Is Remdesivir (Veklury) contraindicated in patients with Acute Kidney Injury (AKI)?

Remdesivir Use in Acute Kidney Injury

Remdesivir is not absolutely contraindicated in AKI, but it should not be used when eGFR is <30 mL/min/1.73 m² according to current guidelines. 1, 2

Absolute Contraindication Threshold

• The American College of Physicians establishes eGFR <30 mL/min/1.73 m² as an absolute contraindication to remdesivir initiation. 1, 2
• This threshold applies regardless of whether the patient has chronic kidney disease or acute kidney injury. 1
• Before starting remdesivir, you must assess renal function (eGFR) to ensure safe administration. 1, 2

Evidence on Safety in Renal Impairment

The guideline recommendation is more conservative than emerging research data suggests:

• A 2023 retrospective study of 416 patients found no significant difference in AKI development between patients with eCrCl <30 mL/min versus ≥30 mL/min (11% vs 7%, OR 1.57,95% CI 0.57-4.3). 3
• The same study showed no difference in hepatotoxicity or mortality between groups, though length of stay was longer in the severe renal impairment group. 3
• A 2021 case report demonstrated safe administration of remdesivir in a patient requiring hemodialysis without serious adverse events. 4
• A 2023 meta-analysis of 5 RCTs involving 3,095 patients found remdesivir was not associated with increased AKI risk (RR 0.71,95% CI 0.43-1.18 for serious adverse events). 5

Clinical Decision Algorithm

For patients with eGFR ≥30 mL/min/1.73 m²:

• Remdesivir can be initiated following standard dosing (200 mg IV day 1, then 100 mg IV daily). 1, 2
• Monitor renal function during treatment as clinically appropriate. 2

For patients with eGFR <30 mL/min/1.73 m²:

• Do not initiate remdesivir per current guidelines. 1, 2
• Consider alternative COVID-19 therapies such as molnupiravir or monoclonal antibodies if available. 1
• If remdesivir is deemed absolutely necessary based on risk-benefit assessment (e.g., no alternatives available, severe COVID-19), this would be off-guideline use requiring careful monitoring. 3, 4

For patients who develop worsening renal function during remdesivir treatment:

• If eGFR drops below 30 mL/min/1.73 m² during a course of remdesivir, clinical judgment should guide whether to continue or discontinue based on severity of COVID-19 and alternative options. 2
• The evidence suggests remdesivir itself may not be directly nephrotoxic and could even have protective effects on kidney injury through anti-inflammatory mechanisms. 6, 5

Important Caveats

• The guideline contraindication at eGFR <30 mL/min/1.73 m² is based on exclusion of these patients from major trials rather than direct evidence of harm. 1
• Emerging real-world data suggests remdesivir may be safer in severe renal impairment than initially thought, but guidelines have not yet incorporated this evidence. 3, 5
• AKI itself is listed as both a serious and non-serious adverse event in remdesivir trials, but this occurred in both treatment and control groups at similar rates. 7
• The greatest benefit of remdesivir occurs in hospitalized patients requiring low-flow oxygen, so the risk-benefit calculation must consider COVID-19 severity. 1, 2