Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.
Guidelines
No recommendations possible based on Level I or II evidence
Suggestions for Clinical Care
(Suggestions are based on Level III and IV evidence)
- Some complementary medicines are toxic to renal tissue. A comprehensive medication and dietary assessment should identify these. Use of these renally toxic agents in existing renal impairment should be advised against. (Level IV evidence and Opinion)
Practitioners should be aware of over-the-counter combination medications, herbal beverages, and alternative/complementary medications when taking a history.
Most complementary medicines are a combination of both toxic and potentially toxic agents.
If the patient continues the agent/s, close monitoring of renal function should be performed. Initially, monitoring may need to be weekly, and with satisfactory results, the monitoring frequency can be reduced. Monitoring needs to be continued for as long as the agent/s are taken, as toxicity may be delayed. If any reduction in renal function is noticed, the complementary agent/s should be ceased and not reintroduced.
Patients will often not volunteer the use of these agents as they are considered non-toxic or not important, as they are not prescribed.
Reviews or case reports of various agents are referred to in the Appendix in the original guideline document.
Some complementary medicines are associated with renal toxicity. Their toxicity is more marked with pre-existing renal disease or reduced glomerular filtration rate (GFR).
Definitions:
Levels of Evidence
Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)
Level II: Evidence obtained from at least one properly designed RCT
Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group
Level IV: Evidence obtained from case series, either post-test or pretest/post-test
