Is allopurinol given to a patient with Acute Kidney Injury (AKI)?

From the Guidelines

Allopurinol should be used with caution in patients with acute kidney injury (AKI) and the dose should be significantly reduced. In AKI, kidney function is compromised, which impairs the clearance of allopurinol and its active metabolite oxypurinol, potentially leading to drug accumulation and increased risk of toxicity 1. If allopurinol is absolutely necessary in a patient with AKI, such as for tumor lysis syndrome prevention, the dose should be significantly reduced, for example, by 50% or more in renal failure, and the patient closely monitored 1. Some key points to consider when using allopurinol in AKI include:

• Starting with a low dose, such as 50 mg/day, in patients with stage 4 or worse CKD 1
• Gradually titrating the maintenance dose upwards every 2–5 weeks to the appropriate maximum dose, while monitoring for drug toxicity 1
• Considering alternative approaches for managing hyperuricemia in AKI, such as rasburicase for severe cases or addressing the underlying cause of the AKI 1 The concern with allopurinol in AKI stems from its mechanism of action as a xanthine oxidase inhibitor, which can lead to accumulation of xanthine crystals in the kidneys when metabolic breakdown products cannot be adequately cleared, potentially worsening kidney injury. Additionally, allopurinol itself can rarely cause hypersensitivity reactions that may affect the kidneys 1. For patients already on allopurinol who develop AKI, temporary dose reduction or discontinuation may be warranted until kidney function improves. It is essential to weigh the benefits and risks of using allopurinol in patients with AKI and to closely monitor patients for signs of toxicity or worsening kidney function.

From the FDA Drug Label

Patients with decreased renal function require lower doses of allopurinol tablets than those with normal renal function. Lower than recommended doses should be used to initiate therapy in any patients with decreased renal function and they should be observed closely during the early stages of administration of allopurinol tablets Although the mechanism responsible for this has not been established, patients with impaired renal function should be carefully observed during the early stages of administration of allopurinol tablets and the dosage decreased or the drug withdrawn if increased abnormalities in renal function appear and persist

Allopurinol can be given to a patient with Acute Kidney Injury (AKI), but with caution and at a lower dose. The patient should be closely monitored for any signs of worsening renal function. The dosage may need to be adjusted or the drug withdrawn if abnormalities in renal function appear and persist 2.

From the Research

Allopurinol Administration in AKI Patients

• There is no direct evidence in the provided studies that specifically addresses the administration of allopurinol to patients with Acute Kidney Injury (AKI) 3, 4, 5, 6, 7.
• However, it is known that allopurinol is used to treat hyperuricemia, which can be a concern in patients with kidney disease 3, 6.
• The studies provided focus more on the comparison between febuxostat and allopurinol in patients with chronic kidney disease (CKD) 3, 6, and the management and pathogenesis of AKI 4, 5, 7.
• In patients with CKD, febuxostat has been shown to reduce serum uric acid concentrations effectively and may suppress the progressive decline in renal function 3, 6.
• There is no clear indication that allopurinol is contraindicated in AKI patients, but its use should be carefully considered based on the patient's specific condition and renal function.

Considerations for Allopurinol Use

• The decision to administer allopurinol to a patient with AKI should be based on a thorough evaluation of the patient's condition, including their renal function and the potential benefits and risks of the medication.
• It is essential to monitor the patient's serum creatinine levels and urine output closely when administering allopurinol to patients with AKI 4, 5, 7.
• Further research is needed to determine the safety and efficacy of allopurinol in patients with AKI.