From the Guidelines
Less nephrotoxic crisis management options should prioritize the avoidance of nephrotoxins and the selection of less nephrotoxic drugs.
Key Considerations
- Assess the necessity of the drug: Determine if the nephrotoxin is essential for the patient, and if a less nephrotoxic alternative is available 1.
- Evaluate the patient's risk factors: Consider the patient's risk factors for kidney injury, such as advanced age, previous AKI episode, chronic kidney disease, diabetes mellitus, proteinuria, or hypertension 1.
- Monitor drug concentrations and serum creatinine levels: Regularly monitor drug concentrations and serum creatinine levels to prevent nephrotoxicity and adjust drug dosing accordingly 1.
- Avoid combining nephrotoxins: Avoid combining nephrotoxins, such as NSAIDs, diuretics, and ACE inhibitors or ARBs, as this can increase the risk of AKI 1.
- Consider the mechanism of nephrotoxicity: Consider the mechanism of nephrotoxicity, whether from direct tubular toxicity, renovasoconstriction, interstitial nephritis, or crystallization, when selecting a treatment regimen 1.
Specific Drug Considerations
- NSAIDs: Withhold NSAIDs in patients with persistent or recovery phase of AKD, unless clearly necessary and no suitable alternative exists 1.
- Aminoglycosides: Use careful dosing and monitoring of aminoglycosides to prevent re-injury in the recovery phase of AKI 1.
- ACE inhibitors: Consider the use of ACE inhibitors, which may have renoprotective properties, but use with caution in patients with AKD 1. By considering these factors and taking a individualized approach to crisis management, healthcare providers can minimize the risk of nephrotoxicity and optimize patient outcomes 1.
From the Research
Nephrotoxic Crisis Management Options
To manage nephrotoxic crisis, it is essential to consider less nephrotoxic options. The following are some strategies that can be employed:
- Using alternative non-nephrotoxic drugs whenever possible 2, 3
- Correcting risk factors, if possible, such as volume depletion, diabetes, heart failure, and sepsis 2
- Assessing baseline renal function before initiation of therapy, followed by adjusting the dosage 2
- Monitoring renal function and vital signs during therapy 2, 4
- Avoiding nephrotoxic drug combinations 2, 3
- Correcting hydroelectrolytic disorders and hypovolemia 3
- Looking for similar options that are less toxic 3
Less Nephrotoxic Medications
Some examples of less nephrotoxic medications or alternatives can be considered:
- Instead of using anti-inflammatories, antibiotics such as vancomycin and aminoglycosides, and chemotherapeutic agents such as cisplatin and methotrexate, which are commonly associated with nephrotoxicity, alternative medications can be used 3
- For patients with certain risk factors, such as age older than 60 years, underlying renal insufficiency, and diabetes, medications with lower nephrotoxic potential can be chosen 2
General Management Principles
General management principles for acute kidney injury include: