Is Tab Acetazolamide (Acetazolamide) safe to use in patients with Acute Kidney Injury (AKI)?

Acetazolamide Should Be Avoided in Acute Kidney Injury

Acetazolamide is contraindicated in patients with marked kidney disease or dysfunction according to FDA labeling, and should not be used in the setting of AKI. 1

FDA Contraindication and Mechanism of Harm

• The FDA explicitly contraindicates acetazolamide in "marked kidney disease or dysfunction," which includes AKI 1
• Acetazolamide is a sulfonamide derivative carbonic anhydrase inhibitor that can cause intratubular crystalluria, leading to mechanical obstruction of renal tubules and anuric AKI 2, 3
• The drug promotes urinary alkalinization and acts as a diuretic, which can worsen volume depletion and exacerbate pre-existing kidney injury 4
• Even low doses (1250 mg over 48 hours) have caused severe anuric AKI requiring hemodialysis in previously healthy individuals 2

Clinical Evidence of Acetazolamide-Induced AKI

• Multiple case reports document anuric AKI with bilateral flank pain following acetazolamide use, requiring hemodialysis for severe metabolic acidosis and hyperphosphatemia 2, 3
• Recovery typically occurs within 96 hours after drug discontinuation and supportive care, but dialysis may be necessary during the acute phase 2, 3
• The combination of acetazolamide with dehydration or other nephrotoxins substantially increases AKI risk 4
• Each additional nephrotoxin increases AKI odds by 53%, and combining three or more nephrotoxins more than doubles AKI risk 5

General Nephrotoxin Management Principles in AKI

• All potentially nephrotoxic medications should be discontinued immediately when AKI is identified, unless the drug is essential for survival 5
• Selection of less nephrotoxic alternatives should be prioritized whenever possible 5
• Nephrotoxins should be avoided when: the patient has known AKI risk factors, a suitable less nephrotoxic alternative exists, the drug is non-essential, or the patient is already receiving other nephrotoxic medications 5
• During the acute kidney disease (AKD) phase following AKI, continued nephrotoxin avoidance remains critical to prevent re-injury 5

Alternative Management Strategies

• For metabolic alkalosis (the primary indication where acetazolamide might be considered in kidney disease), alternative approaches should be pursued rather than using acetazolamide in AKI patients 6
• Volume optimization with appropriate fluid resuscitation should be the priority in AKI management 5
• If acetazolamide was being used chronically before AKI developed, it must be discontinued immediately as part of comprehensive nephrotoxin review 5

Critical Pitfall to Avoid

• Never assume that low doses or short-term use of acetazolamide are safe in AKI—severe anuric kidney injury has occurred even with prophylactic dosing 2
• The FDA contraindication is absolute for marked kidney dysfunction, leaving no room for dose adjustment or "cautious use" in active AKI 1