What medications are used to treat Acute Kidney Injury (AKI)?

Medications for Treating Acute Kidney Injury

There are no specific pharmacologic therapies proven to treat AKI itself—management focuses on discontinuing nephrotoxic medications, optimizing hemodynamics with fluids and vasopressors, and providing supportive care. 1, 2, 3

What NOT to Use: Ineffective Therapies

The evidence is clear that several medications should be avoided as they do not prevent or treat AKI:

• Do not use diuretics (including furosemide) to prevent or treat AKI—they are ineffective for kidney protection and should only be used judiciously for managing fluid overload, not for improving kidney function 1
• Do not use low-dose dopamine—it does not prevent or treat AKI 1, 4
• Do not use recombinant human IGF-1—it is ineffective 1
• Do not use statins specifically for AKI prevention in cardiac surgery—strong evidence shows no benefit 4

Medications to STOP Immediately in AKI

The cornerstone of AKI medication management is identifying and discontinuing nephrotoxic agents. 1, 2

Primary Nephrotoxins to Discontinue:

• ACE inhibitors and ARBs: Temporarily discontinue to prevent further functional kidney damage and promote recovery 1, 2, 5
• NSAIDs: Stop immediately as they reduce renal perfusion 2, 5
• Metformin: Discontinue if GFR <30 ml/min/1.73m² and review if GFR 30-44 ml/min/1.73m² 2
• Lithium: Discontinue and monitor drug levels 2
• Digoxin: Temporarily cease due to toxicity risk with reduced renal clearance 2

The "Triple Whammy" Warning:

Avoid the combination of NSAIDs + diuretics + ACE inhibitors/ARBs at all costs—this dramatically increases AKI risk 1, 2, 6

Antibiotic Considerations:

• Aminoglycosides: Avoid unless absolutely necessary; if required, use appropriate dosing with therapeutic drug monitoring 1
• Trimethoprim-sulfamethoxazole: Do not use if creatinine clearance <15 ml/min 1, 2
• Amphotericin B: Avoid when alternatives exist 1

Additional Nephrotoxins:

• Iodinated radiocontrast media: Avoid when possible; if essential, use lowest dose with adequate hydration 2
• Gadolinium-based contrast: Do not use if GFR <15 ml/min/1.73m² 2
• Calcineurin inhibitors: Require drug level monitoring and dose adjustment 2
• Over-the-counter medications and herbal remedies: Discontinue as they may contain nephrotoxic compounds 2

Medications That ARE Used in AKI Management

Hemodynamic Support (The Primary "Treatment"):

• Vasopressors (norepinephrine preferred): Use in conjunction with fluids for vasomotor shock; titrate to MAP 65-70 mmHg unless chronic hypertension present 1, 4
• Isotonic crystalloids: Use for volume expansion rather than colloids (albumin or starches) 1, 4, 7
  • Avoid hydroxyethyl starches—associated with increased AKI incidence and need for renal replacement therapy 1, 4, 7
  • Exception for albumin: May be rational in cirrhosis with spontaneous bacterial peritonitis, large-volume paracentesis, or severe hypoalbuminemia 1

Contrast-Induced AKI Prevention:

• Prehydration with NaCl 0.9% or sodium bicarbonate solution before contrast exposure 7
• N-acetylcysteine is NOT recommended—evidence does not support its use 7

Fluid Overload Management:

• Diuretics may be used for managing volume overload complications, but NOT for treating AKI itself or improving kidney function 1, 8
• Furosemide dosing when indicated for fluid overload: Initial dose 20-40 mg IV slowly (over 1-2 minutes), may increase by 20 mg increments 8

Critical Dosing Principle

Each additional nephrotoxin increases AKI odds by 53%, and combining 2-3 nephrotoxins more than doubles AKI risk—25% of patients receiving three or more nephrotoxins develop AKI 1, 2, 5

Monitoring Approach During AKI

• Assess temporal relationship between drug administration and AKI onset 1
• Evaluate renal versus non-renal drug excretion pathways 1
• Consider drug interactions (e.g., macrolide antibiotics with statins increase rhabdomyolysis risk) 1
• Monitor therapeutic drug levels for aminoglycosides, calcineurin inhibitors, lithium, and digoxin 1, 2

Common Pitfalls to Avoid

• Do not use diuretics thinking they will "treat" AKI—this is a persistent misconception despite strong evidence against it 1
• Do not continue ACE inhibitors/ARBs during acute AKI thinking long-term benefits outweigh risks—temporary discontinuation is essential 1, 2
• Do not overlook drug-drug interactions that compound nephrotoxicity (clarithromycin + statins, multiple nephrotoxins) 1, 2
• Do not assume all antibiotics are safe—aminoglycosides remain nephrotoxic despite being effective and inexpensive 1