Background: Opioid analgesics are often used to manage moderate to severe pain and are routinely used in the context of palliative care. A significant proportion of patients taking opioids have compromised kidney function. This systematic review aimed to examine the available evidence on the safety and effect of opioid use in adults with kidney disease. 

Methods: We searched eight electronic databases from inception to 26th January 2023. Published original research articles in English reporting on opioid use among adults with reduced renal function were included. Article screening, data extraction, and quality assessment were conducted by at least two investigators independently. This review was registered prospectively on PROPSPERO (ID: CRD42020159091). 

Results: There were 32 observational studies included, four of which included patients in palliative care settings. Fourteen studies reported on morphine use, three involved fentanyl use, two involved hydromorphone use and 13 articles reported on other opioids including codeine, dihydrocodeine, and buprenorphine. Limited data were available on the safety and efficacy of opioid use in relation to impaired kidney function. All included studies showed a moderate or serious risk of bias. 

Conclusions: There is limited and low-quality evidence to inform the safety and effect of opioid use in reduced renal function. Morphine remains the opioid for which there is the most evidence available on safety and effect in the context of renal insufficiency. Further high-quality studies examining clinical outcomes associated with the use of different opioids and opioid doses in renal insufficiency are required. The authors suggest attention to determinants of dose (including volume of distribution, metabolism, and excretion) and kidney function to tailor to the individual patient circumstances. Initiation on a low opioid dose and gradual titration are recommended.