How to manage a patient with impaired renal function and non-cardiac chest pain, with a rise in serum creatinine from 1.9 mg/dl to 2.3 mg/dl, on medications including Ticagrelor (ticagrelor), Aspirin (acetylsalicylic acid), Rosuvastatin (rosuvastatin), Ezetimibe (ezetimibe), and Voltaprazole (pantoprazole)?

Management of Acute Kidney Injury in a Patient with Non-Cardiac Chest Pain and Medication-Related Renal Dysfunction

The patient requires immediate discontinuation of ticagrelor and rosuvastatin due to their interaction causing acute kidney injury, along with hydration and close monitoring of renal function. 1, 2

Assessment of Current Situation

This patient presents with:

• Rise in serum creatinine from 1.9 mg/dl to 2.3 mg/dl (Stage 1 AKD per ADQI classification) 3
• Non-cardiac chest pain with local area tenderness
• Pyuria (15-20 pus cells in urine)
• Small right kidney on ultrasound
• Current medications: ticagrelor, aspirin, rosuvastatin, ezetimibe, and pantoprazole

Key Concerns

1. Drug interaction: Ticagrelor and rosuvastatin can interact, causing rhabdomyolysis and worsening renal function 1, 2
2. Possible urinary tract infection: Suggested by pyuria
3. Underlying chronic kidney disease: Suggested by small right kidney on ultrasound
4. Potential pantoprazole-induced nephritis: Proton pump inhibitors can cause acute interstitial nephritis 4

Management Algorithm

1. Immediate Medication Adjustments

• Discontinue ticagrelor and switch to clopidogrel (75 mg daily) 2
• Discontinue rosuvastatin temporarily 5
• Consider holding pantoprazole due to potential for acute interstitial nephritis 4
• Continue aspirin as it remains essential for cardiovascular protection
• Continue ezetimibe as it has minimal renal effects

2. Hydration and Renal Protection

• Initiate IV hydration with isotonic saline (if no contraindications to volume) 3
• Target urine output of at least 0.5 ml/kg/hour
• Monitor fluid status carefully to avoid volume overload 6
• Consider albumin infusion (1g/kg) if evidence of hypoalbuminemia 3, 6

3. Diagnostic Workup

• Urinalysis and urine culture: To confirm and treat UTI suggested by pyuria
• Daily renal function monitoring: BUN, creatinine, electrolytes 6
• Creatine kinase (CK): To evaluate for rhabdomyolysis from statin-ticagrelor interaction 5
• Urine eosinophils: To evaluate for drug-induced interstitial nephritis 4
• ECG and cardiac enzymes: To definitively rule out cardiac causes of chest pain

4. Management of Non-Cardiac Chest Pain

• Provide appropriate analgesia (acetaminophen preferred)
• Avoid NSAIDs due to renal dysfunction
• Consider topical analgesics for musculoskeletal pain

5. Follow-up Care

• Short-term: Daily monitoring of renal function until stabilized
• Medium-term: Weekly monitoring of renal function for 4 weeks 3
• Long-term: Consider nephrology consultation for CKD management given small right kidney 3

Reintroduction of Medications

After renal function stabilizes:

1. Antiplatelet therapy: Continue clopidogrel instead of ticagrelor 2
2. Lipid management: Consider reintroducing rosuvastatin at lower dose (5 mg) if CK normal and renal function improves, or switch to atorvastatin which has less renal excretion 5
3. Acid suppression: If needed, consider H2 blocker instead of PPI, or reintroduce PPI at lower dose with monitoring 4

Common Pitfalls to Avoid

1. Failing to recognize drug interactions: Ticagrelor and rosuvastatin interaction is underrecognized but potentially serious 1, 2
2. Inadequate monitoring: Renal function should be monitored frequently during acute changes 6
3. Overlooking underlying CKD: Small right kidney suggests chronic disease requiring long-term management 3
4. Assuming non-cardiac chest pain is benign: Requires appropriate evaluation even when ECG is normal
5. Aggressive diuresis: Could worsen renal function in this setting 6

Special Considerations

• The patient's baseline creatinine of 1.9 mg/dl already indicates significant renal dysfunction
• The small right kidney suggests chronic kidney disease that may limit recovery potential
• Medication adjustments must balance cardiovascular risk and renal protection

This management approach prioritizes renal recovery while maintaining essential cardiovascular protection, with careful attention to medication interactions that likely precipitated the acute kidney injury.