Spotting the signs of acute kidney injury

With 65% of cases beginning in the community, pharmacists can help detect acute kidney injury early and review patients’ medicines before their condition worsens. 

Download the full print version of the infographic here

What is acute kidney injury?

  • Acute kidney injury (AKI) is a sudden reduction in kidney function. Without treatment, the balance of fluids, electrolytes and the acid-base cannot be maintained, which can lead to pulmonary oedema and metabolic acidosis;
  • AKI mostly occurs as part of an acute illness, such as influenza or gastroenteritis, owing to several factors: the infection itself, loss of salt and water, and low blood pressure. This can be compounded by medicines that the patient may be taking for this or other conditions; 
  • The diagnosis of AKI is based on a serum creatinine increase of 26.5 micromol/L within 48 hours and a urine output of <0.5mL/kg/hour for more than 6 consecutive hours.

Causes of acute kidney injury

Pre-renal AKI is caused by a prolonged fall in blood pressure, often exacerbated by medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), in the context of acute or serious illness; 

Intrinsic AKI is caused by damage to the kidney following use of certain medicines, a sustained drop in blood pressure, or as a result of kidney disease.

Post-renal AKI is caused by obstruction of urinary flow within the renal tract (e.g. owing to enlarged prostate, medicines that precipitate insoluble crystals or kidney stones). 


Patients with COVID-19 and pre-existing chronic kidney disease (CKD) will be at increased risk of AKI through fever, reduced fluid intake, diarrhoea, and NSAIDs used for treatment of myalgias and headaches. Patients without pre-existing CKD may also develop AKI when presenting with COVID-19 and require renal replacement therapy.

Drugs that need monitoring or dose adjustment owing to accumulation or other effects on the kidneys


  • Benzodiazepines, opioids, tramadol.


  • Acyclovir, aminoglycosides, intravenous (IV) amphotericin, co-trimoxazole, fluconazole, ganciclovir IV, penicillin, teicoplanin, tetracycline, trimethoprim, valganciclovir, vancomycin.


  • Levetiracetam, pregabalin and gabapentin.


  • Beta blockers, calcium-channel blockers, thiazide and loop diuretics.


  • Dipeptidyl peptidase-4 inhibitors, metformin.


  • Calcineurin inhibitors (e.g. ciclosporin, tacrolimus), methotrexate.


  • Allopurinol, digoxin, lithium, low-molecular-weight heparins;
  • Bisphosphonates;
  • Nicorandil, nitrates.

Note: this list is not exhaustive and is only intended to act as an aide-memoire to the medicines optimisation of patients with AKI

Medicines review after acute kidney injury admission

  • Eliminate potential cause (e.g. medicines with nephrotoxic potential);
  • Avoid inappropriate combinations of medicines;
  • Ensure all medicines are clinically appropriate;
  • If a medicine must be used, amend doses appropriate to renal function, monitor blood levels of drugs wherever possible and keep course as short as possible;
  • Following discharge, advise patient if and when to restart medicines.


ACE inhibitors: angiotensin-converting enzyme inhibitors; ARBs: angiotensin II receptor blockers; COX-II: cyclooxygenase-2

Sources: Think Kidneys, Royal College of General Practitioners, National Institute for Health and Care Excellence

Editorial adviser: Clare Morlidge, advanced renal pharmacist, East and North Hertfordshire NHS Trust

Illustration: Alex Webber 

Last updated
The Pharmaceutical Journal, PJ, April 2020, Vol 304, No 7936;304(7936):DOI:10.1211/PJ.2020.20207921

You may also be interested in