Drugs that can damage the kidneys (nephrotoxic)
‘Nephrotoxicity’ is a term used to describe a deterioration in kidney function due to the toxic effects of drugs or chemicals. A nephrotoxic drug is one that is known can damage the kidneys.
Why does it matter?
- AKI. Nephrotoxicity is a major cause of acute kidney injury (AKI; rapid kidney failure). In fact, in 20% of people that are admitted to hospital with AKI, nephrotoxicity is the primary cause
- Other AKI cases. And in many of the other cases of AKI in hospital, kidney toxic drugs are a major or minor component of the illness
- CKD. Nephrotoxicity can cause CKD (chronic kidney disease; slow kidney failure), or worsen kidney function in patients with CKD (or a kidney transplant). If kidney function (as shown by the GFR) is already falling, this is not what you need.
Who is at risk of nephrotoxicity?
Some people are at higher risk of drug-induced nephrotoxicity (kidney damage) than others. Risk factors include:
- Older age (over 60 years)
- Pre-existing CKD – as shown by reduced glomerular filtration rate (eGFR) and raised blood serum creatinine level
- Diabetes
- Dehydration (seen in vomiting, diarrhoea, and bleeding)
- Other medical conditions such as cardiovascular diseases such as hypertension, liver dysfunction, electrolyte imbalances, and sepsis.
So, what drugs that can damage the kidneys (are nephrotoxic)?
Multiple types of tablet can cause drug-induced kidney disease. We will now go through them in alphabetical order.
Antibiotics
Antibiotics such as aminoglycosides (e.g. gentamicin), beta-lactams (cephalosporins, penicillins), quinolones (ciprofloxacin), rifampin, and vancomycin can lead to drug-induced AKI.
Antidepressants and mood stabilisers
Certain antidepressants like fluoxetine, amitriptyline and doxepin can cause rhabdomyolysis (muscle breakdown), leading to AKI. The mood stabiliser lithium used to treat bipolar disorder can also cause AKI via rhabdomyolysis, and CKD via a chronic interstitial nephritis.
Antifungals
Amphotericin B
Antihistamines
Medications such as diphenhydramine can contribute to rhabdomyolysis causing AKI.
Antiparasitic drugs
Pentamidine, a broad-spectrum antimicrobial used to treat parasitic infections, may cause AKI via acute tubular injury.
Antiretrovirals
Antiretroviral drugs used to treat HIV/AIDS, hepatitis, cytomegalovirus infection can cause AKI via acute tubular injury and acute interstitial nephritis. Examples include adefovir, tenofovir, cidofovir, and indinavir.
Antivirals
Antiviral medications such as acyclovir, foscarnet, and ganciclovir are also known to cause drug-induced nephrotoxicity.
Blood pressure tablets
Angiotensin-converting enzyme inhibitors (ACE inhibitors, e.g. ramipril), angiotensin receptor blockers (ARBs, e.g. losartan) can cause AKI, or worsen CKD. They do this by causing tightening of the large and smaller renal arteries. [“Yes, it is confusing that such drugs are potentially harmful to the kidneys and protective of them, at the same time.” CKDEx Ed”]
Chemotherapy
Chemotherapeutic agents such as carmustine, cisplatin, interferon-alfa, methotrexate, and mitomycin-C can cause drug-induced kidney disease.
Contrast-induced nephropathy (CIN)
Intravenous (IV) contrast agents (dyes) used during medical imaging such as CTs, angiograms, MRIs, and other x-rays, can lead AKI, or worsen CKD. This type of renal injury is called contrast-induced nephropathy (CIN). The damage is usually reversible. But in a minority of patients, it can lead to permanent dialysis.
Diabetic tablets
A newish group of diabetic tablets called SGLT2 inhibitors (e.g. canagliflozin, empagliflozin and dapagliflozin) can cause AKI or worsen CKD. But as these drugs also reduce blood pressure, improve heart failure and slow the progression of CKD (all good things), they are used to treat those conditions. Their kidney-toxic effects happen through a similar mechanism to the blood pressure tablets above (ACE/ARBs).
Diuretics (water tablets)
All diuretics can cause AKI, or worsen CKD. Groups include thiazide (e.g. bendroflumethazide), loop (furosemide and bumetanide) and potassium-sparing (spironolactone) diuretics. They do this via causing dehydration, especially if the dose is too high for you.
Herbal products
Certain Chinese herbal medicines such as aristolochic acid can cause drug-induced nephrotoxicity, specifically CKD via chronic interstitial nephritis.
Immunosuppressants
Calcineurin inhibitors that prevent organ rejection after transplant (a good thing) unfortunately can cause drug-induced nephropathy (a bad thing). Examples include tacrolimus and ciclosporin. This is why, if you have had a kidney transplant, we keep measuring the levels of these drugs in your blood. This is so we can find the lowest dose that can both prevent rejection, but also cause least kidney damage.
Proton pump inhibitors (PPIs)
Proton pump inhibitors (drugs that reduce stomach acid production), such as lansoprazole, pantoprazole, and omeprazole, can cause AKI via an acute interstitial nephritis.
Platelet inhibitors
Clopidogrel and ticlopidine, rarely cause AKI via a drug-induced thrombotic microangiopathy (small clots that lead to red blood cell damage).
Recreational drugs
Heroin, cocaine, methamphetamine, methadone, and ketamine can cause drug-induced rhabdomyolysis and acute renal failure.
Statins (HMG CoA-reductase inhibitors)
Cholesterol-lowering tablets called statins (e.g. simvastatin and atorvastatin) can cause rhabdomyolysis, resulting in AKI.
General points
- The above list is by no means a comprehensive list of medications that can cause kidney damage. You are at higher risk of drug-induced kidney damage if you are over 60 years, have underlying CKD, or comorbidities such as diabetes. If this is the case, you should talk to your doctor before starting any new medication that can potentially cause kidney damage.
- Stopping or using the minimum dose of these tablets can help prevent CKD.
- But please do not stop the tablets above if you think they are becoming nephrotoxic (kidney damaging). Speak to your doctor urgently.
Summary
We have described drugs that can damage the kidneys (nephrotoxic). We hope it has been helpful.
Last Reviewed on 19 April 2024