From the Guidelines
When managing acute kidney injury (AKI), medications such as NSAIDs, ACE inhibitors, ARBs, diuretics, metformin, and certain antibiotics (aminoglycosides, vancomycin at high doses) should be temporarily held to prevent further kidney damage, as recommended by the most recent guideline evidence 1. The medications to be held include:
- NSAIDs (ibuprofen, naproxen, celecoxib) which reduce kidney blood flow
- ACE inhibitors (lisinopril, enalapril) and ARBs (losartan, valsartan) which affect kidney filtration pressure
- Diuretics (especially loop diuretics like furosemide) which can cause volume depletion
- Metformin which can accumulate and cause lactic acidosis
- Certain antibiotics (aminoglycosides, vancomycin at high doses) which are directly nephrotoxic Additionally, contrast agents used in imaging studies should be avoided when possible, as they can also worsen kidney function 1. The reason for holding these medications is to prevent further kidney damage and allow for recovery, with regular monitoring of creatinine and electrolytes, as well as maintaining adequate hydration and treating the underlying cause of AKI 1. It is also important to note that when AKI is diagnosed, diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline, as recommended by the most recent guideline evidence 1.
From the FDA Drug Label
As with other aminoglycosides, gentamicin injection is potentially nephrotoxic. The risk of nephrotoxicity is greater in patients with impaired renal function and in those who receive high dosage of prolonged therapy Renal and eighth cranial nerve function should be closely monitored, especially in patients with known or suspected reduced renal function at onset of therapy and also in those whose renal function is initially normal but who develop signs of renal dysfunction during therapy Evidence of ototoxicity (dizziness, vertigo, tinnitus, roaring in the ears or hearing loss) or nephrotoxicity requires dosage adjustment or discontinuance of the drug.
Medications to hold with Acute Kidney Injury (AKI):
- Gentamicin should be held or its dosage adjusted in patients with AKI, as it is potentially nephrotoxic and may worsen renal function 2.
- Other nephrotoxic medications, such as cisplatin, cephaloridine, kanamycin, amikacin, neomycin, polymyxin B, colistin, paromomycin, streptomycin, tobramycin, vancomycin, and viomycin, should also be avoided or used with caution in patients with AKI.
- Potent diuretics, such as ethacrynic acid or furosemide, should be avoided when using gentamicin, as they may enhance aminoglycoside toxicity.
From the Research
Medications to Hold with Acute Kidney Injury (AKI)
Medications that are nephrotoxic or can exacerbate AKI should be held or adjusted in patients with AKI. Some of these medications include:
- Nephrotoxic medications, such as certain antibiotics and NSAIDs 3
- Medications that can cause volume overload, such as diuretics 3
- Medications that require dose adjustment in renal impairment, such as antibiotics 4
Management of AKI
Management of AKI involves:
- Determination of volume status and fluid resuscitation with isotonic crystalloid 3
- Treatment of volume overload with diuretics 3
- Discontinuation of nephrotoxic medications 3
- Adjustment of prescribed drugs according to renal function 3
- Optimization of nutritional status and glycemic control 3
Antibiotic Dosing in AKI
Antibiotic dosing in critically ill patients with AKI can be complicated due to altered pharmacokinetic parameters.
- Antibiotic loading doses may need to be adjusted upwards to account for increased volume of distribution 4
- Maintenance doses may need to be adjusted to reflect enhanced drug clearance due to residual renal function and renal replacement therapies 4
- Antibiotic dosing decisions should be individualized to take into account patient-related, RRT-related, and drug-related factors 4