Medicines optimisation in BCYP with AKI

AKI can be prevented or reduced in severity by early detection and appropriate management.

When a patient is either admitted with AKI, or develops AKI during an admission episode, a thorough review of medication is required:

To eliminate potential cause / risk / contributory factor for AKI
To avoid inappropriate combinations of medications in the context of AKI
To reduce adverse events
To ensure that doses are appropriate for the patient’s level of renal function
To ensure all medicines prescribed are clinically

Paediatric contrast-associated AKI

This section is under review.

High Risk Medicines: actions required in context of AKI

The following list is not exhaustive. Refer to the BNF/BNFc for more information. Consider ALL medications including any “usual” long term medication. Check medication history thoroughly and ask about “Over the Counter” preparations and alternative therapies.

Analgesics

Drug	Problem	Action in presence of AKI	Education Points
NSAIDs	Acute interstitial nephritis Altered intraglomerular haemodynamics	Avoid	Avoid taking whilst at risk of hypovolaemia.
Opioid analgesics	Accumulation of active metabolites – increased CNS side effects.	Reduce dose of short acting preparation	May accumulate in acute kidney injury. Seek advice if at risk of dehydration. If needed, use opiates with minimal renal excretion e.g. fentanyl, oxycodone, hydromorphone.

Antibiotics / Antifungals / Antivirals (See In house guidelines where available)

Drug	Problem	Action in presence of AKI	Education Points
Aciclovir	Crystal nephropathy. Accumulates in reduced renal function leading to mental confusion, seizures. Avoid rapid infusions. Infuse IV over one hour.	Reduce dose	Ensure high fluid intake – enteral or IV Seek medical advice if at risk of dehydration.
Aminoglycosides	Tubular cell toxicity, ototoxicity	Avoid if possible. Monitor drug levels and renal function regularly.
Amphotericin IV – Fungizone®	Tubular cell toxicity Hypokalaemia Avoid rapid infusion	Avoid. Consider Ambisome® preparation
Fluconazole	Accumulation leading to acute mental confusion, coma, seizures.	Reduce dose and check drug interactions	Interactions, (e.g. monitor tacrolimus levels and reduce dose as appropriate; withhold statins as risk of rhabdomyolysis).
Ganciclovir	Crystal nephropathy Accumulates in reduced renal function leading to neutropenia, anaemia and thrombocytopenia. Avoid rapid infusions.	Reduce dose
Penicillins	Acute interstitial nephritis Glomerulonephritis Accumulation leading CNS side effects including seizures.	Reduce dose for prolonged courses. Consider full dose for first 48 hours where infection treatment is priority.
Teicoplanin	Accumulation leading to CNS excitation, seizures, & blood dyscrasias.	Reduce dose Monitor levels
Trimethoprim OR Co-trimoxazole	Acute interstitial nephritis (rare) Interferes with tubular secretion of creatinine (without affecting actual GFR), so can cause apparent AKI particularly amongst patients with CKD Accumulation leading to hyperkalaemia (particularly with high doses), nausea & vomiting.	Avoid or reduce dose	Encourage good fluid intake (oral or IV). Seek medical advice if at risk of dehydration.
Vancomycin	Acute interstitial nephritis Accumulation leading to renal toxicity, ototoxicity.	Reduce dose / increase dose interval Monitor levels

Antiepileptics (including drugs used for neuropathic pain)

Drug	Problem	Action in presence of AKI	Education Points
Gabapentin / Pregabalin	Accumulation in kidney impairment – increase in CNS side effects	Reduce dose
Phenytoin	Acute interstitial nephritis Risk of phenytoin toxicity if patient has low serum albumen levels	Monitor levels

Anti-hypertensives

Drug	Problem	Action in presence of AKI	Education Points
Anti-hypertensives (general)	Hypotension May exacerbate renal hypo-perfusion Longer acting, renal cleared drugs may accumulate in renal impairment	Consider withholding / reduce dose depending on clinical signs
ACEI / ARBs	Altered haemodynamics Hyperkalaemia	These drugs can impair the kidneys’ ability to maintain GFR when perfusion is compromised. In some situations, e.g. in heart failure with adequate blood pressure, continuing may be appropriate. Seek nephrologist advice if undergoing contrast procedure or at risk of AKI.	Avoid taking whilst at risk of hypovolaemia. Seek medical advice if at risk. Monitor BP. If patient is hypertensive, consider alternative antihypertensive agents, e.g., calcium channel blockers, alpha-blockers, beta- blockers if appropriate.

Diuretics

Drug	Problem	Action in presence of AKI	Education Points
Diuretics (general)	Hypo perfusion Loop diuretics preferred as thiazides less effective if GFR very low. However they can potentiate the effects of loop diuretics.	Monitor and adjust dose as necessary.	Dose adjustment may be required. Seek medical advice if at risk of hypovolaemia.
Diuretics – potassium sparing	Hyperkalaemia Hypo perfusion	Avoid	Dose reduction may be required. Seek medical advice if at risk of hypovolaemia.

Immunosuppressants

Drug	Problem	Action in presence of AKI	Education Points
Calcineurin inhibitors e.g. ciclosporin, tacrolimus	Accumulation with risk of nephrotoxicity, neurotoxicity and hyperkalaemia.	Seek advice of transplant centre regarding monitoring levels and dose adjustment.	May accumulate in reduced renal function. Seek medical advice / advice from transplant team if at risk of hypovolaemia.
Methotrexate	Crystal nephropathy Accumulation increases side effects, eg. Excessive bone marrow depression, mucositis, acute hepatic toxicity, acute interstitial pneumonitis.	Dose modification as required Monitor levels and consider folinic acid rescue Correct fluid balance	May accumulate in reduced renal function. Seek medical advice if at risk of hypovolaemia.

Others

Drug	Problem	Action in presence of AKI	Education Points
5 –amino salicylates	Nephrotoxic – tubular and glomerular damage.	Avoid
Digoxin	Accumulation leading to bradycardia, visual disturbances, mental confusion. Aggravates hyperkalaemia.	Reduce dose Monitor drug level	May accumulate in AKI. Seek medical advice if at risk from hypovolaemia

How should AKI be managed to prevent further damage?

Nutritional Considerations