Nephrotoxic Medications in Acute Kidney Injury

Primary Medications to Cease in AKI

The Kidney International guideline recommends temporarily discontinuing Renin-Angiotensin-Aldosterone System (RAAS) Blockers, including ACE inhibitors and Angiotensin receptor blockers (ARBs), in patients with acute kidney injury to prevent further kidney damage and promote recovery 1, 3
The Kidney International guideline suggests that Non-steroidal anti-inflammatory drugs (NSAIDs) should be immediately stopped as they reduce renal perfusion 4
The Kidney International guideline recommends discontinuing Metformin in patients with GFR <30 ml/min/1.73m² and reviewing it in those with GFR 30-44 ml/min/1.73m² 3, 4
The Kidney International guideline suggests that Lithium requires discontinuation and monitoring of drug levels 3, 4
The Kidney International guideline recommends temporarily ceasing Digoxin due to risk of toxicity with reduced renal clearance 4

The Nature Reviews Nephrology guideline recommends avoiding Trimethoprim-sulfamethoxazole if creatinine clearance is <15 ml/min 5

The Kidney International guideline suggests that Iodinated radiocontrast media should be avoided when possible, and if essential, use the lowest possible dose and ensure adequate hydration 3, 4
The Kidney International guideline recommends not using Gadolinium-based contrast media in people with GFR <15 ml/min/1.73m² 4

The Nature Reviews Nephrology guideline warns that the "triple whammy" combination (NSAIDs + diuretics + ACE inhibitors/ARBs) dramatically increases AKI risk and should be avoided 2
The Nature Reviews Nephrology guideline suggests that escalating from two to three nephrotoxic medications more than doubles the risk of developing AKI 2
The Nature Reviews Nephrology guideline recommends avoiding certain drug interactions that increase nephrotoxicity risk, such as some macrolide antibiotics with statins 2

The Nature Reviews Nephrology guideline recommends identifying all potentially nephrotoxic medications in the patient's regimen and assessing the necessity of each medication 1, 2, 4
The Nature Reviews Nephrology guideline suggests considering drug-specific factors, such as renal versus non-renal excretion, and potential for direct nephrotoxicity 1
The Nature Reviews Nephrology guideline recommends resuming medications cautiously after kidney function improves, with close monitoring of renal function 5

The Kidney International guideline recommends discontinuing over-the-counter medications and herbal remedies, as they may contain nephrotoxic compounds 3, 4
The Kidney International guideline suggests that Calcineurin inhibitors require drug level monitoring and possible dose adjustment 4
The Kidney International guideline recommends appropriate dose adjustment of cytotoxic drugs according to GFR rather than complete discontinuation in cancer patients 4