Aki medications
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Acute Kidney Injury (AKI) Medications: Risks, Benefits, and Management
Temporary Discontinuation of Medications to Prevent AKI
Temporary discontinuation of certain medications can potentially reduce the risk of acute kidney injury (AKI). A systematic review and meta-analysis examined the effects of stopping medications like ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), and non-steroidal anti-inflammatory drugs (NSAIDs) in adults undergoing procedures such as coronary angiography and cardiac surgery. The findings suggest that continuing these medications increases the risk of AKI by approximately 15% compared to discontinuation . However, the evidence is of low quality, and there is no data on the impact of drug cessation during intercurrent illnesses in primary or secondary care settings .
NSAIDs and AKI Outcomes
NSAIDs are commonly used but pose a significant risk for AKI. A study analyzing the timing of NSAID administration found that NSAID use within 24 hours of AKI onset worsens patient outcomes, increasing the likelihood of AKI progression and the need for dialysis . Conversely, NSAID use before the early onset of AKI did not show a significant association with adverse outcomes, suggesting that timing is crucial in managing NSAID-related risks .
Medication Management and the 'Sick Day Rule'
Adherence to the 'sick day rule,' which involves temporarily stopping certain medications during acute illnesses, is critical in managing AKI, especially in older adults. A quality improvement initiative highlighted the challenges in adherence to this rule, with many patients continuing medications that could exacerbate AKI. The initiative aimed to improve adherence through education and clear guidelines, showing some success in holding medications like NSAIDs but less so for others like ACE inhibitors and metformin .
Immune Checkpoint Inhibitors and AKI
Immune checkpoint inhibitors, used in cancer therapy, have been associated with AKI. A multicenter study identified risk factors such as lower baseline eGFR and the use of proton pump inhibitors. The study found that tubulointerstitial nephritis was the predominant lesion in patients with immune checkpoint inhibitor-associated AKI, and treatment with steroids improved renal outcomes . However, failure to recover kidney function after AKI was linked to higher mortality rates .
Antiferroptosis Agents in AKI Management
Recent research has identified drugs that can suppress ferroptosis, a form of cell death implicated in AKI. These drugs, including rifampicin and omeprazole, act as lipid peroxyl radical scavengers, reducing organ damage in AKI. In mouse models, these drugs showed promise in ameliorating AKI and liver injury by decreasing lipid peroxidation and cell death . This suggests a potential therapeutic avenue for managing AKI through the repurposing of existing drugs.
Adverse Drug Events During AKI
Adverse drug events (ADEs) are common in patients with AKI, particularly when nephrotoxic or renally eliminated medications are used. A study found that 43% of patients experienced ADEs or therapeutic failures, with most events being preventable. The most common issues were failure to adjust medication for kidney function and the use of nephrotoxic drugs during AKI . Medications like ACE inhibitors, antibiotics, and antithrombotics were strongly associated with ADEs in AKI patients .
Conclusion
Managing medications in the context of AKI is complex and requires careful consideration of the risks and benefits. Temporary discontinuation of certain drugs can reduce AKI risk, but adherence to guidelines like the 'sick day rule' is essential. NSAIDs should be used cautiously, especially around the onset of AKI. Emerging therapies targeting ferroptosis offer new hope, while vigilant monitoring for adverse drug events remains crucial in improving outcomes for AKI patients.
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