared to matched controls. Clin Kidney J. 2021;14(12):2497-2523. PMID: 34950462.
Whittaker CF et al. Medication Safety Principles and Practice in CKD. Clin J Am Soc Nephrol. 2018;13(11):1738-1746. PMID: 29915131.
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Patients with kidney failure receiving dialysis are at significantly increased risk of bleeding compared to the general population, primarily due to platelet dysfunction and reduced clotting factor activity. Several studies of patients receiving dialysis with atrial fibrillation have shown an increased risk of bleeding with warfarin that may outweigh ischemic stroke prevention, while others suggest there may still be benefit to warfarin use, especially in higher-risk groups. DOACs are being increasingly used in patients receiving dialysis due to their ease of use and predictable pharmacokinetics, but evidence for their safety and efficacy in this population is limited because most clinical trials excluded them. Thus, careful consideration and an individualized approach to anticoagulation with a thorough risk-benefit analysis is necessary.
Sources:
Fu EL, et al. Comparative Safety and Effectiveness of Warfarin or Rivaroxaban Versus Apixaban in Patients With Advanced CKD and Atrial Fibrillation: Nationwide US Cohort Study. Am J Kidney Dis. 2024;83(3):293-305. PMID: 37839687.
Kao TW, et al. Anticoagulation for Patients With Concomitant Atrial Fibrillation and End‐Stage Renal Disease: A Systematic Review and Network Meta‐Analysis. J Am Heart Assoc. 2024;13(8):e034176. PMID: 38606775.
Kuno T, et al. Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Hemodialysis. J Am Coll Cardiol. 2020;75(3):273-285. PMID: 31976865.
Pikorney SD, et al. Apixaban for Patients With Atrial Fibrillation on Hemodialysis: A Multicenter Randomized Controlled Trial. Circulation 2022;146(23):1735-1745. PMID: 36335914.
Randhawa MS, et al. Association Between Use of Warfarin for Atrial Fibrillation and Outcomes Among Patients With End-Stage Renal Disease: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(4): e202175. PMID: 32250434.
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Chronic pain management in CKD and patients with kidney failure receiving dialysis is complex, often overlooked and under-treated. In addition to addressing the underlying cause and type of pain (e.g. nociceptive vs neuropathic), non-pharmacological options such as physical therapy, cognitive behavioural therapy, and acupuncture should be explored and encouraged before or alongside pharmacologic options and/or surgical interventions. Non-opioid agents such as acetaminophen, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants should be considered first line pharmacologic therapy before considering opioid agents. However, if opioids are deemed necessary in a select population, there should be an ongoing assessment of risks and benefits, including the potential for opioid use disorder and tolerance.
Sources:
Lu E, et al. Opioid Management in CKD. Am J Kidney Dis. 2021;77(5):786-795. PMID: 33500128.
Roy PJ, et al. Pain management in patients with chronic kidney disease and end-stage kidney disease. Curr Opin Nephrol Hypertens. 2020; 29(6): 671-680. PMID: 32941189.
Tobin DG, et al. Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol. 2022; 18(2):113-128. PMID: 34621058.
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Hypertension in patients with kidney failure receiving dialysis is common, influenced by various factors including fluid overload, increased vascular resistance, activation of the renin-angiotensin-aldosterone system, and increased sympathetic nervous system activity. Volume overload is a major cause of resistant hypertension in these patients especially if the target weight (also known as dry weight) is too high. Determination of target weight requires regular clinical assessments for symptoms of fluid overload, blood pressure measurements, interdialytic weight gains and intradialytic symptoms such as cramping, hypotension, dizziness, or nausea. A gradual reduction in dry weight is often an effective strategy for improving blood pressure control in this population, while also monitoring and mitigating the risk of exacerbating intradialytic symptoms.
Sources:
Agarwal R, et al. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension. 2009;53(3):500-507. PMID: 19153263.
Georgianos PI, et al. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol. 2024;35(4):505-514. PMID: 38227447.
Kim IS, et al. Diagnosis and treatment of hypertension in dialysis patients: a systematic review. Clin Hypertens. 2023;29(1):24. PMID: 37653470.
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The Canadian Society of Nephrology (CSN) established its Choosing Wisely Canada recommendations by striking a Choosing Wisely Working Group from its Clinical Practice Guidelines Committee. The working group created a survey to poll the members of the society, who were asked to vote for 5 tests, 5 investigations and 5 treatments that they felt were overused, misused or had potential to cause harm. Over 400 members were surveyed with a 22% response rate. These responses were collated into themes, and ordered by their frequency of occurrence. Three members of the working group reviewed the list independently; each of whom proposed a top 10 list of recommendations derived from the survey responses. These 3 lists were then reviewed by the working group and a draft top ten list was generated based on the following criteria: strength of evidence; potential for harm; cost saving; frequency of occurrence in clinical practice and pertinence to nephrology. The draft list of ten items was presented at the CSN annual general meeting and members were asked to vote electronically on their agreement with each recommendation. In addition to the membership votes, the working group then considered the strength of evidence and potential for meaningful impact of the recommendations, and a final list of five items was agreed upon. Recommendations 1, 2, and 4 were adapted with permission from the Five Things Physicians and Patients Should Question, © 2012 American Society of Nephrology.
Sources:
Drüeke T, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med. 2006 Nov 16;355(20):2071-84. PMID: 17108342.
Moist LM, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013 Nov;62(5):860-73. PMID: 24054466.
Pfeffer MA, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009 Nov 19;361(21):2019-32. PMID: 19880844.
Singh AK, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006 Nov 16;355(20):2085-98. PMID: 17108343.
Gooch K, et al. NSAID use and progression of chronic kidney disease. Am J Med. 2007 Mar;120(3):280.e1-7. PMID: 17349452.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 S1):S1-266. PMID: 11904577.
Scottish Intercollegiate Guidelines Network (sponsored by NHS Quality Improvement Scotland). Management of chronic heart failure: A national clinical guideline. Edinburgh (UK): Scottish Intercollegiate Guidelines Network (SIGN). [Internet]. 2007 Feb [cited 2014 Sept 23].
US Department of Health and Human Services. National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [Internet]. 2004 Aug [cited 2014 Sept 23].
Fried LF, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013 Nov 14;369(20):1892-903. PMID: 24206457.
Heran BS, et al. Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD003040. PMID: 22513909.
Mann JF, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008 Aug 16;372(9638):547-53. PMID: 18707986.
Phillips CO, et al. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med. 2007 Oct 8;167(18):1930-6. PMID: 17923591.
Yusuf S, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008 Apr 10;358(15):1547-59. PMID: 18378520.
Chandna SM, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011 May;26(5):1608-14. PMID: 21098012.
Jassal SV, et al. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ. 2007 Oct 23;177(9):1033-8. PMID: 17954892.
Kurella M, et al. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007 Feb 6;146(3):177-83. PMID: 17283348.
Kurella Tamura M, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009 Oct 15;361(16):1539-47. PMID: 19828531.
Murtagh FE, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007 Jul;22(7):1955-62. PMID: 17412702.
Cooper BA, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
Nesrallah GE, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
Susantitaphong P, et al. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis. 2012 Jun;59(6):829-40. PMID: 22465328.
Adjeroh L, et al. The association between polypharmacy and health-related quality of life among non-dialysis chronic kidney disease patients. PLoS ONE. 2023;18(11): e0293912. PMID: 37956162.
Hall RK, et al. Drug stewardship in chronic kidney disease to achieve effective and safe medication use. Nat Rev Nephrol. 2024; 20(6):386-401. PMID: 38491222.
McIntyre C, et al. Targeted Deprescribing in an Outpatient Hemodialysis Unit: A Quality Improvement Study to Decrease Polypharmacy. Am J Kidney Dis. 2017;70(5): 611-618. PMID: 28416321.
Sommer J, et al. Adverse Drug Events in Patients with Chronic Kidney Disease Associated with Multiple Drug Interactions and Polypharmacy. Drugs Aging. 2020; 37(5):359-372. PMID: 32056163.
Van Oosten MJM, et al. Polypharmacy and medication use in patients with chronic kidney disease with and without kidney replacement therapy compared to matched controls. Clin Kidney J. 2021;14(12):2497-2523. PMID: 34950462.
Whittaker CF et al. Medication Safety Principles and Practice in CKD. Clin J Am Soc Nephrol. 2018;13(11):1738-1746. PMID: 29915131.
Fu EL, et al. Comparative Safety and Effectiveness of Warfarin or Rivaroxaban Versus Apixaban in Patients With Advanced CKD and Atrial Fibrillation: Nationwide US Cohort Study. Am J Kidney Dis. 2024;83(3):293-305. PMID: 37839687.
Kao TW, et al. Anticoagulation for Patients With Concomitant Atrial Fibrillation and End‐Stage Renal Disease: A Systematic Review and Network Meta‐Analysis. J Am Heart Assoc. 2024;13(8):e034176. PMID: 38606775.
Kuno T, et al. Oral Anticoagulation for Patients With Atrial Fibrillation on Long-Term Hemodialysis. J Am Coll Cardiol. 2020;75(3):273-285. PMID: 31976865.
Pikorney SD, et al. Apixaban for Patients With Atrial Fibrillation on Hemodialysis: A Multicenter Randomized Controlled Trial. Circulation 2022;146(23):1735-1745. PMID: 36335914.
Randhawa MS, et al. Association Between Use of Warfarin for Atrial Fibrillation and Outcomes Among Patients With End-Stage Renal Disease: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(4): e202175. PMID: 32250434.
Lu E, et al. Opioid Management in CKD. Am J Kidney Dis. 2021;77(5):786-795. PMID: 33500128.
Roy PJ, et al. Pain management in patients with chronic kidney disease and end-stage kidney disease. Curr Opin Nephrol Hypertens. 2020; 29(6): 671-680. PMID: 32941189.
Tobin DG, et al. Opioids for chronic pain management in patients with dialysis-dependent kidney failure. Nat Rev Nephrol. 2022; 18(2):113-128. PMID: 34621058.
Agarwal R, et al. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension. 2009;53(3):500-507. PMID: 19153263.
Georgianos PI, et al. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol. 2024;35(4):505-514. PMID: 38227447.
Kim IS, et al. Diagnosis and treatment of hypertension in dialysis patients: a systematic review. Clin Hypertens. 2023;29(1):24. PMID: 37653470.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Time to Talk
Encouraging serious illness conversations.
Chronic Kidney Disease
Making hard choices.
Pain Medicines
What to do if you have heart problems or kidney disease.
Serious Illness Conversations
The importance of earlier and better conversations.