The Role of Pharmacists in Optimizing Pharmacological Treatment for Patients With Comorbidities in Stage 5 Chronic Kidney Disease: A Case Report

Background: Chronic kidney disease (CKD) often worsens with comorbidities such as diabetes and hypertension, requiring precise pharmacological management. Stage 5 CKD presents challenges due to impaired drug clearance, polypharmacy, and high risk of adverse effects. Rational therapy is vital for improving patient safety and outcomes. Case Discussion: A 68-year-old man presented with flank pain, chest discomfort, breathlessness, and reduced urine output. He had stage 5 CKD (eGFR ≈13 mL/min/1.73m²), long-standing hypertension, and type 2 diabetes mellitus. Investigations revealed proteinuria (urine protein/creatinine ratio 4.1), severe anemia (Hemoglobin 7.8 g/dL), thrombocytopenia, and uncontrolled hypertension (190/110 mmHg). He was prescribed 18 medications for CKD, anemia, hypertension, diabetes, neuropathic pain, and supportive care. Guideline-appropriate drugs included linagliptin, cilnidipine, darbepoetin alfa, iron/folic acid, and sodium bicarbonate. However, several required modification: prazosin posed orthostatic hypotension risk, pregabalin and nortriptyline needed renal dose adjustment, and rosuvastatin at 20 mg exceeded the safe range (5–10 mg). Cefuroxime carried neurotoxicity risk in advanced CKD, while gliclazide increased hypoglycemia risk. Ranitidine was replaced with a proton pump inhibitor. Non-essential agents such as cough syrup and cranberry extract were discontinued, and febuxostat was considered appropriate for hyperuricemia. Conclusion: In stage 5 CKD with multiple comorbidities, essential drugs such as sodium bicarbonate, linagliptin, cilnidipine, and darbepoetin alfa with iron/folic acid were suitable. Potentially harmful drugs including gliclazide, ranitidine, high-dose rosuvastatin, cefuroxime, and dual antiplatelet therapy required adjustment or discontinuation to improve safety and clinical outcomes.