PIM prevalence in kidney disease
Polypharmacy and PIM use are prevalent in chronic kidney disease (CKD) patients, with greater numbers of medications associated with higher risk of hospitalization and death . Additionally, hypertension, cerebrovascular disease, and uremic toxins contribute to the adverse effects of PIMs in these patients.
Several studies evaluated the prevalence of PIMs in elderly HD patients using AGS Beers Criteria® or the STOPP/ START guidelines. Japan study indicated that the majority of the patients (57%) were prescribed a PIM  whereas the Norway one demonstrated PIMs ranging from 43 to 63 % . The US patients without the CKD had PIMs prevalence of around 30% as opposed to around 64% in predominantly CKD patients’ cohort.
How to address the PIM prescribing
Because of the PIMs widespread use and associated major risks, optimization of suitable medication is an ongoing challenge in healthcare. Clinical trials suggest that the decrease in PIM prescribing reduce hospital usage , fall rate  as well as mortality rate . The term ‘deprescribing’ has been used to describe the systematic approach that is required for safe and effective cessation of medication. The five-step patient-centered deprescribing process includes analysis of comprehensive medication history, identification of PIMs, determining whether a medication can be ceased and prioritized, planning and initiating withdrawal, and monitoring support and documentation .
Regarding deprescribing in dialysis, quality improvement study  was conducted in order to develop a deprescribing tool for target medications. The study implemented the use of specific tools and algorithms in order to guide deprescribing within five medication classes: quinine, diuretics, α1-blockers, proton pump inhibitors, and statins. Ultimately, there were 78% target medications completely deprescribed six months after the study.
Alternative medications to be used instead of the potentially high-risk medications
Hanlon et al. developed a list of alternative medications that may be used instead of the potentially high-risk ones and potentially harmful drug-disease interactions in the elderly . PIM categories that are commonly used among the CKD patients, can be exacerbated in the dialysis settings, have altered clearance and a safer alternative include sedatives, opioids, antispasmodics, anticholinergics, alpha blockers, and central-acting alpha agonists (slide 13 ). The recent study indicated that anticholinergic antidepressant use was associated with a higher hazard of altered mental status, fall, or fracture in older HD patients further urging for use of alternative treatments .
Barriers and patients’ attitudes to deprescribing
There are intrinsic (knowledge, attitudes and behavior) as well as extrinsic barriers (environment) to deprescribing, many of which are interconnected (Slide 15 ). It is suggested that the lack of evidence and training may decrease health care provider’s efficacy for deprescribing together with poor shared decision making process and low motivation with time constraints. Providers may be hesitant to discontinue medications, particularly when the consequences of discontinuation are unknown and when they have limited access to patient-related data in order to make real-time decisions. Furthermore, various priorities may detract from a provider’s ability to invest time in assessing medication appropriateness .
Knowledge of patient attitudes is crucial for conducting medication deprescribing in practice . The adults older than 65 years of age taking at least one regular medicine and their caregivers completed the questionnaire where a higher total score indicated a greater perceived burden, the concerns about stopping, and involvement in medication management. The analysis revealed that the patients and caregivers were evidently willing to deprescribe but they were also concerned about several barriers in that process .