Can Lola be used in patients with acute kidney injury?

L-Ornithine L-Aspartate (LOLA) in Acute Kidney Injury

LOLA should not be used in patients with acute kidney injury as there is insufficient evidence to support its safety and efficacy in this population. 1

Evidence Assessment

Current Guidelines on LOLA in AKI

• The 2023 Critical Care Medicine guidelines specifically state there is "insufficient evidence to issue a recommendation on using lactulose, rifaximin, flumazenil, branch-chain amino acids, carnitine, zinc, probiotics, and LOLA in critically ill ALF patients with hyperammonemia" 1
• No other major nephrology guidelines (including KDIGO) specifically address LOLA use in AKI patients 1

Nephrotoxic Medication Management in AKI

• Patients with AKI should receive potentially nephrotoxic medications only if needed and only for as long as needed 1
• Kidney function must be monitored in patients who are exposed to agents that could affect kidney function or cause injury 1
• The risk-benefit ratio for medication use in AKI must be carefully considered and therapy personalized according to individual patient risks 1

Rationale for Avoiding LOLA in AKI

• AKI represents a state of altered drug metabolism and clearance that can lead to unpredictable pharmacokinetics 1
• Organ crosstalk, particularly involving the liver and kidney, can influence drug metabolism during AKI 1
• The effects of AKI on drug metabolism are different from those in chronic kidney disease (CKD), making extrapolation from CKD data inappropriate 1

Management Considerations for Medications in AKI

• Drug stewardship is critical in AKI, with the primary goal of balancing the changing risks and benefits of drug utilization and dosing 1
• It's essential to balance the risk of toxicity from drug/metabolite accumulation in AKI versus the risk of therapeutic failure from overly conservative drug avoidance 1
• Certain drug combinations and overall drug burden are associated with worsening AKI 1

Alternatives and Monitoring

• If medication is absolutely necessary in AKI patients, regular monitoring of functional status is needed 1
• Duration and dose of any potentially nephrotoxic agent should be minimized 1
• Evidence-based dosing guidelines should be followed when medications must be used 1

Clinical Pitfalls to Avoid

• Avoid adding medications without clear evidence of benefit to patients with AKI, as polypharmacy increases risk of adverse effects 1
• Be cautious with medications that undergo renal elimination, as there is concern about harm from accumulation of parent drug or metabolites in AKI 1
• Remember that failure to adjust drug doses during renal recovery or with enhanced elimination via extracorporeal clearance may lead to therapeutic failure 1
• Monitor for signs of fluid and electrolyte imbalances that may be exacerbated by medications in AKI patients 2

In conclusion, while LOLA may have applications in other clinical scenarios, current guidelines do not support its use in patients with acute kidney injury due to insufficient evidence regarding its safety and efficacy in this specific population.