What medications should be initially held in a patient with Acute Kidney Injury (AKI)?

From the Guidelines

In patients with acute kidney injury (AKI), several medications should be initially held to prevent further kidney damage and complications, including nephrotoxic antibiotics, NSAIDs, ACE inhibitors, ARBs, diuretics, metformin, and contrast agents, as recommended by the most recent guidelines 1. The medications that should be initially held in a patient with AKI include:

• Nephrotoxic antibiotics such as aminoglycosides (gentamicin, tobramycin) and vancomycin
• NSAIDs like ibuprofen, naproxen, and ketorolac
• ACE inhibitors and ARBs (lisinopril, losartan)
• Diuretics, particularly loop diuretics (furosemide) in hypovolemic patients
• Metformin due to lactic acidosis risk
• Contrast agents when possible Additionally, consider holding or dose-adjusting certain antihypertensives, anticoagulants like DOACs and low-molecular-weight heparins, and medications with narrow therapeutic windows such as digoxin and lithium. The rationale for holding these medications is that AKI impairs drug clearance, leading to accumulation and toxicity, as noted in the study by 1. Many of these medications can also worsen kidney function through various mechanisms: NSAIDs reduce renal blood flow, ACE inhibitors/ARBs affect glomerular filtration pressure, and nephrotoxic antibiotics directly damage tubular cells. Once the patient stabilizes and kidney function improves, medications can be reintroduced with appropriate dose adjustments based on estimated glomerular filtration rate (eGFR), as suggested by 1. It is essential to monitor the patient's condition closely and adjust the treatment plan accordingly, taking into account the potential risks and benefits of each medication, as emphasized in the study by 1.

From the FDA Drug Label

PATIENTS WITH IMPAIRED RENAL FUNCTION Dosage must be adjusted in patients with impaired renal function to assure therapeutically adequate, but not excessive blood levels In adults with renal failure undergoing hemodialysis, the amount of gentamicin removed from the blood may vary depending upon several factors including the dialysis method used. Patients with Impaired Renal Function and Elderly Patients Dosage adjustment must be made in patients with impaired renal function.

Medications to Initially Hold for AKI:

• Nephrotoxic medications: such as gentamicin 2 and vancomycin 3 should be held or dose-adjusted in patients with acute kidney injury (AKI) to prevent further renal impairment.
• Other medications that are renally cleared or known to be nephrotoxic should also be held or dose-adjusted until renal function can be assessed and a new dosing regimen can be determined. Key considerations include:
• Gentamicin: dose adjustment is necessary in patients with impaired renal function to avoid excessive blood levels and potential toxicity.
• Vancomycin: dosage adjustment is required in patients with impaired renal function, and serum concentrations should be monitored to optimize therapy.

From the Research

Medications to Hold in AKI

When managing a patient with Acute Kidney Injury (AKI), it is crucial to adjust medications to prevent further kidney damage. The following medications should be initially held:

• Nephrotoxic medications, as they can exacerbate kidney injury 4, 5
• Aminoglycosides, as they are known to be nephrotoxic 6
• Amphotericin B, due to its potential to cause nephrotoxicity 6
• Non-steroidal anti-inflammatory drugs (NSAIDs), as they can reduce renal blood flow and worsen AKI
• Certain antibiotics, such as those that are primarily excreted by the kidneys, may need to be adjusted or held in patients with AKI

General Management Principles

General management principles for AKI include:

• Determination of volume status
• Fluid resuscitation with isotonic crystalloid
• Treatment of volume overload with diuretics
• Discontinuation of nephrotoxic medications
• Adjustment of prescribed drugs according to renal function 4

Importance of Early Identification and Management

Early identification and management of AKI are essential to prevent long-term kidney damage and reduce the risk of mortality and cardiovascular events 7, 4, 5. A thorough history and physical examination can help categorize the underlying cause of AKI, and laboratory work-up, medication adjustment, and identification and reversal of underlying cause are crucial in the initial evaluation and management of AKI 7.