What medications should be held in patients with Acute Kidney Injury (AKI)?

From the Guidelines

When managing a patient with acute kidney injury (AKI), it is crucial to temporarily hold certain medications that can exacerbate kidney damage, including diuretics, nonselective beta-blockers, NSAIDs, and certain antibiotics, as recommended by the most recent guidelines 1. In the context of AKI, the primary goal is to prevent further kidney damage and improve outcomes in terms of morbidity, mortality, and quality of life. To achieve this, several key medications should be considered for temporary discontinuation. These include:

• Diuretics, such as furosemide and hydrochlorothiazide, which can worsen volume depletion
• Nonselective beta-blockers, as recommended by the AGA clinical practice update 1
• NSAIDs, including ibuprofen, naproxen, and celecoxib, which reduce kidney blood flow
• Certain antibiotics, such as aminoglycosides and vancomycin at high doses, which are directly nephrotoxic
• Metformin, which can accumulate and cause lactic acidosis when kidney function is impaired It's also important to note that contrast agents used in imaging studies should be avoided when possible, and dose adjustments may be necessary for medications that are primarily renally cleared. The decision to hold specific medications should be individualized based on the severity of AKI, underlying conditions, and risk-benefit assessment, taking into consideration the most recent and highest quality evidence available 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Patients with Impaired Renal Function and Elderly Patients Dosage adjustment must be made in patients with impaired renal function. Nephrotoxicity Systemic vancomycin exposure may result in acute kidney injury (AKI). Patients treated with aminoglycosides should be under close clinical observation because of the potential toxicity associated with their use. As with other aminoglycosides, gentamicin injection is potentially nephrotoxic.

Medications to hold with AKI:

• Vancomycin may need to be held or dose adjusted in patients with AKI, as it can cause nephrotoxicity.
• Gentamicin should be used with caution in patients with AKI, as it is potentially nephrotoxic.
• Other medications that may need to be held or dose adjusted in patients with AKI include:
  • Aminoglycosides (e.g. tobramycin, amikacin)
  • Cisplatin
  • Cephaloridine
  • Kanamycin
  • Neomycin
  • Polymyxin B
  • Colistin
  • Paromomycin
  • Streptomycin
  • Viomycin 2, 2, 3

From the Research

Medications to Hold with AKI

• The following medications are associated with an increased risk of acute kidney injury (AKI) and may need to be held or adjusted in patients with AKI:
  • Aminoglycosides (e.g. gentamicin, tobramycin) 4
  • Vancomycin, especially when co-administered with aminoglycosides 4
  • Other nephrotoxic antibiotics and antimicrobials 5, 6
• Patients with pre-existing chronic kidney disease, heart failure, and those receiving multiple nephrotoxic medications are at higher risk of developing AKI 5, 4
• Medication adjustment and monitoring are crucial in the management of AKI, and antibiotic dosing decisions should be individualized to take into account patient-related, renal replacement therapy-related, and drug-related factors 6

Key Considerations

• AKI can be caused by a variety of factors, including sepsis, medications, and invasive procedures 7
• Early recognition and management of AKI are essential to prevent long-term consequences, such as chronic kidney disease and cardiovascular morbidity 7, 8
• Fluid and electrolyte management are critical in the management of AKI, and kidney replacement therapy may be required in severe cases 7