Chronic kidney disease (CKD) represents a major global health burden, affecting millions of individuals across diverse populations. Characterized by a progressive decline in renal function, CKD is associated with significant morbidity, mortality, and healthcare costs [1-5]. The prevalence of CKD has been steadily increasing, largely driven by the rising incidence of diabetes mellitus, hypertension, and aging populations. According to global estimates, approximately 10–15% of adults are affected by some stage of CKD, with many progressing to end-stage renal disease (ESRD) requiring dialysis or transplantation. Beyond its direct impact on renal function, CKD is strongly linked to cardiovascular disease, infections, and metabolic complications, making its management complex and multifaceted [1-5]. Pharmacotherapy plays a central role in the management of CKD, both in slowing disease progression and in addressing associated comorbidities. Patients with CKD often require multiple medications, including antihypertensives, antidiabetics, lipid-lowering agents, erythropoiesis-stimulating agents, phosphate binders, and diuretics. However, prescribing in CKD is uniquely challenging due to altered pharmacokinetics and pharmacodynamics [6]. Reduced renal clearance, changes in protein binding, and accumulation of active metabolites can increase the risk of drug toxicity. Moreover, polypharmacy is common in CKD patients, raising concerns about drug–drug interactions, adverse drug reactions (ADRs), and medication non-adherence. Rational prescribing, therefore, requires careful consideration of renal function, dose adjustments, and evidence-based guidelines. Despite the availability of clinical practice guidelines, inappropriate prescribing remains a significant issue in CKD management [7]. Studies have documented frequent use of nephrotoxic drugs, inadequate dose modifications, and suboptimal adherence to therapeutic recommendations. Such practices not only compromise patient safety but also contribute to disease progression and increased hospitalization rates. For instance, non-steroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics are often prescribed without adequate caution, despite their well-established nephrotoxic potential. Similarly, failure to adjust doses of renally excreted drugs such as digoxin, aminoglycosides, or hypoglycemic agents can result in serious complications [7]. These challenges underscore the need for continuous evaluation of prescribing patterns in CKD populations. Retrospective studies provide valuable insights into real-world prescribing practices, highlighting trends, gaps, and opportunities for improvement. By analyzing medical records and prescription data, such studies can identify common drug classes used, frequency of dose adjustments, prevalence of potentially inappropriate medications, and adherence to clinical guidelines. Importantly, they can also shed light on regional variations in prescribing behavior, reflecting differences in healthcare infrastructure, physician awareness, and patient demographics [8]. In resource-limited settings, where access to nephrology specialists and advanced therapies may be restricted, understanding prescribing trends becomes even more critical for optimizing patient care. This study aims to systematically evaluate drug prescribing patterns among patients with chronic kidney disease through a retrospective review of medical records. Specifically, it seeks to identify the most commonly prescribed drug classes, assess the appropriateness of dose adjustments based on renal function, and determine the prevalence of potentially inappropriate medications. By doing so, the study intends to highlight areas of concern in current prescribing practices and propose strategies to enhance rational pharmacotherapy in CKD management. Ultimately, the insights gained will contribute to safer, more effective, and evidence-based care for patients living with chronic kidney disease.

This retrospective observational study was conducted to evaluate drug prescribing patterns among patients diagnosed with chronic kidney disease (CKD). The study was carried out in the Department of Nephrology in collaboration with Department of Pharmacology from February 2025 to January 2026, using medical records and prescription data from patients who attended outpatient clinics and inpatient wards. Eligibility Criteria • Patients were included if they met the following criteria: • Adults aged ≥18 years. • Diagnosed with chronic kidney disease, defined according to Kidney-Disease: Improving Global Outcomes (KDIGO) guidelines [9]. • Had at least one documented prescription during the study period. • Exclusion criteria were: • Patients with incomplete medical records or missing prescription data. • Patients with acute kidney injury without underlying CKD. • Pregnant or lactating women. • Patients receiving renal replacement therapy (dialysis or transplantation) at the time of data collection. Sample Size The sample size was determined based on the availability of medical records during the study period. A total of 501 CKD patient records were screened, of which 257 met the inclusion criteria and were analyzed. The sample size was considered adequate to provide meaningful insights into prescribing trends and to allow subgroup analysis across different CKD stages. Outcome Parameters • The primary outcome parameters included: • Drug classes prescribed: frequency and distribution of antihypertensives, antidiabetics, lipid-lowering agents, diuretics, phosphate binders, and other medications. • Dose adjustments: proportion of drugs appropriately modified according to renal function. • Potentially inappropriate medications (PIMs): prevalence of nephrotoxic drugs or contraindicated agents prescribed to CKD patients. • Polypharmacy: defined as the concurrent use of ≥5 medications. • Secondary outcomes included: • Drug–drug interactions: identification of clinically significant interactions. • Adverse drug reactions (ADRs): documentation of suspected ADRs related to prescribed medications. Data Collection Data were collected retrospectively from patient medical records, prescription charts, and laboratory reports. Information extracted included demographic details (age, sex), clinical characteristics (CKD stage, comorbidities), laboratory parameters (serum creatinine, estimated glomerular filtration rate [eGFR]), and complete drug prescription details (drug name, dose, frequency, route, and duration). Data were anonymized and coded to ensure confidentiality. Methodology Each prescription was reviewed against standard treatment guidelines, including KDIGO recommendations and national prescribing protocols. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. Dose appropriateness was assessed by comparing prescribed doses with recommended renal dose adjustments. Potentially inappropriate medications were identified using established criteria, including Beers criteria and nephrology-specific recommendations. Polypharmacy and drug–drug interactions were evaluated using validated drug interaction databases. Statistical Analysis Data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) version 26. Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Chi-square test was used to measure statistical significance of association between DDI and polypharmacy.

The majority of patients (49.4%) were aged 60 years or older, with a predominance of males (59.9%). CKD stages were distributed across the spectrum, with stage 4 being the most common (32.7%), followed by stage 3 (28.0%) and stage 5 pre-dialysis (24.5%). Hypertension was the most prevalent comorbidity (68.5%), followed by diabetes mellitus (55.3%) and cardiovascular disease (23.7%). This population profile reflects typical CKD patient characteristics, with a high burden of age-related and cardiometabolic comorbidities [Table 1]. Table 1. Baseline Characteristics of CKD Patients (n = 257) Variable Frequency (n) Percentage (%) Age (years) 18–39 42 16.3 40–59 88 34.2 ≥60 127 49.4 Sex Male 154 59.9 Female 103 40.1 CKD Stage Stage 1–2 38 14.8 Stage 3 72 28.0 Stage 4 84 32.7 Stage 5 (pre-dialysis) 63 24.5 Comorbidities Hypertension 176 68.5 Diabetes mellitus 142 55.3 Cardiovascular disease 61 23.7 Antihypertensives were the most frequently prescribed (77.0%) and also showed the highest compliance with dose adjustment (81.8%). Most drug categories, including antidiabetics, lipid-lowering agents, and diuretics, demonstrated good compliance rates (76–77%). In contrast, antibiotics and NSAIDs had notably lower adjustment compliance (65.1% and 33.3%, respectively), indicating a potential area for improvement in medication safety practices for these classes in CKD patients [Table 2, Figure 1]. Figure 1: Distribution of Prescribed Drug Classes Table 2. Dose Adjustment Compliance According to Renal Function Drug Category Total Prescriptions Dose Adjusted (n) Compliance (%) Antihypertensives 198 162 81.8 Antidiabetics 134 102 76.1 Lipid-lowering agents 92 71 77.2 Diuretics 116 89 76.7 Antibiotics 63 41 65.1 NSAIDs 27 9 33.3 NSAIDs were the most common PIM (10.5%), followed by metformin in advanced CKD stages (5.4%), aminoglycosides (4.3%), and digoxin (3.1%). Overall, 23.3% of patients were prescribed at least one PIM, highlighting a significant medication safety concern in this population, particularly regarding drugs with known renal risks or contraindications in reduced kidney function [Table 3]. Table 3. Prevalence of Potentially Inappropriate Medications (PIMs) Medication Type Patients Prescribed (n) Percentage (%) NSAIDs 27 10.5 Aminoglycosides 11 4.3 Digoxin 8 3.1 Metformin (Stage 4–5 CKD) 14 5.4 Total PIMs 60 23.3 Polypharmacy was common in the cohort, with 55.3% of patients taking 5–10 medications and 14.8% taking more than 10 medications. Drug-drug interactions (DDIs) were frequently observed, with 18.3% of patients having clinically significant DDIs and 28.0% having minor DDIs. Table 4. Polypharmacy and Drug–Drug Interactions Parameter Frequency (n) Percentage (%) Patients with 5-10 drugs 142 55.3 Patients with >10 drugs 38 14.8 Clinically significant DDIs 47 18.3 Minor DDIs 72 28.0 The prevalence of significant DDIs rose sharply with increasing medication burden: 5.7% in patients with fewer than 5 drugs, 16.4% in those with 5–10 drugs, and 44.7% in those with more than 10 drugs. The chi-square test result (p < 0.0001) confirms a statistically significant strong association between higher levels of polypharmacy and increased risk of clinically important drug interactions. Table 5: Association of Clinically Significant DDIs with Polypharmacy Clinically Significant DDI Patients with <5 drugs (n=87) Patients with 5-10 drugs (n=142) Patients with >10 drugs (n=38) Yes 5 (5.7%) 25 (16.4%) 17 (44.7%) No 82 (94.3%) 127 (83.5%) 21 (55.3%) P-Value (Chi-square test) <0.0001

Our study highlights critical medication safety issues in CKD patients, particularly concerning polypharmacy, dose adjustment non-compliance, and the prevalence of potentially inappropriate medications (PIMs). The high rate of polypharmacy (55.3% on 5–10 drugs, 14.8% on >10 drugs) and clinically significant drug-drug interactions (DDIs) in 18.3% of patients underscores a substantial risk for adverse drug events (ADEs), hospitalizations, and worsened clinical outcomes. The strong association between polypharmacy and significant DDIs (p < 0.0001) indicates that medication burden is a key modifiable risk factor. Furthermore, suboptimal renal dose adjustment compliance—especially for antibiotics (65.1%) and NSAIDs (33.3%)—suggests gaps in prescribing practices that may exacerbate renal injury or lead to toxicity. The identification of PIMs in nearly one-quarter of patients reinforces the need for heightened pharmacovigilance and guideline adherence in this vulnerable population. Several factors may explain our findings. First, the high comorbidity burden (hypertension 68.5%, diabetes 55.3%) necessitates multi-drug regimens, leading to polypharmacy. Second, prescribers may lack awareness or tools for renal dose adjustment, particularly for non-nephrology specialty drugs like antibiotics and NSAIDs. Third, fragmented care and inadequate medication reconciliation may contribute to PIMs and DDIs [6,7]. Finally, the absence of routine DDI screening in clinical workflows likely permits hazardous combinations to go unrecognized until ADEs occur. Similar to Chaudhary et al. (2021), Busari et al. (2019), and Santos-Díaz et al. (2020) [10,12], we observed high polypharmacy rates and significant DDI prevalence. Our DDI rate (18.3% clinically significant) is consistent with Santos-Díaz et al. (2020) (91% with potential DDIs) and Busari et al. (2019) (85.7% clinically significant), though methodological differences in DDI detection tools account for variability [11,12]. Our finding of suboptimal adjustment for antibiotics and NSAIDs mirrors concerns raised by Sommer et al. (2020), which identified hazardous drug combinations leading to QTc prolongation, hyperkalemia, and bleeding [13]. This suggests global consistency in prescribing risks for renally cleared medications. Our PIM prevalence (23.3%) is comparable to rates reported in studies from India, such as those by Mamadi et al. (2019) and Al-Ramahi (2012), where NSAIDs and metformin in advanced CKD were common [14,15]. Prasad et al. (2021) also noted underuse of evidence-based therapies (e.g., RAAS blockers in only 47.9% of indicated patients), reflecting systemic gaps in guideline implementation [16]. Our most prescribed drug classes (antihypertensives, antidiabetics) match patterns reported by Mamadi et al. (2019) and Al-Ramahi (2012) [14,15], confirming that cardiovascular and metabolic management dominates CKD pharmacotherapy. However, our lower use of phosphate binders (28.8%) compared to studies focusing on later CKD stages (e.g., Bajait et al., 2014) may reflect our cohort's inclusion of earlier CKD stages [17]. Collectively, these studies—including ours—demonstrate that medication-related harm in CKD is a pervasive, cross-continental issue driven by polypharmacy, inadequate dose adjustment, and guideline-practice gaps. Interventions such as computerized DDI screening, renal dosing protocols, pharmacist-led medication reviews, and continuous education are urgently needed to improve medication safety and outcomes in CKD patients worldwide [18, 20]. A key limitation of this study is its retrospective design and reliance on a single-center cohort, which may limit the generalizability of the findings to other settings or populations. The cross-sectional nature captures medication data at one point in time and cannot establish causality between prescribing patterns and clinical outcomes. Furthermore, the assessment of drug interactions and appropriateness was based on prescription records rather than direct clinical evaluation of adverse events, potentially underestimating actual patient harm. Finally, the study did not capture data on prescriber rationale, patient adherence, or the impact of non-pharmacological factors on the observed medication safety issues. Future clinical research should prioritize large-scale, multi-center, prospective studies to longitudinally track the causal relationships between specific prescribing patterns, drug interactions, and hard clinical outcomes such as hospitalization rates, progression of CKD, and mortality. In practice, the implementation and rigorous evaluation of integrated clinical decision support systems—automating renal dose adjustments, flagging high-risk drug combinations, and screening for PIMs—within electronic health records is essential. Furthermore, developing and testing pharmacist-led medication therapy management protocols and multidisciplinary care models focused on systematic medication reconciliation and deprescribing initiatives represent critical steps toward translating evidence into sustainable improvements in medication safety for CKD patients.

In conclusion, this study reveals a high burden of polypharmacy, clinically significant drug-drug interactions, and suboptimal renal dose adjustment among CKD patients, with a strong association between increasing medication numbers and adverse interaction risk. The findings highlight significant gaps in current prescribing practices and medication safety protocols, aligning with global evidence that underscores the vulnerability of this population to medication-related harm. These results emphasize the urgent need for systematic interventions, including the integration of clinical decision support tools, enhanced prescriber education, and multidisciplinary medication review processes, to mitigate risks and improve the overall quality and safety of pharmacotherapy in chronic kidney disease management.

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