Chronic kidney disease (CKD) represents a major public health challenge worldwide, with an estimated prevalence of 10–13% among adults and a substantial contribution to global morbidity and mortality.¹˒² In India, the prevalence of CKD is rising steadily, largely attributable to the increasing burden of diabetes mellitus and hypertension.³ The management of CKD typically involves treatment of multiple comorbid conditions, leading to unavoidable polypharmacy. Several studies have demonstrated that polypharmacy in CKD patients is associated with a higher risk of adverse drug reactions (ADRs), drug–drug interactions (DDIs), poor medication adherence, and increased healthcare utilisation.⁴˒⁵ These risks are further compounded by altered renal clearance, changes in drug metabolism, and modified pharmacodynamic responses seen in CKD.6,7 Medication reconciliation is defined as a structured process of obtaining a complete and accurate list of a patient’s medications and comparing it with current prescriptions to identify and resolve discrepancies.8 Evidence from international studies indicates that medication reconciliation, particularly when led by pharmacists or clinical pharmacologists, can reduce medication discrepancies, DDIs, and preventable ADRs in high-risk populations.9,10 Despite this evidence, Indian data evaluating medication reconciliation in ambulatory CKD care—especially within Clinical Pharmacology services—are limited.11,12 Most existing Indian studies focus on inpatient or dialysis populations, highlighting a gap in outpatient CKD medication safety research.

Study Design and Setting This cross-sectional observational study was carried out over a six-month period in the Clinical Pharmacology outpatient department of a tertiary care teaching hospital in eastern India. Study Population Adult patients with a confirmed diagnosis of CKD attending the Clinical Pharmacology OPD and receiving multiple medications were screened for inclusion. Inclusion Criteria Patients aged 18 years or older with CKD who were receiving five or more medications and attending the OPD for medication reconciliation for the first time. Exclusion Criteria Patients unwilling to provide informed consent or unable to communicate verbally were excluded. Study Procedure Medication reconciliation was performed during a single outpatient visit. The medication list at presentation was reviewed and optimised during the same encounter by a clinical pharmacologist, taking into account clinical history, renal function, and relevant laboratory parameters. As no follow-up was undertaken, the study was classified as cross-sectional. Study Variables Number of prescribed medications, medication discrepancies, adverse drug reactions, and potential drug–drug interactions. Sample Size The sample size was estimated using the formula n = Z²pq/d², assuming an approximate CKD prevalence of 10% in India,³ a 95% confidence level, and an allowable error of 8%. Based on feasibility, 55 patients were included. Statistical Analysis Data were analysed using SPSS software. Continuous variables were summarised as mean ± standard deviation, and categorical variables were expressed as frequencies and percentages.

A total of 55 adult patients with chronic kidney disease (CKD) and polypharmacy were included in the study. The mean age of participants was 56.4 ± 12.1 years, with a male predominance. Hypertension and diabetes mellitus were the most common comorbidities. Most patients had advanced disease, with CKD stages 3–5 observed in more than three-fourths of participants (Table 1). The burden of polypharmacy was high, with a mean of 8.6 ± 2.4 medications prescribed per patient. Nearly half of the patients were receiving 8–10 drugs concurrently, while more than one-fifth were prescribed more than 10 medications (Table 2). Medication reconciliation identified clinically significant discrepancies in 70.9% of patients, most commonly inappropriate dosing according to renal function, unnecessary continuation of medications, duplicate therapy, and omission of indicated drugs (Table 4). Following medication reconciliation during the same outpatient visit, there was a statistically significant reduction in the mean number of prescribed medications (8.6 ± 2.4 vs 7.2 ± 2.1; p < 0.001). The proportion of patients with potential drug–drug interactions, inappropriate renal dosing, and duplicate medications also decreased significantly after reconciliation (Table 3). These changes are visually represented in Figure 1. Adverse drug reactions were identified in 30.9% of patients, with gastrointestinal and electrolyte-related reactions being the most frequently observed (Table 5). Table 1. Baseline Demographic and Clinical Characteristics of Study Participants (n = 55) Variable Number (%) / Mean ± SD Age (years) 56.4 ± 12.1 Age ≥60 years 28 (50.9) Male 36 (65.5) Female 19 (34.5) Hypertension 44 (80.0) Diabetes mellitus 38 (69.1) Both HTN and DM 31 (56.4) CKD stage 3–5 42 (76.4) Hospitalisation in last 6 months 21 (38.2) Most patients were middle-aged or elderly with a male predominance. Hypertension and diabetes mellitus were the most frequently observed comorbid conditions. Table 2. Distribution of Polypharmacy among CKD Patients Number of medications Patients n (%) 5–7 drugs 17 (30.9) 8–10 drugs 26 (47.3) >10 drugs 12 (21.8) Mean number of drugs 8.6 ± 2.4 Polypharmacy was common, with nearly half of the patients receiving eight to ten medications concurrently. Table 3. Impact of Medication Reconciliation on Prescribing Parameters Parameter Before reconciliation After reconciliation Statistical test p-value Mean number of drugs per patient 8.6 ± 2.4 7.2 ± 2.1 Paired t-test <0.001 Patients with ≥1 potential DDI 60.0% 34.5% McNemar’s test 0.002 Inappropriate renal dosing 38.2% 12.7% McNemar’s test <0.001 Duplicate medications 25.5% 5.5% McNemar’s test <0.001 Prescription optimisation during the same outpatient visit resulted in a reduction in pill burden and potential drug–drug interactions. Table 4. Types of Medication Discrepancies Identified during Reconciliation Type of discrepancy Patients n (%) Inappropriate dose for renal function 21 (38.2) Duplicate therapy 14 (25.5) Unnecessary continuation of drugs 18 (32.7) Omission of indicated medication 11 (20.0) At least one discrepancy present 39 (70.9) Clinically significant medication discrepancies were identified in a substantial proportion of patients. Table 5. Pattern of Adverse Drug Reactions (ADRs) Identified (n = 17) ADR category Number (%) Gastrointestinal 6 (35.3) Electrolyte imbalance 5 (29.4) Central nervous system 4 (23.5) Dermatological 2 (11.8) Patients with ≥1 ADR 17 (30.9) Adverse drug reactions were documented in nearly one-third of patients, with gastrointestinal and electrolyte-related reactions being the most common.

The present study demonstrates a high burden of polypharmacy among CKD patients attending an outpatient Clinical Pharmacology service, consistent with recent international findings.4,5 The complexity of CKD management and coexistence of multiple chronic conditions contribute substantially to this burden. Medication reconciliation revealed clinically important discrepancies in a significant proportion of patients, indicating that medication-related problems persist even in ambulatory care settings. Inappropriate dosing according to renal function was a prominent issue, reflecting known pharmacokinetic challenges in CKD.6,13 Optimisation of prescriptions during the same clinical encounter resulted in a reduction in pill burden and potential DDIs. Although long-term clinical outcomes were not assessed, these immediate improvements are in line with prior studies demonstrating the effectiveness of medication reconciliation in enhancing prescribing quality.9,10,14 The identification of ADRs in nearly one-third of patients underscores the vulnerability of CKD patients to drug-related harm. The pattern of ADRs observed aligns with existing literature on medication safety in ambulatory care.5,7,15 By focusing on an outpatient Clinical Pharmacology setting, this study contributes Indian data to an area where evidence remains limited and supports the routine incorporation of medication reconciliation into ambulatory CKD care.11,12 Strengths And Limitations Strengths: The study provides real-world outpatient data and demonstrates the feasibility of structured medication reconciliation within a Clinical Pharmacology service. Limitations: The single-centre, cross-sectional design and lack of follow-up limit assessment of long-term clinical outcomes.

Medication reconciliation performed at the point of care effectively identifies medication discrepancies, reduces potential drug–drug interactions, and enhances medication safety among patients with chronic kidney disease and polypharmacy.

1. Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, et al. Global prevalence of chronic kidney disease: a systematic review and meta-analysis. PLoS One. 2016;11(7):e0158765. 2. Lv JC, Zhang LX. Prevalence and disease burden of chronic kidney disease. Lancet. 2019;393(10174):193-202. 3. Mohanty NK, Sahoo KC, Pati S, Sahu AK, Mohanty MK. Prevalence of chronic kidney disease in India: a systematic review. Int J Environ Res Public Health. 2020;17(11):456. 4. Oosting IJ, Pippias M, Jager KJ, Abrahams AC, Evans M, Stel VS. Polypharmacy in patients with chronic kidney disease: a systematic review and meta-analysis. Kidney360. 2024;5(2):250-263. 5. Onor IC, Onor OC, Stanifer JW, et al. Polypharmacy in chronic kidney disease: health outcomes and medication-related problems. Am J Med Sci. 2024;368(4):300-308. 6. Whittaker CF, Miklich MA, Patel RS, Fink JC. Medication safety principles and practice in chronic kidney disease. Clin J Am SocNephrol. 2018;13(11):1738-1746. 7. Mason NA. Polypharmacy and medication-related complications in chronic kidney disease. CurrOpinNephrolHypertens. 2011;20(5):492-497. 8. Penm J, Vaillancourt R, Pouliot A. Defining medication reconciliation: a systematic review. Res Social Adm Pharm. 2019;15(6):632-640. 9. Ahmadi H, Houshmand Y, Raees-Jalali GA, Karimzadeh I. Medication reconciliation by pharmacists in adult patients with chronic kidney disease. Pharmacy (Basel). 2024;12(6):170. 10. Salameh LK, Basheti IA, Abu Farha R. Impact of pharmacist-directed medication reconciliation on medication discrepancies and adverse drug reactions. Int J Clin Pharm. 2024;46(4):765-774. 11. Singh H, Arora P, Sharma S, et al. Drug utilisation pattern and medication-related problems in patients with chronic kidney disease in India. Indian J Nephrol. 2022;32(2):145-151. 12. Datta S, Banerjee A, Mukherjee S, et al. Medication safety issues in chronic kidney disease: an Indian perspective. J ClinDiagn Res. 2021;15(6):FC01-FC05. 13. Schmidt IM, Hübner S, Nadal J, et al. Patterns of medication use and polypharmacy in chronic kidney disease. Nephrol Dial Transplant. 2019;34(9):1525-1533. 14. Mekonnen AB, McLachlan AJ, Brien JA. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes. BMJ Open. 2016;6(10):e010003. 15. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564.